- Email: [email protected]
Is there a role for higher education in preparing nurses?
Nurse Education Today (2006) 26, 622–626
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Is there a role for higher education in preparing nurses? Roger Watson
*
School of Nursing and Midwifery, The University of Sheffield, Sheffield S10 2TN, United Kingdom Accepted 19 July 2006
KEYWORDS
Summary Nurse education is now almost wholly situated within universities internationally. However, issues such as the necessity of higher education for what is seen as a practical occupation and the question of whether or not nursing is a profession arise. Newman viewed universities as places where training was given but character was also formed and self-awareness was developed through exposure to a wide range of disciplines and this type of education has helped to shape other professions. If nursing fulfills the criteria for a profession then it requires nurses to be properly educated in higher education. Poor media images of nursing, opposition from within and outside of the profession and poor funding for research, especially in the UK, where most nurses still do not enter the register with a degree, mean that the place of nursing in higher education remains on the periphery. Nurses must be competent to practice and higher education is not incompatible with the development of competent practitioners. However, higher education should take competent practitioners to a higher level whereby they become capable: able to respond appropriately in unfamiliar situations and to unfamiliar events. This paper argues for the role of higher education for nurses in terms of developing capability. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 622–626 and Nurse Education in Practice Vol. 6, No. 6, pp. 314–318.
Nurses; Nursing; Nurse education; Higher education; Competence; Capability
Introduction Why is it, when we expect the best preparation for those who would represent us in a court of law, those who teach us and those who design the buildings we live in to have the best possible preparation * Tel.: +44 1142 229 848; fax: +44 1142 229 712. E-mail address: [email protected].
– a recognised university qualification – that nurses, who administer medications and support us through health crises, are considered by many to operate at the level of common sense and with a set of skills devoid of context, consequences and moral perspective? Not all we learn is taken in the academy, a great deal is learned ‘on the job’ – and this applies to doctors – but the question is then begged of who we
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
Is there a role for higher education in preparing nurses? learn from ‘on the job’. What was their preparation and how do they know what they need to know, and how do they contextualise this within clinical specialities, within professional boundaries and with the best possible evidence that what they are imparting is the best possible practice? In this paper I will consider some of the arguments for and against the higher education of nurses and what the higher education of nurses achieves.
The role of universities Universities are amongst the oldest and most robust institutions in the world. They rank alongside the church and the army as a collective institution that has survived the ravages of time, the vagaries of political change and the movements of national boundaries. However, while the church existed to explain the ravages of time, and the army to enforce or resist political change and move or maintain national boundaries, the purpose of a university has been both to study these ravages and changes and to educate those who enact and enforce them. The question remains – why? Is there a distinction between education and training (Watson, 2001, 2002)? Maskell and Robinson (2002), in The new idea of a university provide some excellent material and, in their turn, quote liberally from Newmans’s famous treatise on the idea of a university. Maskell and Robinson are highly critical of the expansion of higher education in the UK, not because of the expansion itself but of the redefinition of higher education and, indeed, the vandalism that has been carried out to the idea of a university. They begin by criticising the view that higher education is merely an investment, a way of ensuring economic success. Of course, ensuring economic success and viewing higher education as an investment is not wrong; however, it is wrong to view higher education only in this way. Surely, higher education serves a higher moral purpose and, while economic investment motivates some, a higher moral purpose motivates more of us. Maskell and Robinson, in addressing the purpose of higher education, say that: ‘To join the modern consensus we have first to deny a number of traditional distinctions. To begin with we have to believe that education is the same as training’ (pp. 23–24). They cite Newman, who said that ‘it is more correct to speak of a University as a place of education, than of instruction . . . Education is a higher word; it implies an action upon our mental nature, and the formation of character; it is something individual and permanent . . . cultivation of mind is surely worth seeking for its own sake’ (p.
