A previous post seems to have sparked a lively debate as to whether nurses should study for a nursing degree. Much of this relates to what might be termed the Daily Mail/Dr Crippen Stance on Nurse Education.
This stance tends to go something like this:
Nurses don’t need a university degree. Most of nursing is practical stuff – washing, dressing, feeding. Since nurse education moved from the old nursing schools into the universities nurses have become too big for their boots. They all want to become nurse specialists or nurse practitioners, and as a result are forgetting about basic, hands-on care.
Regular readers will know that I profoundly disagree with the Daily Mail/Dr Crippen Stance. For one thing it’s simply not my experience that nurses are all rushing to advanced practitioner roles. A surprisingly high proportion of the nurses I’ve worked with have no ambition to rise above the level of staff nurse.
As for those who do want to move on to other things, why should they be condemned for it? Nursing must be the only profession on the planet where education, ambition, drive and a desire to advance oneself would be considered vices. How would Dr Crippen react if he was told he should have remained an SHO and not sought to move on to anything higher? As for the Daily Mail journalists lambasting “too posh to wash” nurses, what would their response be to any suggestion that they should return to being Assistant Proofreader at the Monmouthshire Gazette?
On the subject of the Daily Mail, why do nearly all journalists have a degree, and often a postgraduate qualification as well? Surely all you need is to be able to write reasonably well, and to have a practical mastery of shorthand and typing? Why not simply complete a practical course in journalism skills?
I would imagine that the response of any journalist reading this would be that their BA in English and their MA in Journalism have taught them how to analyse and assimilate information, how to read critically and how to communicate effectively in both oral and written form, and that this makes them better journalists.
Fair enough, but is the above also not true of nurses?
To answer this question, I’ve devised a little exam paper, which you can find below. Pick up your pencils…..now.
UNIVERSITY OF ZARATHUSTRA“TOO POSH TO WASH” NURSING EXAM
You have one busy shift as nurse-in-charge of a hectic psychiatric ward to complete this paper. You will also be required to ensure that all personal care and feeding tasks are completed correctly for every single patient on the ward, administer all medications, update all nursing notes, de-escalate aggressive and agitated patients and answer a series of phone queries from the sublime to the ridiculous.
While answering these questions, you will be interrupted constantly. If you disappear into the office to work on them in peace, a HCA will knock on the door ten minutes later to tell you that a fight is breaking out on the ward. At some point in the exam, the examiner may ask you to answer three of these questions simultaneously.
Required Pass Mark: 100%
1. You have to feed back the progress of seven patients to the ward round. Identify the relevant information that the multi-disciplinary team needs to know, and present it in a sufficiently concise way that people don’t start nodding off. Be prepared to justify your statements in front of a roomful of professionals.
2. A patient is appealing against his section.
(a) Complete a full nursing report for the Mental Health Review Tribunal. Identify all relevant information and build a comprehensive argument to justify why this patient needs to be on section.
(b) Now read back through your report and find the one single isolated sentence that the patient’s solicitor will seize upon and use to utterly destroy your argument.
3. You are about to administer an injection of insulin to a patient with Type 1 Diabetes. You check his blood sugar levels first, which turn out to be 2.5 mmol/l
(a) What does this mean?
(b) What do you now do?
4. A patient tells you that the psychiatrist has prescribed him Olanzapine. He wants to know what this is for, and what the side effects are likely to be. What is the answer, and how might you explain this to him? When answering, bear in mind that the patient is deeply suspicious of you, and believes you to be part of a giant non-specific conspiracy.
5. A patient is being prepared for discharge, but will require a care package when he returns to the community. His social worker dumps a form the size and shape of the Yellow Pages on your desk and asks you to complete the relevant sections.
(a) Identify which sections of the form are relevant to you, and which can be safely left to the social worker and the OT.
(b) Then identify the patient’s future care needs and construct an argument that he will need support to achieve these needs. Note that failure to argue your case persuasively enough may result in the patient not getting the care package.
6. A HCA tells you that he thinks a patient might be starting to have an oculogyric crisis.
(a) What sort of things are you looking for to confirm whether the HCA is correct or not?
(b) If the HCA is correct, what do you now do?
7. Your ward manager wants to introduce regular motivational interviewing sessions on the ward, and wants your help in implementing this.
