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The good old days of nurse training: Rose-tinted or jaundiced view?
ARTICLE IN PRESS
International Journal of Nursing Studies 43 (2006) 135–137 www.elsevier.com/locate/ijnurstu
Editorial
The good old days of nurse training: Rose-tinted or jaundiced view? Keywords: Nursing; History; Education
As a profession we are disadvantaged with a descriptive verb for what we do—namely nursing! Many people feel that nursing is common sense, a trait with which you are born, that the caring woman next door can do it expertly and that kindness, respect and compassion are the main criteria for becoming a nurse. In the 21st century, these traits are important but they do not make a competent and professional nurse. To meet present and future health and social care challenges, nurses must also be analytical, assertive, creative, competent, confident, computer literate, decisive, reflective, embracers of change and the critical doers and consumers of research. Most of these qualities were not inculcated in the old apprenticeship system of nurse training. In the United Kingdom, there has recently been a plethora of newspaper articles and letters stating that recently qualified nurses are ‘too posh to wash’ and ‘not fit to practice’ (Magnet, 2003) and calling for a return to the ‘golden age of nurse training’ (Meerabeau, 2004). This call has also been supported by some nurse managers and policy makers who feel that the move to university-based education was a mistake. They too embellish their assertions by harping back to the past. This retrospective ‘rose-tinted’ view of how nurses were trained previously is often peppered with anecdotes highlighting qualities such as caring and obedience. This reflects the quasi-religious sisterhood of veils and vocation, the militaristic belts, buckles and epaulettes and the unquestioning devotion to duty. Perhaps they should remember Nightingale’s remark that obedience was ‘‘suitable praise for a horse’’! (Nightingale, 1859). The claim that nurse training in the past was better merits some analysis. According to Revans (1964), total attrition from UK nursing in the early 1960s was around 50% per year and this figure remained high over subsequent decades. Reform of UK nurse education in the mid-1980s (Project 2000), which moved nurse 0020-7489/$ - see front matter r 2005 Published by Elsevier Ltd. doi:10.1016/j.ijnurstu.2005.09.007
education into the universities, was an attempt to halt this decline by increasing the attraction of nursing as a career through improving its status. It was based too on the great success of degree courses for nurses in some universities (King’s College London, Edinburgh, Manchester, Ulster, Nottingham and others) established in the early- and mid-1970s. These courses ran in parallel with hospital-based pre-registration programmes from the early- to mid-1970s, but attracted well-motivated university students with good A-levels, who chose to read for a degree over 4 years in Nursing Studies in preference to other degree programmes. These graduates received a liberal education and high-quality clinical supervision from well-qualified and experienced staff, and produced excellent academic and clinical work. Research into the careers of graduates showed also that, contrary to their critics, these university programmes produced graduates who were retained longer in clinically based nursing than nurses from the hospitalbased programmes (Montague and Herbert, 1982; Howard and Brooking, 1987). Project 2000 was thought to be a mechanism by which the standards of care delivered by the majority could be raised to that of this university elite. How far this has occurred is debatable, but our judgement is that without Project 2000 reforms, recruitment to nursing would be very much more difficult than today and standards of care would be lower overall. It is conveniently forgotten that nurses in the ‘good old days’ were often regarded as handmaidens— subservient, dependent and unthinking, and patients were subjected to ritualistic and routine practices passed down without question from one generation of nurses to the next. Examples of evidence-based practice 20 years ago were salt and Savlon baths, soap and water back rubs, older patients sitting around walls in tilt chairs for most of the day, and reference to disease entities rather than persons.
