Career guidancefor student nurses: an unmet need

Career guidance for student nurses: an unmet need Louise Marsland Career guidance is important both organizationally and for the individual, especially at a time of re-emerging concerns about retention, and increasing complexity of nursing careers due to rapidly changing systems of health care provision. A questionnaire survey of I 015 newlyqualified registered general nurses explored their experiences of career guidance whilst students, in relation to three areas: • applying for first post • taking post-basic courses • longer term plans. Findings revealed that few students were provided with guidance. Furthermore, a substantial unmet need was demonstrated, especially in relation to discussions about individual career planning.

INTRODUCTION

Louise Marsland BSc, RMN, Research Associate, Nursing Research Unit, King's College, London

University, Cornwall House, Waterloo Road, London SE I 8WA, UK

(Requests for offprints to LM) Manuscript accepted I 0 October 1995

The management of nurses' careers is important both organizationally and for the individual. At an organizational level, mairttaining sufficient numbers, and the management of inter and intra-organizational mobility is essential for the maintenance of quality care (Cole 1993). For many individuals, career progress is central to personal morale and job satisfaction (Mackay 1988, 1989, Mercer et al 1976). Career guidance therefore has a potential contribution to make at each of these levels?

Career guidance and retention The importance of career guidance in nursing was recognized nearly 50 years ago by Cohen

NurseEdocationToday(I 996) 16, I O- 18 © 1996PearsonProfessionalLtd

(1948), and his call for provision has been echoed in documents such as 'The Way Ahead' (Department of Health 1988). Recent decades, however, have seen a lack of attention to strategies that may contribute to the retention of nurses, since the workforce has been maintained by a 'constant replacement system' (United Kingdom Central Council (UKCC) 1986); those who left and did not return were replaced by a ready supply of new entrants to training (Committee on Nursing 1972, Mercer 1979, Price Waterhouse 1988). During the 1980s, demographic changes in the population structure indicated that the mid to late 1990s would see a reduction in numbers of schoolleavers, and that the National Health Service (NHS) would thus have a smaller pool of potential recruits upon which to draw (National Economic Development Office/ Training Agency 1988). Although the potential impact of the so-called 'demographic time bomb' on the nursing workforce was obscured by the economic recession of the early 1990s, more recently, reports have emerged that some parts of the country and some specialties are again experiencing a shortage of nursing staff" (Naish 1995). Furthermore, concern has extended to the potentially adverse consequences of attrition among experienced staff, and the loss to the health service of their years of accumulated knowledge and skills. Suggested approaches to maintaining the nursing workforce in the 1990s have focused on three strategies: • targeting alternative sources of labour for recruitment • offering opportunities and facilities to encourage re-entry after a break from nursing employment • promoting retention by providing more attractive conditions of service and better prospects for career development (Pearce 1988, Vousden 1988, Worthington 1990). Thus, a place for career guidance once again exists on the agendas of those responsible for the nursing workforce.

Career guidance and the changing nature of nursing careers In 1994, Mangan commented that a career in nursing is often typified as that of a staff nurse, who after practising at this level for a number of years becomes a sister/charge nurse, before moving into management, education or the higher echelons of clinical specialism. This linear view of nursing careers, however, ignores the multifarious opportunities for nurses both within and outside the NHS.

Career guidance for student nurses: an unmet need

Opportunities for nurses are additionally complex due to considerable changes occurring in the NHS. The new managerialism introduced following the Griffiths Report (Department of Health and Social Security 1983) had a considerable effect on the traditional progression of nurses. General managers, who are not necessarily nurses, have the authority to redefine nursing, create new divisions of labour within health care teams and to rethink nursing's place in the newly created order (Keyzer 1992). Whilst some nurses have maintained their positions in middle management, the birth of the new business orientated culture of the NHS meant that the majority were squeezed out as hierarchies were flattened in a bid to improve efficiency (Mangan 1993). More recently, the NHS and Community Care Act introduced in 1990 has led to major changes in the organization and provision of the health services. This major reform has resulted in a number of developments directly affecting nurses; for example, health care trusts have greater freedom to introduce their own conditions of service, such as the appointment of staff on fixed term contracts. Furthermore, the increased emphasis on community based care means that more nurses will be required to work in this setting (Mackay 1989). A third maj or area of change is the introduc6on of the Project 2000 Diploma Course. This carried with it far reaching implications not only for nursing education but for the structure of the nursing workforce. The introduction of a single level of registered nurse, assisted by unqualified support workers and a small number of specialist practitioners suggests that the role of the registered nurse may become increasingly supervisory. Finally, an increasing emphasis on post-basic education and the number of post-basic courses available, together with the introduction of schemes such as credit accumulation, means that nurses need up-to-date information and advice about the post-basic requirements for their chosen career pathway. Guidance may help nurses to find their way through the new structures and opportunities that are emerging in the NHS and the profession more generally. Following research into the careers of senior nurses, researchers at the NHS Women's Unit (1995) comment 'the planning of nursing careers needs to be given higher priority, helping individual nurses to gain access to the education and experience required to meet their career Objectives'.