(a) What research evidence is there for and against the efficacy of motivational interviewing in your particular field of nursing? Having found the research evidence, use this data to go back and tell your manager whether or not you think this is a good idea.
(b) What obstacles might you encounter in trying to implement these sessions on the ward? How might you overcome this?
8. The new Mental Capacity Act has just come into force. How might this major piece of new legislation affect consent issues on your ward? Bear in mind that failure to gain valid consent for any procedure from administering medication to giving somebody a bath renders you liable to criminal prosecution for battery.
9. You are administering medication to a patient on Section 3 of the Mental Health Act. As you do so, you notice that the Responsible Medical Officer has completed the Certificate of Capacity to Consent incorrectly.
(a) What do you now do?
(b) If you fail to do (a) correctly, what are the direct legal and professional implications to you personally?
10. Your local NHS trust has just installed the new electronic patient records system in your ward office. Teach your ward manager how to find his way around the computer and navigate through the new system to find the information he wants. Bear in mind that your ward manager is computer illiterate to the extent that he would struggle to successfully operate an etch-a-sketch.
All the above are scenarios that an average staff nurse would come across on a daily basis. Not a research nurse. Not an advanced practitioner. Not a ward manager. A regular, common-or-garden staff nurse.
Given the sheer amount of information in these scenarios that have to be remembered, assimilated, analysed and communicated, I’d say the kind of analytical and critical skills learned as part of a university degree are absolutely crucial to that a nurse in this day and age.
Right enough. The Daily Mail stance is an abomination against rational thought.
My primary concern is that making nursing a degree only course would prevent some potentially excellent nurses from applying in the first place. Some of the comments have pointed out that the Universities are trying hard to encourage a variety of people to become a nurse, not just those with a high standard of academic qualifications. So that’s good.
Looking at the questions though they almost all seem to be covered by the standard HND qualification and experience. Some things can be taught others can only be learned.
Question 7 would probably be better done by someone that had done the degree
Question 10 is just an excellent excuse to spend lots of time in the office … being interrupted by HCAs!
It is an excellent sample of the day to day activities of an RMN.
I think my answer would be have both the degree and the HND course. Have the degree graduates start a couple of points up the pay scale to start with. To reward them for their extra investment of time and effort.
Anyway that’s me done on this topic. Back to my sitcoms.
ZARATHUSTRA
Excellent! Excellent!
I could not have put it better. If you asked ‘Joe public’ what do nurses do?
and what qualifications do they need?
They wouldn’t have a clue!
Oculogyric crisis! good one, never actually witnessed one but have heard some of y colleagues mention how frightening it be.
Excellent exam paper, one which Crippen could not pass.
I’ve only ever seen one oculogyric crisis, and that wasn’t a particularly severe one. Still, it gave me a few pointers about what to look for in future.
A psychiatrist I know is convinced that in a couple of years olanzapine, risperidone and quetiapine will all have been banned, and we’ll be back to using chlorpromazine again. Guess that means we can all look forward to some juicy oculogyric crises in a couple of years then.
Advanced Practitioner, your colleagues are absolutely correct. The one I saw (walking in circles, falling over furniture, dribbling, eyes facing the back of the skull) made me glad I was wearing brown trousers.
Loved the test – send it to the Daily Mail, but mark it “Elementary Nursing Test”.
Lovin’ your work Zarathustra.
I was one of the first degree graduate nurses and I have to say it has helped me not a jot in advancing my career. Nor has it precluded me from wiping arses, making the tea or mopping the floor when it was needed.
But it taught me to question everything. And to ensure that everything I said and did could be supported by evidence and justified as good practice too.
As my 4th year mentor said – degree nurses have the evidence-based theoretical background of the P2K nurse, suppprted by the practical training of the traditionally trained nurse. He meant it as a compliment and I take it as such to this day.
My primary concern is that making nursing a degree only course would prevent some potentially excellent nurses from applying in the first place
This concern is often trotted out. I don’t care3 about them, is the easy answer to that. What about those potentially excellent nurses who would be turned off from applying for a course because it WASN’T at an academically challenging level? I’m rather tired of worrying about – for want of a better word – dullards, and would much rather we recruited sharp-minded, academically-able candidates.