ARTICLE IN PRESS 136
Editorial / International Journal of Nursing Studies 43 (2006) 135–137
Most nurses of our generation can recall being placed in charge of a ward on night duty while they were still students and witnessing large pressures sores that would be rare today—possibly made worse through the inappropriate use of EUSOL, a desloughing agent which also harmed granulation tissue. The philosophy of ‘batch processing’ was commonplace, where all patients were treated the same regardless of their individual needs; they all had their temperatures, pulses, respirations and blood pressures taken (and most tended to read 36.8 1C, 80 bpm, 20 rpm, and 120/80 mmHg, respectively!), were weighed, medicated and subject to backs rounds every 4 hours. Paradoxically, there was also less pressure on staff: patients often spent weeks in hospital and, as they recuperated, many assisted nurses to distribute meals, feed other patients and make beds. How does this compare to today? Nursing has become ‘intensified’; health-care assistants carry out procedures, ONCE THE REMIT OF QUALIFIED NURSES, and nurses are extending their role into medical and even surgical practice (McKenna, 2004). The fact is that there is now less time to ‘nurse’ than there was previously. Patient throughput has increased and new treatments and technologies require confident and competent practitioners. Modern health care is complex and hospitals are little more than large intensive care units where, as soon as patients are over the acute stage of their illness, they are discharged to community care. This means that community nurses are undertaking home-based interventions, which were recently practised in the safety of a ‘hi-tech’ clinical setting. Contemporaneously, public expectations of health care are rising and their tolerance of error is diminishing. Therefore, nursing is no longer the common sense carrying out of uncomplicated tasks under the direction of others, nor is it a vocation for which short-term technical training will suffice. It is a profession that requires highly knowledgeable individuals frequently making sophisticated decisions, often with inadequate information and resources. Newly registered nurses from the mid- to late 20th century would be unprepared and overwhelmed if faced with the complexities and pressures of a 21st century health-care setting. Calls for returning to the ‘sitting next to Nelly’ system of training are based upon selective reminiscences and a lack of acceptance that nursing and health care have changed, as have the people who require nursing care. A report completed by the Judge Institute,(1999) in Cambridge, England, examined future trends and patterns in health and social care. It noted that over the next 15 years and beyond, there will be complex changes in demography, disease patterns, lifestyle, social and physical environment, targeting health and social need, public expectations and information technology. To meet and address these challenges expertly, we
require intelligent and well educated, as well as highly motivated and caring nurses. The anti-intellectual notion of the ‘overqualified nurse’ is not new and has been propagated in literature from the 19th, 20th, and 21st centuries (Bradshaw, 2001). Interestingly, Thompson and Watson (2005) pointed out that physicians are seldom castigated for being over-educated or too well qualified. Who wants to be in a busy medical ward looked after by a caring nurse who cannot calculate the correct infusion rate or know the difference between micrograms and milligrams when distributing medication such as Digoxin? People require and deserve to be cared for by intelligent, caring and skilled nurses who have been educated in an environment where the best knowledge, skills and understanding in their field is being produced, challenged, tested and then applied. In essence, this means nurses having a university qualification. Other than anecdote, there is no evidence that degree-qualified nurses are less caring. In contrast as outlined above, there is a plethora of research reports illustrating the benefits of graduate nurses (Howard and Brooking, 1987). More recently, in a cross-sectional study of 168 US hospitals, Aiken et al. (2003) found that a 10% increase in the proportion of graduate nurses was associated with a 5% decrease in the likelihood of death and failure to rescue within 30 days of admission. All professions have a small number of individuals within their ranks who are incompetent and potentially dangerous; nursing is no exception. Such individuals did not first appear with the advent of university-based nursing programmes and calling for a return to imaginary halcyon days will not lead to their demise.
References Aiken, L.H., Clarke, S.P., Cheung, R.B., et al., 2003. Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association 290, 1617–1623. Bradshaw, A., 2001. The Nurse Apprentice. Ashgate, Aldershot, p. 1860–1977. Howard, J.M., Brooking, J.I., 1987. The career paths of nursing graduates from Chelsea College, University of London. International Journal of Nursing Studies 24 (3), 181–189. Judge Institute, 1999. Policy Futures For UK Health. Science and Technology Trends and Issues Forward to 2015: Implications for Health Care, Technical Series No. 4. The Nuffield Trust and the Judge Institute of Management Studies. Magnet, J., 2003. What’s wrong with nursing? Prospect (December), 40–45. McKenna, H.P. (Ed.), 2004. Role drift to unlicensed assistants: risks to quality and safety, Quality and Safety in Health Care 13 (6), 410–411.
ARTICLE IN PRESS Editorial / International Journal of Nursing Studies 43 (2006) 135–137 Meerabeau, E., 2004. Be good, sweet maid, and let who can be clever: a counter reformation in English nursing education? International Journal of Nursing Studies 41, 285–292. Montague, S.E., Herbert, R.A., 1982. Career paths of graduates of a degree-linked nursing course. Journal of Advanced Nursing 7 (4), 359–370. Nightingale, F., 1859. Notes on nursing: what it is and what it is not. Churchill Livingstone, Edinburgh. Revans, R.W., 1964. Standards for morale: cause and effect in hospitals. Nuffield Provincial Hospital Trust. Nuffield Provincial Hospital Trust, Oxford University Press, London. Thompson, D., Watson, R., 2005. All bathwater and no baby: revisiting a national curriculum and state examination for nursing? Nurse Education Today 25, 165–166.