Research into career guidance Career guidance may then be an important component in improving retention and pro-

II

moting the careers of nurses, helping them to formulate and realize short and longer term goals. If nurses do not know about career opportunities, and have no facilities to discuss their future in nursing, they may fail to perceive feasible pathways to follow. Published research on career guidance in nursing is minimal. That which is available, however, indicates that qualified nurses rarely receive the guidance they require (Rogers 6: Lawrence 1986, Schober 1987, 1988, Winson 1992, NHS Women's Unit 1994, 1995). In relation to the training period, MacGuire (1980) referring her 1961 research, comments that the majority of entrants to training do not aspire higher than staff nurse grade and seem to have little concept of the possible career developments open to them. She suggests that advancement within nursing is still restricted by training choices made on entry, before the full significance of such decisions can be appreciated. Findings such as these highlight the urgent need for attention to be directed at guidance during the earliest stages of nursing careers. Little research has focused on this period, and the findings of one survey undertaken by Crofts (1992), reveal a picture of inadequate provision similar to that observed for trained nurses. O f the 90 second and thirdyear students from four colleges of nursing who completed questionnaires about their career guidance needs and experiences (a 75% response), less than half had discussed their plans with someone, and only 12% had been offered career advice. Seventy percent said that they would seek career advice before qualifying. In the same study, students identified the personal tutor as the member of staff whom they were most likely to approach, but the majority of the 21 nurse teachers (52% response) who were also questioned commented that they had never received career guidance themselves and consequently did not feel confident to provide it. The importance of career guidance during pre-registration education became apparent during exploratory work for a longitudinal questionnaire survey of the careers of registered general nurses. During a series of semistructured interviews undertaken to identify topics for the first questionnaire, sent at qualification, some newly qualifying nurses expressed a sense of desertion, of having been brought to the point of qualification and simply abandoned. Concern and anxiety about changes in the health care system and about how best to develop a career path through it were rife, and for those who had career aspirations, bewilderment about the best route to follow was commonplace. It was this strength of feeling, coupled with the dearth of related

12 NurseEducationToday

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research in nursing, that alerted the research team to the need for a detailed investigation o f this area.

METHODS The data reported in this paper were collected during the first phase of a longitudinal questionnaire panel survey of the careers of traditionally trained Registered General Nurses (R.GNs). Thus, aspects of the design were determined by the needs of this larger study.

The sample A cohort of 1164 nurses who qualified between September 1990 and August 1991 was recruited from all colleges of nursing in three regional health authorities. The three regions were purposively selected to provide a sample whose colleges together encompassed a wide range of educational and service experiences as well as a variety of student populations in terms of demographic characteristics and catchment areas. Sets were selected over the whole academic year as piloting had revealed some variation in characteristics o f entrants across the different intakes.

The questionnaire

IThroughout the remainder o f this article 'information provided' and 'discussions held' are referred t o collectively as 'guidance'.