623
25). Another writer on higher education, Gordon Graham (2002), in an equally Newmanesque work, Universities: the recovery of an idea, conveys this eloquently from a Socratic perspective when he says: ‘people can master practical techniques while being quite unable to ‘‘give an account’’ of them’ (p. 40), without denigrating such practical mastery. A regular commentator on the state of higher education in the UK, Gary Day (2006) puts this very bluntly with regard to the idea that skills are more important than subject knowledge, he says ‘what is the point of being able to communicate if you have nothing to say?’ (p. 13). Turning to Newman, Graham analyses the distinction between the professional and the technical – analogous to the training–education distinction – and considers the emergence of the profession of the surgeon from the barber and the development of a liberal, in Newmanesque terms, education as opposed to training. According to Graham, the emergence of the profession of surgery ‘had to do not merely with the mastery of different techniques, but with the acquiring of a certain self-consciousness’ (p. 44). Surely this is the mark that higher education leaves on those who endure it and that such a self-consciousness is the hallmark of a profession; in the Socratic sense, people who can give an account of themselves. Graham (2002) does not denigrate technical education, thus: ‘Still, though there are these inarticulate skills that are no worse off for their inarticulacy, it is also the case that there are practical tasks the performance of which is improved by the addition of more intellectual accomplishments’ (p. 41). However, he does warn against the obsession we now have with transferable skills: ‘The error on the appeal to transferable skills does not lie in its falsehood, but in the fact that it attempts to explain value in terms of use . . . learning to play the piano makes people more adept at chopping vegetables’ (p. 24).
What is a profession? Why would nursing not be considered to be a profession? The reasons could include the view that nurses are trained as opposed to educated; that nurses are largely controlled by other professional groups – principally medicine – and that they are not, ultimately, accountable for what they do. This raises the issue of accountability (Watson, 1992, 1995a,b, 2004; Tilley and Watson, 2004; Tierney and Watson, 2004; Watson and Tilley, 2004) which relates to the Socratic idea of ‘giving an account’ of what you do rather than simply doing it through mastery of certain skills.
624 Why could nursing be considered a profession? Quite simply, on the basis of its accountability and, indeed, multiple accountability– which is, surely, the hallmark of any profession (Watson, 1992, 1995a,b; Tilley and Watson, 2004). Take any other profession, be it doctor, teacher or lawyer; they are accountable to their patients and clients; they may be employed in a hospital or firm and they may have some local regulating body in addition to a national body which validated their initial registration as a member of their profession, and which continues to validate their status as a continuing member of that profession. Contrary to what many believe, nursing has had a long relationship with higher education. This goes back to the century before last in the USA with nursing being represented at Ivy League universities such as Yale and in many fine land grant universities such as Penn State. In Europe it is widely considered that The University of Edinburgh (Weir, 1996) established the first university department of nursing rapidly followed by Manchester in the 1960s. Edinburgh was certainly the first of those two to offer degrees to nurses. However, depending on your definition of Europe, it is possible that Turkey established the first university department of nursing (Smith, 1978). What is interesting about the development of university level nursing education in the UK is the struggles it gave rise to between those who were for it and those who were against it and this is exemplified in Weir’s (1996) book on the history of the development of nursing at The University of Edinburgh – A leap in the dark. An analogous, but earlier, development is covered in McGann’s (1992) history of the post-Nightingale development of nursing in the UK – The battle of the nurses. What is interesting about McGann’s book is that it is about the development of nursing as a profession, in the first instance, and a self-regulating profession, in the second instance. While nurse education features in it, the concept of university level education for nurses is not mentioned. The similarity between these two works is that there was support for the development of nursing as a profession and support for the higher education of nurses; and there was opposition – and the opposition came from inside and outside the profession.