137
Hugh McKenna University of Ulster, UK E-mail address: [email protected] David Thompson Chinese University of Hong Kong Roger Watson University of Sheffield, UK Ian Norman King’s College London, UK
International Journal of Nursing Studies 43 (2006) 135–137 www.elsevier.com/locate/ijnurstu
Editorial
The good old days of nurse training: Rose-tinted or jaundiced view? Keywords: Nursing; History; Education
As a profession we are disadvantaged with a descriptive verb for what we do—namely nursing! Many people feel that nursing is common sense, a trait with which you are born, that the caring woman next door can do it expertly and that kindness, respect and compassion are the main criteria for becoming a nurse. In the 21st century, these traits are important but they do not make a competent and professional nurse. To meet present and future health and social care challenges, nurses must also be analytical, assertive, creative, competent, confident, computer literate, decisive, reflective, embracers of change and the critical doers and consumers of research. Most of these qualities were not inculcated in the old apprenticeship system of nurse training. In the United Kingdom, there has recently been a plethora of newspaper articles and letters stating that recently qualified nurses are ‘too posh to wash’ and ‘not fit to practice’ (Magnet, 2003) and calling for a return to the ‘golden age of nurse training’ (Meerabeau, 2004). This call has also been supported by some nurse managers and policy makers who feel that the move to university-based education was a mistake. They too embellish their assertions by harping back to the past. This retrospective ‘rose-tinted’ view of how nurses were trained previously is often peppered with anecdotes highlighting qualities such as caring and obedience. This reflects the quasi-religious sisterhood of veils and vocation, the militaristic belts, buckles and epaulettes and the unquestioning devotion to duty. Perhaps they should remember Nightingale’s remark that obedience was ‘‘suitable praise for a horse’’! (Nightingale, 1859). The claim that nurse training in the past was better merits some analysis. According to Revans (1964), total attrition from UK nursing in the early 1960s was around 50% per year and this figure remained high over subsequent decades. Reform of UK nurse education in the mid-1980s (Project 2000), which moved nurse 0020-7489/$ - see front matter r 2005 Published by Elsevier Ltd. doi:10.1016/j.ijnurstu.2005.09.007
education into the universities, was an attempt to halt this decline by increasing the attraction of nursing as a career through improving its status. It was based too on the great success of degree courses for nurses in some universities (King’s College London, Edinburgh, Manchester, Ulster, Nottingham and others) established in the early- and mid-1970s. These courses ran in parallel with hospital-based pre-registration programmes from the early- to mid-1970s, but attracted well-motivated university students with good A-levels, who chose to read for a degree over 4 years in Nursing Studies in preference to other degree programmes. These graduates received a liberal education and high-quality clinical supervision from well-qualified and experienced staff, and produced excellent academic and clinical work. Research into the careers of graduates showed also that, contrary to their critics, these university programmes produced graduates who were retained longer in clinically based nursing than nurses from the hospitalbased programmes (Montague and Herbert, 1982; Howard and Brooking, 1987). Project 2000 was thought to be a mechanism by which the standards of care delivered by the majority could be raised to that of this university elite. How far this has occurred is debatable, but our judgement is that without Project 2000 reforms, recruitment to nursing would be very much more difficult than today and standards of care would be lower overall. It is conveniently forgotten that nurses in the ‘good old days’ were often regarded as handmaidens— subservient, dependent and unthinking, and patients were subjected to ritualistic and routine practices passed down without question from one generation of nurses to the next. Examples of evidence-based practice 20 years ago were salt and Savlon baths, soap and water back rubs, older patients sitting around walls in tilt chairs for most of the day, and reference to disease entities rather than persons.
