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Why does fear and loathing surround nursing degrees?


As a sometime historian, I might be forgiven for the sense of deja vu listening to the hysteria surrounding the move to degree entry for nurses. What is it about nurses and degrees that polarises opinion?

No other profession has to defend itself against the absurd accusation of being “too clever to care” or “too posh to wash”. These arguments belong to the 19th century and should be consigned to the dustbin of history.

Darwin’s evolutionary biology was used by doctors and scientists to argue against the higher education of women on the grounds that energy required for reproduction would be diverted to the brain, damaging their fertility and the fitness of the race. Under this theory, growth and development had to be reconciled with energy expenditure and conservation. Thus, any energy required for intellectual exertion would deprive other areas of supply.

Fears of “brain-forcing”, malnutrition of the cortical cells and neurasthenia were afflictions caused by overtaxing the brain through education. Indeed, the ability of women to be educated was determined by the smaller size of their brains, often observed in postmortem studies of the insane. Fatigue, fear of exhaustion and the enforced idleness that governed women’s lives was what Florence Nightingale railed against in her feminist tract Cassandra.

‘You wonder, when hearing antediluvian opinions about nursing degrees, whether they were the work of the devil or whether you’d been teleported back to the 19th century’

Of course, the application of this theory was highly selective - it did not affect the majority of working class women employed in factories or domestic service.

The fear of overeducating women was that women would be “unsexed” and unfit for marriage. The picture of the “bluestocking” was one of ridicule, the shrivelled spinster, oblivious to her appearance and repulsive to men. Thus it was middle class women who led the charge to open the professions to women and who were vilified in turn for daring to storm the citadel of medicine. Their physical delicacy was derided as making them unfit for the dissection room. By contrast, it was women’s proximity to nature in nursing which was perceived by medical commentators as the ideal prelude to marriage and motherhood.

The point of the above is that both class and gender attitudes continue to shape public perception of nurses’ ability to be educated. Attitudes are slow to change but now medicine admits more women into the profession than men.

Yet, you wonder, when listening to the antediluvian opinions expressed about nursing degrees, whether they were the work of the devil or whether you’d been teleported back to the 19th century.

Nurses’ brains are not shaped like bedpans. That doesn’t stop the power of nostalgia, however, pulling us back into our comfort zone, the “good old days” of yore at times of threat or rapid change.

The public perception that poor care is caused by nurses being better educated needs to be challenged. But it is not better education which is the cause. On the contrary, evidence demonstrates that better educated nurses deliver higher quality care.

The problem is how care is organised, whether it enables nurses to spend time with patients, their families and loved ones. We need nurses with the skills and capabilities to champion care and respond creatively to the challenges of tomorrow. And, believe me, these challenges are some of the greatest of our times.

The sheer scale and speed with which we need to meet that challenge needs clever hands, hearts as well as heads. We are at a critical juncture where we face a double squeeze - a squeeze on care combined with an economic squeeze. This combination is potentially combustive unless we respond quickly and with all the ingenuity we can muster. We need a strategy for investment, innovation and the will to succeed.

If we can put a man on the moon, surely we can crack the quality of care. If we can tackle climate change, surely we can implement care standards. If we can break world records in sports, be world class leaders in the creative industries, surely we can provide truly world class care.

We cannot achieve any of this alone. We need to work creatively and in collaboration with patients, carers and families as well as other professionals, policymakers and managers. To achieve this, moving to degree entry is a must - not apocalypse now.

The world has not collapsed in countries that have already taken this path, such as in the rest of the UK and much of mainland Europe. There has been no choking off of applications. Far from it - applications and recruitment are up, in keeping with the trend in other professions, notably teaching and social work which have also raised the bar.

Furthermore, the students I meet are an inspiration and a source of hope for the future. They are a credit to the profession and the public. Letters from grateful patients testify to the high standards our students achieve. We have much to be proud of.

Perhaps our greatest enemy is not the prejudice and ignorance of others but our own internal fear - fear of what to do when the blindfold of prejudice is lifted, when we have no one to blame but ourselves. Let us lead the charge and light the path ahead. Let not Cassandra call us back and say: “I told you so.”

Anne Marie Rafferty is dean of the Florence Nightingale School of Nursing and Midwifery, King’s College London


Readers' comments (13)

  • As a history nut and a Nurse I think I love you.

    There is enough research out there that shows us that a more well rounded and high level of education for nurses leads to better patient outcomes. Patients have higher survival rates when there are a higher proportion of degree educated RN's at the bedside, doing all the care.

    The media has always depicted nursing as merely a caring profession. There is a lot more to nursing than just caring.

    When we focus on the angel thing to the exclusion of all else we leave the public in the dark about what we do. And the average person's mind is already warped about nursing, thanks to the way we are depicted in the mass media.

    You can see evidence of this in reading a lot of the online discussions about degree training for nurses. People do not understand what a bedside nurse is or does. They cannot see the woods for the trees. Unlicensed support workers were brought in to do basic care because no one realised just how important it is for a well educated RN to do basic care so that she can assess her patient. The RN is left running her tail off, taking short cuts trying to do all the meds for 30 patients because she is the only nurse.

    The degree doesn't help an RN be wonderful when she finds herself the sole nurse for 30 patients with care assistants only to assist. No nurse could handle that well, even with brains, caring, and a strong work ethic.

    We need well educated RN's at the bedside with a manageable number of patients and good back up.