Prejudice against university educated nurses University educated nurses have been described as ‘too posh to wash’ (http://www.nursingadvocacy. org/news/2004may/10_reuters.html; (accessed 24.04.2004) – or have their heads so full of non-
R. Watson sense – sociology especially comes in for criticism here – that they cannot provide essential aspects of care (always referred to as ‘basic’ care). The UK daily broadsheet newspaper The Daily Telegraph, in response to an announcement that the government were to introduce ‘dignity nurses’ to the NHS to ensure that older people were cared for properly, reported (Sargeant, 2006) how medical consultants ‘complain that standards of nursing care are, as one put it, ‘‘dangerously low’’’. A recently qualified staff nurse explained why: she had spent the majority of her training on sociological and gender issues. ‘The practical aspects of nursing, doing for the sick what they could not do for themselves, has been downgraded.’ (p. 4). Continuing in this vein, ‘A . . . sister in charge of elderly men in the inner city has scant respect for new nurses.’ ‘‘They picture themselves at a computer or with a doctor on his rounds. They are horrified to discover that 90 per cent of their time is taken up with doing things for the patient’’. Other than such caustic anecdotes, there really is no evidence for this. The arguments against it can be mounted on two fronts: one, that those who report this are seeing the past through the inevitable ‘rose coloured spectacles’ (McKenna et al., 2006) and, second, that things have changed considerably from the ‘good old days’. The profile of patients is changing rapidly; who can be treated and kept alive – if not necessarily cured – is always increasing, the population is ageing, therefore, we have more people with illness and disability. None of this, of course, excuses poor care but it does point to heavier workloads against a background of relatively diminishing resources; it points to patients who require nursing care starting at a lower point in their recovery trajectory – if, indeed, they can recover. The sequelae are bound to be more complications; in addition, the care that people witness is often not – in the UK at least – being provided by someone who was university educated: it may be being provided by a health care assistant who looks like a nurse and does some of the tasks that nurses used to do. Suzanne Gordon (2005) provides material from the USA to support this negative image of nursing. Looking at media images of nurses she reports ‘. . . what many people believe: nurses are people, mainly women, who don’t have the patience, stamina, ambition, curiosity, or intelligence to make it though medical school, and who work in a field wholly owned and operated by doctors’ (p. 148). Nurses are ‘sexpots and sadists’; ‘kind but dumb’ and in terms of how hospitals promote nursing, using evidence from
Is there a role for higher education in preparing nurses? Canada she says: ‘When hospital PR staff define research, it’s almost always doctors who do it, as if nurses didn’t participate in a great deal of that research . . . While PR staff in hospitals, medical schools and centers, and other institutions diligently promote physicians and biomedical researchers, they do little to promote nursing.’ (p. 174).
UK nurse education All pre-registration nurse education in the UK is university based but only 4% of those entering the register from a university are graduates (Sastry, 2005). If higher education has a role to play in the education of nurses, then that must afford students the higher education experience, part of which is to be taught by research active staff who are at the leading edge of their subject – without that, nurse education may as well be in further education – where it may well end up and where, if things don’t change, I advocate it ends up. In fact, I have described the entry of nurse education into UK universities as a Trojan Horse (Watson and Thompson, 2003). What is more – and, again, the subject of another keynote – is the profligacy with which academic titles have been dispensed throughout nursing. The titles hide a multitude of sins; in the UK we now have deans without doctorates and professors without publications (Thompson and Watson, 2006).
Competence The UK Department of Health produced a new model for nurse education and this was encapsulated in Making a Difference (Department of Health, 1999) which included plans for everything from cadet nurses to nurse consultants who were to take nursing practice to a new level. The curriculum was to be competence or skills based with less emphasis on the educational component. However, the measurement of competence, if it is to be taken seriously, is likely to be complex and multi-faceted with no ‘quick fix’. The competence model of training was originally introduced for plumbers and electricians (Watson, 2002); but nursing is not simply skills based and nurse education – as opposed to training – is the acquisition of skills, knowledge and attitudes. Are essential aspects of modern healthcare work in our societies – which are increasingly multicultural and where the moral dilemmas of healthcare are encountered more frequently easily encapsulated in a competence framework? How can you
625
help someone to make the right decisions if they do not understand the basis on which they already make their decisions? Can a Humanist and a Roman Catholic reconcile their different ethical perspectives in a competence framework? On the other hand, there are those who might say that moral dilemmas and ethical thinking are not in the nurses’ domain. The problem with the competence model for preparing nurses is that it undermines professionalism, it prepares people who may be incapable of giving an account of themselves. Being accountable is not comfortable but, assuming the professions do not simply exist to serve themselves, the public is more likely to be protected by people who may be called to account than by people who will simply hide behind the professionalism of others.