The questionnaire was developed with a pilot group (n=112) who qualified six months ahead of the main study cohort. The initial aims of the research into career guidance were to ascertain what career guidance, if any, had been received during pre-registrat~0n education, its perceived value in relation to factors such as by w h o m it was initiated and whether it was received on an individual or group basis, and views about a number of issues arising from the hterature (for example, the best person to provide guidance and the rationale behind its pro~si~n (Hoyt 1968). Devising que}~ions proved problematic, however, and the aims o f the questionnaire were revised to focus on: • whether information had been provided on 17 aspects relating to three main areas o f

plans: applying for first post, taking postbasic courses and longer term plans, and whether discussions had been held about five aspects of individual career plans in these areas. • whether those who had been provided with information or had discussions had wanted more and whether those who had not been provided with information or had discussions had wanted some. • from w h o m and/or where information had been provided, and with w h o m discussions had been held. An example of the question structure is shown in the Box opposite. For discussion o f the difficulties o f designing questions on career guidance see Marsland et al (1993). The primary interest of the research was in whether guidance had emanated from an N H S health authority source. During piloting, attempts were made to include a list o f sources for respondents to ring; the diversity required, however, entailed more space in the questionnaire than was feasible and so the question was left open-ended. Responses were coded as guidance having been provided if one or more health authority sources were specified. If a non-health authority source only was specified this was coded as guidance not having been provided. The findings reported in this paper focus on two main issues that emerged from the data: guidance 1 provided and guidance that was wanted but not received.

FINDINGS The questionnaire was returned by 1015 members of the cohort, an 87% response rate.

Guidance provided about applying for first post Obtaining a first post was a matter o f considerable concern for pilot cohort members. Five separate aspects o f obtaining this post were identified; three focused on the provision o f information and two on discussions about individual plans (Table 1). The majority o f main study respondents (79%) received information about h o w to apply for their first post, and over half (54%) received details of posts that were available and for which they could apply. Fewer (37%), however, had information about the range of specialties in which it is possible to work as a newly qualified staff nurse. Just one quarter had a discussion about the specialties in which it would be helpful to gain experience in

Career guidance for student nurses: an unmet need

(n = 10~S) Aspects of applying for first post

%

n

How to apply tor first post

79

803

Vacancies (Le. available posts for which could apply)

54

551

Range of specialties in which could work as a newly qualified nurse

37

376

Specialties in which it would be helpful to gain experience in relation to future plans

25

25 i

Clinical specialties for which your particular skills might be most suitable

14

147

information about:

Discussion about:

N.B. The non-response for each item was lessthan 4%; all other respondents said they did not have the information or discussion specified.

relation to their future plans, and 14% on the clinical specialties for which their particular skills might be most suitable. Guidance provided basic courses

about taking

post-

Post-basic courses were defined as those for which nationally recognized certificates are awarded. Participants were asked if they had been provided with information about National Board courses, since a range of nursing career paths require completion of one or more of these. They were asked also if they had been provided with information about other post-basic courses, such as shortened courses for other parts of the register, and about educational opportunities outside the N H S (Open University or nursing degrees, for example).

13

Finally, they were asked if they had had any discussions about which courses would be relevant to their ideas about their own future. Table 2 shows that 37% of respondents said that they were provided with information about the various clinical courses offered by the National Boards, but far fewer had specific details of which courses were needed for particular areas of nursing and at what stage to apply. This latter point had been of particular concern to some of the pilot cohort who had no knowledge of the possible time period between application and start date; for some this had subsequently caused a delay to their plans. Only a minority of respondents had received information about other post-basic courses (18%), or about educational opportunities outside the N H S (28%). Just 17% of respondents had bad a discussion about post-basic courses that might be relevant to their particular ideas for the future. Guidance plans

provided

about

longer term

The eleven aspects of longer term plans explored included information about nine pathways open to nurses, and discussions about two aspects of individual plans. In Table 3, the aspects are grouped into three broad types: a) career development in the N H $ generally; b) specific pathways in five different areas of nursing (midwifery or health visiting) and c) working outside the NHS.