This is, of course, not the politically correct response to your concern that I would give at a departmental meeting :-s
Beakie
I’m rather tired of worrying about – for want of a better word – dullards, and would much rather we recruited sharp-minded, academically-able candidates
I believe what you meant to say was, “Given your excellent people and practical skills but difficulties with academic study, I think you would be well-suited to a role as nursing auxiliary or support worker.” Right?
Yes, yes, that’s exactly it Z – that management module taught you well!
Well no, not dullards (or excellent people with …) they plainly would make poor nurses
They would end up dropping off the course. Become HCAs, tell everybody they learned you need to know about practical nursing and proceed to lovingly tend the giant chip on their shoulder. Every ward has one!
Sharp minded and acacdemically able do not always go hand in hand. All I am saying that if the course went to degree only that there should be pathways set up to allow those with limited initial academic skills a chance to get on the course.
When I did my training there was an Access to Nursing Course that was a particularly good example of this. A six month course for older people sharp minds and more life experience than academic qualifications that, if passed, got them a place on the nursing course. Plenty of time to weed out the dullards and support the sharp minded.
Diploma or Degree does not have to be an either or set up. It is perfectly practicable to offer both courses at the same time. The University bods are meant to be clever, they can work it out
I think we have to accept that certain combinations of very inexperienced docs & nurses [or burnt out experienced staff] can have dire consequences for patients.
Knowledge can minimise risk [to a certain extent, anyway], ‘knowledge’ as they is ‘power’.
If nurses wish to advocate on behalf of patients, or understand complex [and combined] psychological, phsyiological, and even social problems, wouldn’t it be helpful if they understood the growing mountain of research evidence – and implications for practice ?
Look at some of the crazy psychiatric ‘treatments’ from the not too distant past, ‘insulin coma therapy’, ‘dialysis’ [to cleanse the blood of toxins thought to be implicated in schizophrenia] not to mention the dreaded ‘lobotomy’ – how many nurses would routinely subscribe to such practices nowadays – presumably they were complicit in the past because doctors told them what to do ?
Will there be similar controversy in the future from todays practices, such as irreversible drug induced tardive dyskinisia ?
For some the ‘quacks’ have become unpopular with docs & nurses alike but the fact is they are simply product of extensive post-reg education, combined with years of experience.
Funnily enough nobody seems to mind when nurses cross over into a senior managerial posts [our Trusts CEO is a nurse] but do seem to have a circumscribed view about which clinical activities are appropriate.
I might be wrong but my guess is that in 20-30 years time nurses will be scratching their heads when they look back at the ‘university’, or the ‘quack’ debate thinking ‘what was all the fuss about’ ?
” They would end up dropping off the course. Become HCAs, tell everybody they learned you need to know about practical nursing and proceed to lovingly tend the giant chip on their shoulder. Every ward has one!”
Yes they do!
“I wanted to be a RMN, but I didn’t want to be in the office doing paperwork all day” is a common come back!
“Diploma or Degree does not have to be an either or set up. It is perfectly practicable to offer both courses at the same time. The University bods are meant to be clever, they can work it out
”
My University do this. Although there are talks of scrapping the Diploma, my Uni have the belief that it *would* alienate potential good nurses from applying. Therefore it is to be further debated in the future.
It is no easy task deciding who would be good at the job by looking at qualifications (or lack) of, and 1 interview really.
Everyone [should] know that for many reasons a person may not have acquired decent grades at school, but that does not make them dumb or unable to study for a nursing degree.
As for the journalists, surely some tabloid journalists only need 1 class on:
“How to make the most innocuous information sound dramatic and sensational”
oooooooh!
Fabulous argument and post you give there Zed.
(p.s. I can’t answer 3, perhaps I should go and read up!)
This is a fabulous post to go to the BritMeds, but the arguments that would inevitably follow may be lacking as Dr C is on a break.
hmm
I forgot to add in my previous comment, that at the moment, the students who qualify with a Diploma almost always go on to study for their degree within the first year of qualify, at extra cost to themselves.
In Mental Health in my area, a degree is not necessary to secure the position you would wish, so there must be another reason all students think the degree option is better. Even for those not deemed “sharp” enough to gain it first time round.
In Wales they’ve already gone down the degrees-only route. To be honest I suspect that it’s only really a matter of time before the rest of the UK follows suit.