Capability So, how do we encapsulate competence within a higher education framework while ensuring that those being educated get the best from a higher education system? In other words, how do we ensure that our health care workforce is competent, as we would surely wish it to be, but justify the role of higher education in its preparation? Educating for capability may be one solution. Stephenson and Yorke (1998) explore the concept of capability in Capability and quality in higher education. Stephenson (1992 in Stephenson, 1998) encapsulates this thus: ‘Capability can be observed when we see people with justified confidence in their ability to
take effective and appropriate action; explain what they are about; live and work effectively with others; and continue to learn from their experiences as individuals and in association with others, in a diverse and changing society (p. 2)
Stephenson and Yorke describe capability as being something beyond competence; in other words, competence is just a first step and capability is a higher order achievement. Competence is what you would expect of someone trained to carry out a set of familiar tasks repeatedly in a familiar set of circumstances – clearly a worthy aim in itself – but capability is the ability to deal with unfamiliar tasks in unfamiliar situations. This is something that you cannot train a person to do because training, by its definition, requires repetitive performance until a task is done automatically. You
626 cannot train someone for the unexpected; in fact, our reaction under unexpected circumstances is instinctive: we flee or we fight. Capability goes beyond competence. So, how do we achieve capability? We educate people, we give them a broad range of experiences, knowledge and skills, which may not seem immediately relevant to the job they are normally expected to do. In this way, they not only become competent but capable of reacting appropriately in unexpected circumstances and in unfamiliar surroundings – they don’t panic; they apply logical thinking; they seek solutions through lateral thinking and by drawing on latent knowledge.
Conclusion The title of this paper posed the question: is there a role for higher education in preparing nurses? The answer to that question depends on whether or not we view the preparation of nurses as training or as education and, to some extent, that is predicated upon whether or not we view nursing as a profession. Whether or not higher education has a role in preparing nurses also depends on what the purpose of a university is and there is support for the idea that a university is not just for training people (instruction, as Newman called it) but also with the formation of character and the preparation of people who can give an account of themselves. Indeed, accountability is the hallmark of a profession. In this paper I have argued in favour of the role of higher education in preparing nurses because I firmly believe that nursing is a profession and that nurses are required to act beyond the level of mere competence, but also to be capable of adapting to unfamiliar circumstances in unfamiliar contexts. If we do not advocate the preparation of nurses via the higher education route then we are likely get the nursing workforce that we deserve.
References Day, G., 2006. A university ought to cultivate joined-up thinking in its students. But it can’t do that if it dismisses knowledge. The Times Higher 7 (April), 13.
R. Watson Department of Health, 1999. Making a Difference. Department of Health, London. Gordon, S., 2005. Nursing Against the Odds. Cornell University Press, New York. Graham, G., 2002. Universities: the Recovery of an Idea. Imprint Academic, Charlottesville, PA. Maskell, D., Robinson, I., 2002. The New Idea of a University. Imprint Academic, Charlottesville, PA. McGann, S., 1992. The Battle of the Nurses. Scutari Press, London. McKenna, H., Thompson, D., Watson, R., Norman, I., 2006. The good old days of nurse training: Rose-tinted or jaundiced view?. International Journal of Nursing Studies 43 135–137. Sargeant, H., 2006. The patient comes a sorry second in modern hospital. The Daily Telegraph 24 (April), 4. Sastry, T., 2005. The Education and Training of Medical and Health Professionals in Higher Education Institutions. HEPI, London. Smith, J.P., 1978. Higher education and nursing. Journal of Advanced Nursing 3, 219–220. Stephenson, J., 1998. The concept of capability and its important in higher education. In: Stephenson, J., Yorke, M. (Eds.), Capability and Quality in Higher Education. Kogan