The most striking finding is the small number of respondents who had been provided with guidance about any aspect of longer term plans. Twenty five per cent had information about the range of careers available to qualified nurses in the NHS, but for all other aspects relating to career development in the N H S generally, and i~:~i~i~i~:~:~:!i~:#:~:E:~i~:~:~:~:zi~i~:~i~:!!~):::::::::::::::i~i~:~:~:.~:~i:~:~i~:~:~:i:~:!:#:~1~i~!~::~:~:~:~:~:~:::::::::::~¢i~i::i:~i~i~:~i~:#:~:~:~to:~:~:specific ~:~ pathways in nursing, midwifery or health visiting, less than 20% received any input. Information about specific pathways in the (n = 10tS) Aspects of taking post-basic courses % n five different areas of nursing (part b) showed that respondents were most likely to receive informaInformation on: tion about nursing education, although only 16% The various clinical courses offered by the National Boards 37 379 received this. Next was developing a career in e.g. ENB 216 stoma care clinical practice (12%). Information about develNational Board courses needed for particular areas of nursing 17 168 oping careers in nursing and general manageHow soon before starting date to apply for National Board courses II I 12 ment in the N H S and in nursing research were Other post-basic courses 18 182 each received by less than 10% of respondents. e.g. shortened courses for other parts of the register Working as a nurse or midwife in the forces Educational opportunities outside the NHS 28 283 was the aspect of longer term plans about e.g. Open University degree which respondents were most likely to have Discussion about: had information (28%); more respondents were Post-basic courses relevant to your particular ideas 17 168 provided with information about this than about your future about any career pathway within the NHS. Thirty-four per cent (342) of respondents said N.B. The nomresponse for each item was lessthan 3%; all other respondentssaid they did not have the information or discussionspecified. they had no guidance on any aspect of longer term plans.

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14

Nurse Education Today

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l

%

n

I

25

252

Areas of work within NHS for which your particular skills might be most suited

15

149

How you might plan your career in the NHS by step by step

I0

102

Clinical practice (e.g. starting as a staff nurse and working up towards a clinical nurse specialist post)

12

123

Nursing* education Nursing* management Nursing* research General management in the NHS

16 9 8 6

163 89 83 56

28 12 8

283 I 17 84

Aspects of longer term plans a) Career development in NHS generally Information

on:

Range of careers available in the NHS to people who have

qualifiedas nurses Discussionabout:

b) Specific pathways in nursing, midwifery and health visiting Information on how to developa career in:

c) Working outside the NHS Information

on:

Working as a nurse or midwife in the forces Working as a nurse or midwife abroad Opportunities for work outsidethe NHS for which RGN qualification would be relevant

N.B. The non-response for each item was less than 3%; all other respondentssaid they did not havethe information or discussionspecified. *In the questionnairethis read as nursing, midwifery or health visiting.

A p p l y i n g f o r first post: g u i d a n c e wanted Looking back at Tables 1 to 3 the findings show that for 20 of the 22 aspects, only a minority of respondents had been provided with guidance. The two exceptions were information about how to apply for a first post, and about vacancies available. For 17 of the other 20 aspects, the proportion who had guidance was less than one third. It appears, therefore, that newly qualified nurses are embarking on their post-qualification careers with little knowledge of the opportunities available. It could be argued that the period prior to qualification is too early to take on board information relating to longer term career planning; that the main concern at this time is obtaining a first post and only then may thoughts turn to a longer term perspective. In order to ascertain how newly qualified nurses felt in this respect, members of the cohort who had received guidance about an aspect were asked if they would have liked more, and those who had not received any were asked if they would have liked some. Table 4 shows that for each aspect of applying for first post, around half of those who were

provided with guidance would have liked more. An interpretation of these figures is difficult, however, since it was not possible to establish h o w much guidance respondents had received. The findings in the second column are less ambiguous; these respondents had not received any guidance, and in that sense were all in the same position. For each aspect, around 80 to 90% o f those who had not had guidance said that they had wanted some. It is further illuminating to consider these respondents as a proportion of the cohort as a whole (Column 3), particularly in relation to discussions about individual career planning. Sixtyfive percent of all respondents had not had a discussion about specialties in which it would be helpful to gain experience in relation to future plans and yet wanted one. The corresponding figure for discussions about specialties for which the respondents' skills might be particularly suited was 73%. Clearly then, a substantial unmet need exists among newly registered general nurses concerning discussion about individual career plans for applying for their first post.

T a k i n g post-basic courses: g u i d a n c e wanted Similar findings emerged for guidance wanted about taking post-basic courses (Table 5). The figures for those who had guidance but wanted more were slightly higher than those for applying for first post, around 60%, rather than 50%. As with first post, however, about 85% or more of those who did not have guidance had wanted some. These figures as a proportion of the cohort as a whole (Column 3) show that as with applying for first post, a substantial unmet need existed concerning guidance about taking post-basic courses.