To me, one of the compelling reasons to do so is that if you need a degree to be a physiotherapist or an occupational therapist, but only need a diploma to be a nurse, this implies that nursing is less difficult than physiotherapy or OT. This in turn can and does affect our status as a profession, and the quality of applicants we get.
I agree with Beakie that it’s less important to avoid putting off the less able candidates than it is to be attractive to the more able ones.
I agree in theory, but to get the students in in the first place isn’t so easy. There needs to be a mixture.
Perhaps when Nursing is still viewed as a “vocation” it is irrelevant to be compared to OT or Phsyio?!
Oh, and Bloo, the answers to question 3 are:
(a) The patient is in hypoglycemia.
(b) I’d give him 3 tablets of dextrose or, if his level of consciousness is deteriorating, squeeze some Hypostop gel into his mouth. I’d then offer him some food such as a banana or a sandwich. I’d remain with the patient until the symptoms of hypoglycemia have disappeared, then check his blood sugar again. I’d delay giving the insulin injection until his blood sugar has increased to above 4 mmol/l.
As it stands at the moment, you have diploma nurses coming out of uni having barely scraped through every assessment and assignment at a capped 40% after about three or sometimes more attempts at each. There’s no way they are as capable as degree students who get a first. However, both of them will be paid at band 5 at their first post-qualifying job. I think the current system is unfair to both sets of students.
I would much rather they had a real option – to go to uni for two years, step off then and come out with a useable qualification that could see them working at – say – band 4.
It’s a return to the old EN course by any other name, I’m aware of that, and there were problems with that old system, not least of which was the over-representation of black and minority ethnic people among ENs. However, I can’t see that the current system being sustainable either.
How many diploma nurses actually manage to scrape through the whole course using all the re-subs allowed?
Surely there are students who scrape on one or two exams or essays, but not for all, same as there are degree nurses who scrape through as well?
If I get a degree, it will be a degree, no distinction between a 2:1 or 1st for example. Does this mean I will be a lesser nurse or am less able?
(I do not scrape through either fyi)
I have worked with highly academically able nurses who are a bit crap on their problem solving and interpersonal skills, but could ace any coursework thrown at them.
I agree nursing should be to degree level, I do not agree that everyone who goes into nursing has to be of a very high academic level, as I feel you are suggesting
Sounds to me like you’re doing a BSc unclassified, which is different and less academically challenging than an Honours degree.
In order to get a First in an Honours degree course, you have to work bloody hard, and you have to show some academic AND practical abililty (given that 50% of the course is marked by practical assessment). Students who get that are clearly more capable than those who scrape through on multiple resubs (at whatever level).
I haven’t worked with many nurses who are crap practically but good academically. Very few. Generally, the ones who are crap academically also tend to be plodders practically. That may sound harsh, but in my experience, it’s true. I see no reason to try and attract more plodders into nursing.
My experience is different. I have worked with both. Yes there are nurses/students who are neither bright practically or academically, but there is a mix of both out there.
Are you saying I will be a sub-standard nurse who didn’t have to work as hard because I am not doing honours?
It came down to convenience and finance for me. Nothing to do with academic quality.
Are you saying I will be a sub-standard nurse who didn’t have to work as hard because I am not doing honours?
No, I’m simply pointing out that your degree does not entail as much work as an honours degree.
Ahem! Just come back from number 5 of 5 chaotic late shifts from hell. I know I have not stopped doing STUFF, I know I have not been able to spend enough time with patients just getting to know what is going on for them, and your post Zarathrusthra just sums it up excellently. I might add that I have also had to be receptionist for 2 wards and the crisis team, because reception is short staffed, been covering the crisis out of hours ‘phone, because they are short staffed, and simultaneously doing a one to one and all the general ward checks, beacuse WE are short staffed! I get home and try to work out what I have done, and why I feel I have not done my job. . . I love your post, it reminds me of all those things and more I have been doing.
Sounds to me like some people were using you rather unfairly, olanzapine.
This post is now on the Britmeds over at Dr Rant
http://www.drrant.net/2007/08/.....33_19.html
From the way the comments thread is going, I fear I may have inadvertently triggered yet another blogfight, this time with the nurses going on the offensive.
Oops I did it again.