Page, London, pp. 1–14. Stephenson, J., Yorke, M., 1998. Capability and Quality in Higher Education. Kogan Page, London. Thompson, D.R., Watson, R., 2006. Professors of nursing: what do they profess? Nurse Education in Practice 6, 123– 126. Tierney, A.J., Watson, R., 2004. Accountability in nursing research. In: Tilley, S., Watson, R. (Eds.), Accountability in Nursing and Midwifery, second ed. Blackwell, Oxford, pp. 170–189. Tilley, S., Watson, R., 2004. Accountability in Nursing and Midwifery, second ed. Blackwell, Oxford. Watson, R., 1992. Justifying your practice. Nursing 5 (3), 11– 13. Watson, R., 1995a. In Introduction: accountability in nursing. In: Watson, R. (Ed.), Accountability in Nursing Practice. Chapman & Hall, London, pp. 1–17. Watson, R., 1995b. Accountability in Nursing Practice. Chapman & Hall, London. Watson, R., 2001. Elitism, Advanced Practice and the Charge of the Light Brigade. NT Research 6, 791–796. Watson, R., 2002. Clinical competence: Starship Enterprise or straitjacket? Nurse Education Today 22, 476–480. Watson, R., 2004. Accountability and clinical governance. In: Tilley, S., Watson, R. (Eds.), Accountability in Nursing and Midwifery, second ed. Blackwell Publishing, Oxford, pp. 21– 37. Watson, R., Thompson, D.R., 2003. The Trojan horse of nursing education. Nurse Education Today 24, 73–75. Watson, R., Tilley, S., 2004. Introduction. In: Tilley, S., Watson, R. (Eds.), Accountability in Nursing and Midwifery, second ed. Blackwell Publishing, Oxford, pp. 1–8. Weir, R., 1996. A Leap in the Dark. Jamieson Library, Penzance.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Is there a role for higher education in preparing nurses? Roger Watson
*
School of Nursing and Midwifery, The University of Sheffield, Sheffield S10 2TN, United Kingdom Accepted 19 July 2006
KEYWORDS
Summary Nurse education is now almost wholly situated within universities internationally. However, issues such as the necessity of higher education for what is seen as a practical occupation and the question of whether or not nursing is a profession arise. Newman viewed universities as places where training was given but character was also formed and self-awareness was developed through exposure to a wide range of disciplines and this type of education has helped to shape other professions. If nursing fulfills the criteria for a profession then it requires nurses to be properly educated in higher education. Poor media images of nursing, opposition from within and outside of the profession and poor funding for research, especially in the UK, where most nurses still do not enter the register with a degree, mean that the place of nursing in higher education remains on the periphery. Nurses must be competent to practice and higher education is not incompatible with the development of competent practitioners. However, higher education should take competent practitioners to a higher level whereby they become capable: able to respond appropriately in unfamiliar situations and to unfamiliar events. This paper argues for the role of higher education for nurses in terms of developing capability. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 622–626 and Nurse Education in Practice Vol. 6, No. 6, pp. 314–318.
Nurses; Nursing; Nurse education; Higher education; Competence; Capability
Introduction Why is it, when we expect the best preparation for those who would represent us in a court of law, those who teach us and those who design the buildings we live in to have the best possible preparation * Tel.: +44 1142 229 848; fax: +44 1142 229 712. E-mail address: [email protected].
– a recognised university qualification – that nurses, who administer medications and support us through health crises, are considered by many to operate at the level of common sense and with a set of skills devoid of context, consequences and moral perspective? Not all we learn is taken in the academy, a great deal is learned ‘on the job’ – and this applies to doctors – but the question is then begged of who we
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
Is there a role for higher education in preparing nurses? learn from ‘on the job’. What was their preparation and how do they know what they need to know, and how do they contextualise this within clinical specialities, within professional boundaries and with the best possible evidence that what they are imparting is the best possible practice? In this paper I will consider some of the arguments for and against the higher education of nurses and what the higher education of nurses achieves.