L o n g e r t e r m plans: g u i d a n c e w a n t e d Findings on longer term plans reveal a more varied picture (Table 6). The proportion wanting more guidance ranged from 12% in relation to information about the forces, to 67% for discussions about the two aspects o f individual career planning. Turning to those who were not provided with guidance, it was those aspects concerned with careers in the N H S generally (part a) about which respondents were most likely to have wanted some guidance. O f particular note, 78% of all respondents did not have a discussion on h o w they might plan their career in the N H S step by step, and said that they would have liked one.

Career guidance for student nurses: an unrnet need

(I) Had some guidance (n = I 015) Aspects of applying for first post

%

n

% of (I) who wanted more %

(2) Not had any guidance (n = I 015) %

n

% of (2) who wanted some %

15

(3) All respondents: % who had no guidance and wanted some %

n

Information on: How to apply for first post

79

803

58

18

186

81

15

15 I

Vacancies

54

551

49

43

436

88

38

387

Range of specialties in which could work as a newly qualified nurse

37

376

53

60

606

91

54

55 I

Specialties in which it would be helpful to gain experience in relation to future plans

25

251

50

72

736

90

65

664

Clinical specialties for which your particular skills might be most suitable

14

147

50

83

838

88

73

740

Discussion about:

Figures for specific pathways in nursing (part b) showed that 90% of those who were not provided with information about developing a career in clinical practice would have liked some; this figure represents 77% of the total cohort. This is a surprisingly large figure, given that clinical practice is the career route of choice for many nurses. Figures for the other pathways shown are smaller but even for the lowest, general management, 51% o f respondents had not been provided with information and wanted some. O f the third group of aspects (part c), it was opportunities for work outside the N H S about

which respondents were most likely to have wanted some information.

Discussion about individual careers Tables 1-6 contain findings about information provided on various aspects of post-qualification careers and on discussions about the individual's own career plans. These latter findings relate to what might be called 'personalized guidance' (Marsland et al 1993) and are brought together in Table 7, to demonstrate the degree o f u n m e t need in this area. For each of the aspects o f individual career planning

i ii i! i i i i i ii { ii! iiiiii{iiiiiiiiiiiii i{i ii ii i{iii iiiiii i! iiiiiiii{i!i!iiii {iiiii{iiiiiiii{iiiiiiiii{iii!iiiiiiiii i i i{{ iii{i!iii! ! ii!i iiiiii!i!ii iiiiiii!i!i!i!iiii{{iiiiii ( I ) Had some guidance (n = I 015) %

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The various clinicaJ courses offered by the National Boards - e.g. ENB 216 stoma care

37

379

67

61

619

National Board courses needed for particular areas of nursing

17

168

61

81

How soon before starting date to apply for National Board courses

II

I 12

48

Other post-basic courses e.g. shortened courses for other parts of the register

18

182

Educational opportunities outside the NHS - e.g. Open University degree

28

17

Aspects of taking post-basic courses

(2) Not had any guidance (n = I 015) %

n

% of (2) who wanted some %

(3) All respondents: % who had no guidance and wanted some %

n

93

57

575

822

95

77

778

87

880

95

83

839

63

80

809

92

73

745

283

64

70

714

85

60

608

168

60

81

824

88

72

726

Information on:

Discussion about: Post-basic courses relevant to your particular ideas about your future

¸

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Nurse Education Today

::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

:::::::::::::::::::::::::::::::::::::::::: :.:.:::::+:::.: :.:.:...:1 :... :. :::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

( I ) Had some guidance (n= 1015) %

n

% of (I) who wanted more %

25

252

25

73

743

Areas of work within NHS for which your particular skills might be most suited

15

149

67

83

How you might plan your career in the NHS step by step

I0

102

67

12 16 9 8 6

123 163 89 83 56

28 12 8

283 I 17 84

Aspects of longer term plans

(2) Not had any guidance (n = 1015) %

n

% of (2) who wanted some %

::::::::::::::::::::::::::::