I read the britmeds. What does it tell you when the only comments are about this post, nothing at all about the other links on the blog?
I don’t think anyone on there is saying degrees are a bad thing, but have swung in another direction blaming government for staffing levels (13 to 1 is absolutely ridiculous) rather than blaming education.
I quite agree with one of the anonymous posters who said
“Of course people like Dr. Crippen, Dr. Rant, and the illiterate twunts at the daily mail are incapable of making these kinds of connections. Dr. Rant probably doesn’t even read these comments.
I can’t believe that these f*cktards think that nurse training and nurses’ attitudes have led to the mess we are in regarding nursing care”
I have no idea who said it, but it sounds pretty true to me.
Also, why does Dr Rant link himself/their blog with Dr Crippens view? It’s almost like reading as if Dr Crippen posted.
Oh God. I really didn’t want to get involved in this but in the absence of OSB I guess it’s down to me to speak up for the dinosaurs like me who have never been any closer to a univeristy than watching Paxman sneering at the oinks on a Monday night. Not being an academic I can’t forward an objective argument, so I’ll just chuck in my subjective opinion to balance the books as it were and await the flak.
I’m very confused here. You lot are arguing that nurses nowadays are NOT “too posh to wash”. Isn’t it a constant theme on this site that too many staff nurses hide in the office avoiding contact with the patients and only a small proportion are motivated to be involved in direct patient care? I’m not siding with the Mail or Crippen but just viewing this from the Mental Nurse perspective as I see it. The fact that you folks are here posting and debating in your own time suggests you are more committed than most. While I understand the sentiment that there is much more to nursing nowadays than wiping arses, I thought previous discussions had evolved into a a kinda consensus that an essential ingredient for a skilled nurse was someone with a naturally caring, sensitive nature as well as an education. Although they are in the minority, I’m sure we’ve all met highly educated nurses who are complete ruthless, insensitive bastards. I’m not saying nurses shouldn’t be educated to degree level but I am hoping that this isn’t the start of a call to war akin to the old RMN versus EN day.
In response to the exam thing. I don’t have a degree nor even a diploma, just an RMN college course. Despite this I was trained to recognise oculogyric crisis, the main difference being a “not too posh to wash” nurse was that my first experience of this I spotted myself rather than being told by a HCA, as I was on the shop floor. As for RMNs dealing with diabetes or other physical illness, lets just pray they get a district nurse in. I can think of loads of badly and often dangerously managed physical illnesses by RMNs (with and without degrees) but a typical experience is arriving on a late shift and finding 3 RMNs (two had diplomas, one a degree) arguing and perplexed at how to set up a syringe driver when all that was required was basic arithmetic (some folks confuse education with intelligence). As for the mental health act questions, an intimate knowledge of the English act will be of litle use to you if you get a job in Glasgow or Edinburgh.
A few years ago I returned to psychiatric nursing after a few years in general nursing. First day back, I was the only RMN on the night shift, given a 15 minute handover and left in charge of an admissions unit. I was apprehensive to say the least but the HCA’s gave me some helpful background info. Things went downhill when I started the 10pm meds. I opened the drug trolley expecting to see the old familiars… Chlorpromazine, Trifluoperazine and Haloperidol… nope… there were new drugs I’d never heard of Olanzapine, Risperidone and Quetiapine. I didn’t go on a university course, in a quiet period of the night I read up all about these drugs and by morning could have confidently answered questions about all of them. My second night I was asked to prepare patient summaries for reviews the following morning. Using a combination of spending time with the patients, observations and reading their recent nursing notes I was able to do a reasonable job of this. I was shocked to see different section numbers on the office board, the mental health act had changed since I last worked in the bin but the principles were very much the same. Even if I had previously completed a degree course, it would all have been outdated and irrelevant. The admin and paperwork side of things had also changed but the nursing care had not. I was able to quickly identify a guy becoming acutely paranoid and support him with confidence. The situation escalated during the night when he had olfactory hallucinations of petrol and was desperate to get out of the building. Eventually I had to phone the duty doc who asked me “What do you think I should I prescribe?”, some things never change. What I’m trying (badly) to say is that the most important things in being an effective staff nurse were intelligence, motivation, my basic understanding of mental illness and previous years of experience of supporting people, not academia.