The role of universities Universities are amongst the oldest and most robust institutions in the world. They rank alongside the church and the army as a collective institution that has survived the ravages of time, the vagaries of political change and the movements of national boundaries. However, while the church existed to explain the ravages of time, and the army to enforce or resist political change and move or maintain national boundaries, the purpose of a university has been both to study these ravages and changes and to educate those who enact and enforce them. The question remains – why? Is there a distinction between education and training (Watson, 2001, 2002)? Maskell and Robinson (2002), in The new idea of a university provide some excellent material and, in their turn, quote liberally from Newmans’s famous treatise on the idea of a university. Maskell and Robinson are highly critical of the expansion of higher education in the UK, not because of the expansion itself but of the redefinition of higher education and, indeed, the vandalism that has been carried out to the idea of a university. They begin by criticising the view that higher education is merely an investment, a way of ensuring economic success. Of course, ensuring economic success and viewing higher education as an investment is not wrong; however, it is wrong to view higher education only in this way. Surely, higher education serves a higher moral purpose and, while economic investment motivates some, a higher moral purpose motivates more of us. Maskell and Robinson, in addressing the purpose of higher education, say that: ‘To join the modern consensus we have first to deny a number of traditional distinctions. To begin with we have to believe that education is the same as training’ (pp. 23–24). They cite Newman, who said that ‘it is more correct to speak of a University as a place of education, than of instruction . . . Education is a higher word; it implies an action upon our mental nature, and the formation of character; it is something individual and permanent . . . cultivation of mind is surely worth seeking for its own sake’ (p.
623
25). Another writer on higher education, Gordon Graham (2002), in an equally Newmanesque work, Universities: the recovery of an idea, conveys this eloquently from a Socratic perspective when he says: ‘people can master practical techniques while being quite unable to ‘‘give an account’’ of them’ (p. 40), without denigrating such practical mastery. A regular commentator on the state of higher education in the UK, Gary Day (2006) puts this very bluntly with regard to the idea that skills are more important than subject knowledge, he says ‘what is the point of being able to communicate if you have nothing to say?’ (p. 13). Turning to Newman, Graham analyses the distinction between the professional and the technical – analogous to the training–education distinction – and considers the emergence of the profession of the surgeon from the barber and the development of a liberal, in Newmanesque terms, education as opposed to training. According to Graham, the emergence of the profession of surgery ‘had to do not merely with the mastery of different techniques, but with the acquiring of a certain self-consciousness’ (p. 44). Surely this is the mark that higher education leaves on those who endure it and that such a self-consciousness is the hallmark of a profession; in the Socratic sense, people who can give an account of themselves. Graham (2002) does not denigrate technical education, thus: ‘Still, though there are these inarticulate skills that are no worse off for their inarticulacy, it is also the case that there are practical tasks the performance of which is improved by the addition of more intellectual accomplishments’ (p. 41). However, he does warn against the obsession we now have with transferable skills: ‘The error on the appeal to transferable skills does not lie in its falsehood, but in the fact that it attempts to explain value in terms of use . . . learning to play the piano makes people more adept at chopping vegetables’ (p. 24).
What is a profession? Why would nursing not be considered to be a profession? The reasons could include the view that nurses are trained as opposed to educated; that nurses are largely controlled by other professional groups – principally medicine – and that they are not, ultimately, accountable for what they do. This raises the issue of accountability (Watson, 1992, 1995a,b, 2004; Tilley and Watson, 2004; Tierney and Watson, 2004; Watson and Tilley, 2004) which relates to the Socratic idea of ‘giving an account’ of what you do rather than simply doing it through mastery of certain skills.
624 Why could nursing be considered a profession? Quite simply, on the basis of its accountability and, indeed, multiple accountability– which is, surely, the hallmark of any profession (Watson, 1992, 1995a,b; Tilley and Watson, 2004). Take any other profession, be it doctor, teacher or lawyer; they are accountable to their patients and clients; they may be employed in a hospital or firm and they may have some local regulating body in addition to a national body which validated their initial registration as a member of their profession, and which continues to validate their status as a continuing member of that profession. Contrary to what many believe, nursing has had a long relationship with higher education. This goes back to the century before last in the USA with nursing being represented at Ivy League universities such as Yale and in many fine land grant universities such as Penn State. In Europe it is widely considered that The University of Edinburgh (Weir, 1996) established the first university department of nursing rapidly followed by Manchester in the 1960s. Edinburgh was certainly the first of those two to offer degrees to nurses. However, depending on your definition of Europe, it is possible that Turkey established the first university department of nursing (Smith, 1978). What is interesting about the development of university level nursing education in the UK is the struggles it gave rise to between those who were for it and those who were against it and this is exemplified in Weir’s (1996) book on the history of the development of nursing at The University of Edinburgh – A leap in the dark. An analogous, but earlier, development is covered in McGann’s (1992) history of the post-Nightingale development of nursing in the UK – The battle of the nurses. What is interesting about McGann’s book is that it is about the development of nursing as a profession, in the first instance, and a self-regulating profession, in the second instance. While nurse education features in it, the concept of university level education for nurses is not mentioned. The similarity between these two works is that there was support for the development of nursing as a profession and support for the higher education of nurses; and there was opposition – and the opposition came from inside and outside the profession.