(3) All respondents: % who had no guidance and wanted some %

n

94

68

695

842

90

74

755

88

894

88

78

788

51 44 56 37 64

86 82 89 90 92

871 831 902 914 937

90 75 69 66 55

77 61 61 60 51

786 624 622 605 517

12 60 43

71 87 90

718 880 914

40 69 78

28 60 70

286 607 712

a) Career development in NHS generally Information on: Rangeof careers available in the NHS to people who have qualified as nurses Discussion about:

b) Specific pathways in nursing Information on how to develop a career in: Clinical practice Nursing education Nursing management Nursing research General management c) Working outside the NHS Information on: Working as a nurse or midwife in forces Working as a nurse or midwife abroad Opportunities for work outside the NHS for which RGN qualification would be relevant

listed, 25% or less of respondents had had discussion, and of these 50% or more would have liked more. O f those who did not have a discussion, the majority would have liked one. Most strikingly, however, Column 3 shows that for the cohort as a whole, between 65% and 78% of respondents did not have a discussion about each o f the aspects and would have liked one.

CONCLUSION Taken together the findings reveal that a lack of information, and discussion about aspects o f individual career planning, is a concern to the majority of nurses, even at this very early stage in their career. A substantial umet need in relation to guidance provided during pre-registration education is demonstrated. This research was undertaken with traditionally trained RGNs. It is likely that the greater variety of training experiences incorporated into the Project 2000 Diploma Course curriculum, plus the opportunity in some colleges to defer branch selection until after the common core foundation programme, will increase rather than decrease the need for pre-registra-

tion guidance. Since the data in this research were collected, changes that have taken place in nursing and nurse education may have made providing guidance for students increasingly difficult. Tutors may, for example, have felt unsure about offering advice as they were unable to predict h o w a diploma level education would influence nursing. The nursing profession will never be static, however, and the changing nature of nursing careers means that topic based guidance such as explored in this research may be unrealistic. Systems of guidance therefore need to be devised to assist nurses to plan and implement their careers in a constantly changing environment. Career guidance is only one o f many influences on careers; it is well documented that the careers o f men and women nurses tend to differ, yet they presumably have equal access to career guidance opportunities as students. Changes in organizational structures and value systems within the profession may, therefore, be as important as career guidance in facilitating the careers o f nurses. Many questions remain unanswered by this research; who should be providing guidance, and what responsibility do student nurses have to obtain the information they require, for

Career guidance for student nurses: an unmet need

( I ) Had some guidance (n = I 015) Aspects of careers discussed

%

n

% of ( I ) who wanted more o~

(2) Not had any guidance (n = I 015) o~

n

% of (2) who wanted some o~

Specialties (for first post) in which it would be helpful to gain experience in relation to future plans

25

251

50

72

736

Clinical specialties (for first post) for which your particular skills might be most suitable

14

147

50

83

Post-basic courses relevant to your particular ideas about your future

17

168

60

Areas of work (long term) within NHS for which your particular skills might be most suited

15

149

How you might plan your career in the NHS step by step

I0

102

(3) All respondents: % who had no guidance and wanted some o/~

n

90

65

664

838

88

73

740

81

824

88

72

726

67

83

842

90

74

755

67

88

894

88

78

788

example? A separate interview study with newly qualified nurses and those involved in their preregistration experience was initiated to investigate these more complex issues. Subsequent questionnaires in the careers study ask about levels of satisfaction with career guidance during the post-qualification years, and whether dissatisfaction contributed to decisions to leave specific nursing posts, or to leave the NHS completely. The current climate in the N H S is one of uncertainty. Nurses are wanting career guidance during the very earliest stages of their careers. Career guidance is not only relevant to those with early ambitions to specialize and gain promotion, but also to those who's aim is to continue providing high quality patient care at a D or E grade. For both groups, opportunities may be restricted by job availability and/or family commitments. If attrition is to be minimized, and nurses enabled to fulfil their maximal potential, they must be assisted to make constructive career decisions, whatever their personal and professional circumstances. ACKNOWLEDGEMENTS I should like to thank the following: Department of Health who fund the research; Sarah Robinson who directs the programme of careers research; Trevor Murrells for statistical advice; other colleagues at the Nursing Research Unit for their comments on drafts of this article; the nurses of the pilot group for their help in developing questions, and those of the main study who compIeted the questionnaire; finally to Geraldine Reast for typing the original manuscript. REFERENCES CohenJ 1948 Minority report to the report on the working party on the recruitment and training of nurses. HMSO, London

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