In my subjective and uneducated opinion, the fundamentals of mental illness are pretty simple and can be learned in a few hours. The last place I worked in the bin was a dementia unit. I did a 1 hour traing session on dementia with a small group of HCA’s, outlining different types of dementia. Then spent the next few days working with them and the patients. The HCAs were soon able to identify who had multi infarct, who had lewy bodies, etc and outline problems specific to each. Dealing with these problems confidently only comes with experience. Dealing with them successfully, you need to be sensitive, positive and motivated.
It would be an absolute tragedy to have division among nurses that used to exist between RMNs and ENs. I remember the animosity only too well and God forbid that it rears it’s head again.
(PS. Does this spiel get me an honorary degree?)
Will there be examinations on emotional intelligence, social skills and humour? Seems to me that they might be more useful than the ability to write a good bibliography.
Mo said: “some folks confuse education with intelligence”
How very true. The difference with you being a good, caring nurse, isn’t the degree or lack of degree, it’s the intelligence and motivation as you said.
I don’t believe intelligence can be measured in qualifications alone, which is why I don’t think Nursing Degrees should have standard University entrance requirements as this has the potential to alienate inteliigent people without the qualifications.
Nursing is not a “standard” job.
Mo, I would give you an honorary degree, but I am not qualified to do such a thing.
That would be an ideal olanzapine, but how would you start to test these things effectively?!
Azulinebloo, I would start by secretly film nursing handovers and count how many times the word “behaviour” was used and the context/tone!
It is one of those expressions that riles me. Everything we can observe a person doing is “behaviour”, yet nurses seem to use it in a different and derogatory way. I’m sorry I can’t remember who posted it, but it is like the thought experiment someone on this blog tried of substituting the words “personality disorder” with “arsehole”.
But, I am wandering off topic, so I’ll hush for now!
In my subjective and uneducated opinion, the fundamentals of mental illness are pretty simple and can be learned in a few hours.
I couldn’t disagree more. I’ve been a psychiatric nurse for nigh on 15 years now, and I learn more and more every day.
It’s highly laudable to hear that your still learning beakie. However, in a strange way you kind of bolster my argument. Despite all that education you failed to interpret a simple sentence that I’m sure even a lay person could understand. The basic “fundamentals” did not refer to the all encompassing accumulated science. I’m sure you could give a one hour talk on schizophrenia to a group of students and provide them with a fairly good understanding in that short time.
Sorry if I failed to get my point across. I was trying to say that a huge proportion of my nurse education (treatment, pharmacology and law) had became irrelevant during my gap years. However, having a basic understanding of say schizophrenia, I was quickly able to bring myself up to speed with current protocols without undergoing some graduate course.
I’m trying not to sound like a luddite and I don’t think nurses should be looked down upon or denied a university education. But while subjects like genetics and biochemistry are relevant and fascinating, I don’t think being unable to excel in these areas should bar a skilled nurse from practice.
I wasn’t talking about the all-encompassing accumulated science. I was talking about the fundamentals – such as “what constitutes a mental illness anyway”. I would be kidding myself if I thought I could “give” students anything more than a superficial understanding of schizophrenia in an hour.
Our students don’t have to excel in genetics or biochemistry. They have to be competent at NURSING.
…excellent piece Z and I know that this comment is shockingly late but have only just read this – not sure why. Your statement about journos and qualifications: many years ago, journos didn’t have degrees in journalism, nor MAs in journalism – they did basic journo courses and covered things like shorthand, legal matters including libel and etc – this was back in the day when nurses didn’t do degrees either – and neither did teachers or occupational therapists. There was a time when teacher training could be done by the old Cert.Ed – 2 years in a college – OTs did their stuff over 2 years and SRNs did their stuff over 3 years. it’s not just nursing that’s changed – the whole educational and training structure has altered in the last 40 years – I am not here to discuss the rights and wrongs of it – I just want to point out that when we get the rabid commentators arguing against degrees for nurses that they really need to look at the whole training and ed spectrum. About 20 years prior to what I’m talking about female nurses and teachers had to give up working once they married – maybe everyone who argues against progress, against nurses working to a degree programme, would like us to return to that situation.
[...] week I posted my little mock exam paper to show why I think the “Nurses are over-educated and too posh to wash” brigade are [...]