Prejudice against university educated nurses University educated nurses have been described as ‘too posh to wash’ (http://www.nursingadvocacy. org/news/2004may/10_reuters.html; (accessed 24.04.2004) – or have their heads so full of non-
R. Watson sense – sociology especially comes in for criticism here – that they cannot provide essential aspects of care (always referred to as ‘basic’ care). The UK daily broadsheet newspaper The Daily Telegraph, in response to an announcement that the government were to introduce ‘dignity nurses’ to the NHS to ensure that older people were cared for properly, reported (Sargeant, 2006) how medical consultants ‘complain that standards of nursing care are, as one put it, ‘‘dangerously low’’’. A recently qualified staff nurse explained why: she had spent the majority of her training on sociological and gender issues. ‘The practical aspects of nursing, doing for the sick what they could not do for themselves, has been downgraded.’ (p. 4). Continuing in this vein, ‘A . . . sister in charge of elderly men in the inner city has scant respect for new nurses.’ ‘‘They picture themselves at a computer or with a doctor on his rounds. They are horrified to discover that 90 per cent of their time is taken up with doing things for the patient’’. Other than such caustic anecdotes, there really is no evidence for this. The arguments against it can be mounted on two fronts: one, that those who report this are seeing the past through the inevitable ‘rose coloured spectacles’ (McKenna et al., 2006) and, second, that things have changed considerably from the ‘good old days’. The profile of patients is changing rapidly; who can be treated and kept alive – if not necessarily cured – is always increasing, the population is ageing, therefore, we have more people with illness and disability. None of this, of course, excuses poor care but it does point to heavier workloads against a background of relatively diminishing resources; it points to patients who require nursing care starting at a lower point in their recovery trajectory – if, indeed, they can recover. The sequelae are bound to be more complications; in addition, the care that people witness is often not – in the UK at least – being provided by someone who was university educated: it may be being provided by a health care assistant who looks like a nurse and does some of the tasks that nurses used to do. Suzanne Gordon (2005) provides material from the USA to support this negative image of nursing. Looking at media images of nurses she reports ‘. . . what many people believe: nurses are people, mainly women, who don’t have the patience, stamina, ambition, curiosity, or intelligence to make it though medical school, and who work in a field wholly owned and operated by doctors’ (p. 148). Nurses are ‘sexpots and sadists’; ‘kind but dumb’ and in terms of how hospitals promote nursing, using evidence from
Is there a role for higher education in preparing nurses? Canada she says: ‘When hospital PR staff define research, it’s almost always doctors who do it, as if nurses didn’t participate in a great deal of that research . . . While PR staff in hospitals, medical schools and centers, and other institutions diligently promote physicians and biomedical researchers, they do little to promote nursing.’ (p. 174).
UK nurse education All pre-registration nurse education in the UK is university based but only 4% of those entering the register from a university are graduates (Sastry, 2005). If higher education has a role to play in the education of nurses, then that must afford students the higher education experience, part of which is to be taught by research active staff who are at the leading edge of their subject – without that, nurse education may as well be in further education – where it may well end up and where, if things don’t change, I advocate it ends up. In fact, I have described the entry of nurse education into UK universities as a Trojan Horse (Watson and Thompson, 2003). What is more – and, again, the subject of another keynote – is the profligacy with which academic titles have been dispensed throughout nursing. The titles hide a multitude of sins; in the UK we now have deans without doctorates and professors without publications (Thompson and Watson, 2006).