ARTICLE IN PRESS 136
Editorial / International Journal of Nursing Studies 43 (2006) 135–137
Most nurses of our generation can recall being placed in charge of a ward on night duty while they were still students and witnessing large pressures sores that would be rare today—possibly made worse through the inappropriate use of EUSOL, a desloughing agent which also harmed granulation tissue. The philosophy of ‘batch processing’ was commonplace, where all patients were treated the same regardless of their individual needs; they all had their temperatures, pulses, respirations and blood pressures taken (and most tended to read 36.8 1C, 80 bpm, 20 rpm, and 120/80 mmHg, respectively!), were weighed, medicated and subject to backs rounds every 4 hours. Paradoxically, there was also less pressure on staff: patients often spent weeks in hospital and, as they recuperated, many assisted nurses to distribute meals, feed other patients and make beds. How does this compare to today? Nursing has become ‘intensified’; health-care assistants carry out procedures, ONCE THE REMIT OF QUALIFIED NURSES, and nurses are extending their role into medical and even surgical practice (McKenna, 2004). The fact is that there is now less time to ‘nurse’ than there was previously. Patient throughput has increased and new treatments and technologies require confident and competent practitioners. Modern health care is complex and hospitals are little more than large intensive care units where, as soon as patients are over the acute stage of their illness, they are discharged to community care. This means that community nurses are undertaking home-based interventions, which were recently practised in the safety of a ‘hi-tech’ clinical setting. Contemporaneously, public expectations of health care are rising and their tolerance of error is diminishing. Therefore, nursing is no longer the common sense carrying out of uncomplicated tasks under the direction of others, nor is it a vocation for which short-term technical training will suffice. It is a profession that requires highly knowledgeable individuals frequently making sophisticated decisions, often with inadequate information and resources. Newly registered nurses from the mid- to late 20th century would be unprepared and overwhelmed if faced with the complexities and pressures of a 21st century health-care setting. Calls for returning to the ‘sitting next to Nelly’ system of training are based upon selective reminiscences and a lack of acceptance that nursing and health care have changed, as have the people who require nursing care. A report completed by the Judge Institute,(1999) in Cambridge, England, examined future trends and patterns in health and social care. It noted that over the next 15 years and beyond, there will be complex changes in demography, disease patterns, lifestyle, social and physical environment, targeting health and social need, public expectations and information technology. To meet and address these challenges expertly, we
require intelligent and well educated, as well as highly motivated and caring nurses. The anti-intellectual notion of the ‘overqualified nurse’ is not new and has been propagated in literature from the 19th, 20th, and 21st centuries (Bradshaw, 2001). Interestingly, Thompson and Watson (2005) pointed out that physicians are seldom castigated for being over-educated or too well qualified. Who wants to be in a busy medical ward looked after by a caring nurse who cannot calculate the correct infusion rate or know the difference between micrograms and milligrams when distributing medication such as Digoxin? People require and deserve to be cared for by intelligent, caring and skilled nurses who have been educated in an environment where the best knowledge, skills and understanding in their field is being produced, challenged, tested and then applied. In essence, this means nurses having a university qualification. Other than anecdote, there is no evidence that degree-qualified nurses are less caring. In contrast as outlined above, there is a plethora of research reports illustrating the benefits of graduate nurses (Howard and Brooking, 1987). More recently, in a cross-sectional study of 168 US hospitals, Aiken et al. (2003) found that a 10% increase in the proportion of graduate nurses was associated with a 5% decrease in the likelihood of death and failure to rescue within 30 days of admission. All professions have a small number of individuals within their ranks who are incompetent and potentially dangerous; nursing is no exception. Such individuals did not first appear with the advent of university-based nursing programmes and calling for a return to imaginary halcyon days will not lead to their demise.
References Aiken, L.H., Clarke, S.P., Cheung, R.B., et al., 2003. Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association 290, 1617–1623. Bradshaw, A., 2001. The Nurse Apprentice. Ashgate, Aldershot, p. 1860–1977. Howard, J.M., Brooking, J.I., 1987. The career paths of nursing graduates from Chelsea College, University of London. International Journal of Nursing Studies 24 (3), 181–189. Judge Institute, 1999. Policy Futures For UK Health. Science and Technology Trends and Issues Forward to 2015: Implications for Health Care, Technical Series No. 4. The Nuffield Trust and the Judge Institute of Management Studies. Magnet, J., 2003. What’s wrong with nursing? Prospect (December), 40–45. McKenna, H.P. (Ed.), 2004. Role drift to unlicensed assistants: risks to quality and safety, Quality and Safety in Health Care 13 (6), 410–411.
ARTICLE IN PRESS Editorial / International Journal of Nursing Studies 43 (2006) 135–137 Meerabeau, E., 2004. Be good, sweet maid, and let who can be clever: a counter reformation in English nursing education? International Journal of Nursing Studies 41, 285–292. Montague, S.E., Herbert, R.A., 1982. Career paths of graduates of a degree-linked nursing course. Journal of Advanced Nursing 7 (4), 359–370. Nightingale, F., 1859. Notes on nursing: what it is and what it is not. Churchill Livingstone, Edinburgh. Revans, R.W., 1964. Standards for morale: cause and effect in hospitals. Nuffield Provincial Hospital Trust. Nuffield Provincial Hospital Trust, Oxford University Press, London. Thompson, D., Watson, R., 2005. All bathwater and no baby: revisiting a national curriculum and state examination for nursing? Nurse Education Today 25, 165–166.
137
Hugh McKenna University of Ulster, UK E-mail address: [email protected] David Thompson Chinese University of Hong Kong Roger Watson University of Sheffield, UK Ian Norman King’s College London, UK