    Currently many large wards are staffed with 1 RN, a student who is not allowed to do as much as nursing students did years ago because of liability (not university's fault) but rather our sue happy culture) and two care assistants only all shift. This is where the problems lie. It is not nurse attitude or education that is the problem.

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  • This is a joy to read but like many comments there is much rhetoric and little substance.
    How do we empower nurses to lead the fight, take charge and light the path. No one denies that this needs to happen but at the moment the voices of our leaders are absent from the debate. I suspect we need a modern day Florence- are you up for the challenge Professor Rafferty?

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  • I think you're missing the point. Maybe this is deliberate but maybe not. The issue is not about whether nurse training is primarily clinical (hospital based), or primarily academic (university based). It is about whether nursing staff who do clinical work will have control over the quality and content of nurse training or whether this will be handed over to out of touch, academics. I've seen the outcome at first hand. I'm a British mental health nurse currently working in Australia. The change to degree training was made here several years ago. The academics who control nurse training here have reduced the mental health component to three weeks out of a three year course. At the end of their degree based nurse training in Australia mental health nurses know as much as you would expect them to know after three weeks of training. They're unemployable but of course they have to be employed because there's no-one else to employ. They have no choice in practice but to become doctor's unquestioning assistants. Their working day is limited to giving out medication and restraining people because knowledge and skill are required to do anything else. This is the real reason for concern about academic training replacing clinical training. Universities are not as closely in touch with what is really needed as clinical staff and they have their own agendas, beliefs and eccentricities. Specialist areas within nursing are the most likely to lose out over time as the universities adapt training to meet the needs of the university.

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  • It is something of a generalisation to state that all academic teachers of nursing are either out of date or eccentric; all have been clinical nurses and the vast majority continue to work in practice but, in addition, most have a much greater - and in depth - knowledge about the topics that they teach - and an insight into current research and the evidence base for practice. Perhaps the failure - if failure there is - lies more in failing to clearly draw the links between theory and practice - and the ability of senior clinical staff to build on or capitalise on the skills, knowledge and expertise of graduate nurses?

    Furthermore, many innovative and creative ideas in nurse education are blocked by the restrictive practices of the NMC who dictate the content of courses and their assessment. It is time out governing body rethought its own attitudes to education for practice.

    It is surely time that the problems were scrutinised as a whole and not in part as is evident from much of the narrow boundaries of the discussion. It is not about graduate vs 'other' nurses but about what the students are taught and how they are encouraged to apply that knowledge; clinical staff ARE involved in determining curricula but often without the underlying knowledge to support their decisions. Leave it all to the practitioners and there will be as many - albeit different - problems as there are today.

    Professor Rafferty is right - many of the problems and fears we experience are generated by Celstine prophecy. Think the worst and that is what you get! Alongside stronger leadership, we need some positive thinking - that may be all it takes it improve the lot of nurses.

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  • Hey - what's a few extra modules to study? Cummon people - it's not that taxing is it, really?

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  • In the day of cutbacks and so much talk about employing less qualitifed nurses to reduce costs where will nurses with degrees find jobs to match their level of education, who will employ them and how will they be renumerated?

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  • Hi Anonymous,

    I think you're missing the point. Why does this surprise me about someone who quotes from the Celestine Prophecy? However wonderfully academic you think your opinions/theories are, the evidence is that what you're suggesting does not work. I am working in a country that has already gone down this path and it's a disaster. I can only speak from the perspective of psychiatric nursing but this has been killed as a profession in Australia as a result of the move to university led nursing. The university curriculum is dominated by general nurses and the usual failed clinicians who become academics. For heavens's sake, before you try this experiment, please check the existing evidence. There's lots of it. Australia has already made this mistake. So has New Zealand.

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  • Nursing needs to regroup. There should not be adult or children's training and neither should exclusive community nurse training be developed. Nurses should spend three years learning to nurse to diploma or degree level, following this they can continue to consolidate general practice or specialise and gain a degree or post graduate degree in their chosen field. The constant fracturing off of nursing is not good for a profession's strength or development of fundamental professional knowledge.
    There has always been nursing degrees and it has been presented in the press as if this is a new idea. I don't believe that you need to start nursing with a degree but you do have to be better educated than some (not all) students I have met.

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  • i feel that this issue is misunderstood by academics who are actually pushing their own agenda without looking at the needs of nurses or their patients.

    without practical experience on which to base academic exploration the time spent in academia is a wasted exercise....there can be no personal eureka moment for the inexperienced nurse.

    you need the basics which is that;at the heart of nursing care your relationship with your patient is what counts. if you don't get it or can't do it you can't nurse and a degree won't change that.

    we need nurses who can nurse and then access academia to advance their skills not the other way round.

    P.S. the celestine prophecy and the following numerous books are only of value if you run out of toilet paper. unless you are the increasingly wealthy author :)

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  • Doesn't matter much whether it's a diploma a certificate or a degree if the content and the teaching quality is confusing and irrelevant. The great lesson of Project 2000 'a space odyssey' is that if your going to teach sociology and health psychology to nurses then please get experts in those fields to teach it to them and not some nurse without a M.Sc. or P.hd to rattle through these important subjects after skimming through the book the night before. Clowns.

    Also please try and teach your students some anatomy and physiology /pharmacology - at least to 1st year of degree level. It might save a few lives on the wards. Like everyday.

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