Competence The UK Department of Health produced a new model for nurse education and this was encapsulated in Making a Difference (Department of Health, 1999) which included plans for everything from cadet nurses to nurse consultants who were to take nursing practice to a new level. The curriculum was to be competence or skills based with less emphasis on the educational component. However, the measurement of competence, if it is to be taken seriously, is likely to be complex and multi-faceted with no ‘quick fix’. The competence model of training was originally introduced for plumbers and electricians (Watson, 2002); but nursing is not simply skills based and nurse education – as opposed to training – is the acquisition of skills, knowledge and attitudes. Are essential aspects of modern healthcare work in our societies – which are increasingly multicultural and where the moral dilemmas of healthcare are encountered more frequently easily encapsulated in a competence framework? How can you
625
help someone to make the right decisions if they do not understand the basis on which they already make their decisions? Can a Humanist and a Roman Catholic reconcile their different ethical perspectives in a competence framework? On the other hand, there are those who might say that moral dilemmas and ethical thinking are not in the nurses’ domain. The problem with the competence model for preparing nurses is that it undermines professionalism, it prepares people who may be incapable of giving an account of themselves. Being accountable is not comfortable but, assuming the professions do not simply exist to serve themselves, the public is more likely to be protected by people who may be called to account than by people who will simply hide behind the professionalism of others.
Capability So, how do we encapsulate competence within a higher education framework while ensuring that those being educated get the best from a higher education system? In other words, how do we ensure that our health care workforce is competent, as we would surely wish it to be, but justify the role of higher education in its preparation? Educating for capability may be one solution. Stephenson and Yorke (1998) explore the concept of capability in Capability and quality in higher education. Stephenson (1992 in Stephenson, 1998) encapsulates this thus: ‘Capability can be observed when we see people with justified confidence in their ability to
take effective and appropriate action; explain what they are about; live and work effectively with others; and continue to learn from their experiences as individuals and in association with others, in a diverse and changing society (p. 2)
Stephenson and Yorke describe capability as being something beyond competence; in other words, competence is just a first step and capability is a higher order achievement. Competence is what you would expect of someone trained to carry out a set of familiar tasks repeatedly in a familiar set of circumstances – clearly a worthy aim in itself – but capability is the ability to deal with unfamiliar tasks in unfamiliar situations. This is something that you cannot train a person to do because training, by its definition, requires repetitive performance until a task is done automatically. You
626 cannot train someone for the unexpected; in fact, our reaction under unexpected circumstances is instinctive: we flee or we fight. Capability goes beyond competence. So, how do we achieve capability? We educate people, we give them a broad range of experiences, knowledge and skills, which may not seem immediately relevant to the job they are normally expected to do. In this way, they not only become competent but capable of reacting appropriately in unexpected circumstances and in unfamiliar surroundings – they don’t panic; they apply logical thinking; they seek solutions through lateral thinking and by drawing on latent knowledge.
Conclusion The title of this paper posed the question: is there a role for higher education in preparing nurses? The answer to that question depends on whether or not we view the preparation of nurses as training or as education and, to some extent, that is predicated upon whether or not we view nursing as a profession. Whether or not higher education has a role in preparing nurses also depends on what the purpose of a university is and there is support for the idea that a university is not just for training people (instruction, as Newman called it) but also with the formation of character and the preparation of people who can give an account of themselves. Indeed, accountability is the hallmark of a profession. In this paper I have argued in favour of the role of higher education in preparing nurses because I firmly believe that nursing is a profession and that nurses are required to act beyond the level of mere competence, but also to be capable of adapting to unfamiliar circumstances in unfamiliar contexts. If we do not advocate the preparation of nurses via the higher education route then we are likely get the nursing workforce that we deserve.
References Day, G., 2006. A university ought to cultivate joined-up thinking in its students. But it can’t do that if it dismisses knowledge. The Times Higher 7 (April), 13.
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