Graduates on wards

The next generation of nurses will need better qualifications as well as more pay, says Sue Howard

Debate about the move of nursing towards an all-graduate profession has gained momentum in recent weeks, fuelled in part by growing concern about nurse shortages and pay. The Royal College of Nursing argues the immediate way to solve the worst nurse shortage crisis in 25 years is through tackling how we value our nurses and what we pay them. The education issue comes into play when the occasional commentator considers that shortages are, in fact, caused by the way today's nurses are educated and is unrelated to the difficulties of making ends meet with a starting salary that lags 17 per cent behind that of a newly qualified teacher. Education is being blamed for shortages rather than the more uncomfortable - and expensive - explanation of pay.

Nevertheless, as educators, we should always welcome a public discussion about education. And a debate could not be more timely with, aside from the more populist pay arguments, a major review of nursing education now underway. Set to be nursing's very own Dearing, the United Kingdom Central Council for Nursing Midwifery and Health Visiting commission into the future of pre-registration nursing education will report next year.

Today, 90 per cent of student nurses are studying for a higher education diploma with the remaining 10 per cent following degree courses. For the first time last year the number of applicants for the diploma course fell behind the number of available places, while degree courses are oversubscribed. So the message from the "marketplace" seems relatively clear. Many diploma students top-up their qualification to degree level almost immediately on qualification, usually paying for the privilege.

If we consider the pool of potential nurses from which we must draw, we see young people with far greater choices and whose expectations - and those of their parents - include gaining a degree. (Mature applicants must be targeted too; but a profession of which a quarter will be eligible for retirement by the year 2000 cannot afford to neglect its young.) It could be considered that, like it or not, a graduate profession is on the horizon. If we cannot offer that level of qualification, we just will not recruit.

This sense of inevitability, however, is clearly not the central argument for moving towards a graduate profession. The fundamental issue is the impact such a transition would have on patients. Will tomorrow's degree nurses be too "academic" to care for them? And this is a vital question, given that 80 per cent of hands-on patient care in the National Health Service is provided by nurses. Sadly, we seem to be steeped in a culture that believes someone who is able to function on a theoretical level cannot perform practically - and vice versa. But if we look at the research, we discover graduate nurses tend to stay longer at the hands-on clinical stage of their career than other nurses.

The future of the health service, as envisioned by this government, relies on a strong and motivated nursing workforce. In the next few years we will see nurses prescribing and commissioning local healthcare services, and NHS Direct, the nurse-led telephone consultation line, becoming most people's first contact with the health service. If nursing is to meet this challenge it will need highly skilled individuals, strong leaders and researchers to provide the evidence on which to base increasingly demanding practice. Again, there is a certain inevitability about the transition to a graduate profession as we consider the expanding roles of tomorrow's nurses.

Parity with other healthcare professionals is also crucial to the debate. Nurses have worked hard to ensure that they are partners in multi-disciplinary care and yet in the UK remain among the very few healthcare professionals who are not prepared to first degree level.

In the move towards graduate status, there are crucial issues to address: flexible entry and exit points on the way to registration, student support and the future role of the nurse teacher. Existing arguments about gaps between theory and practice and fitness for purpose, still need addressing, whether we are talking about diplomas or degrees. But these are challenges to tackle, not to use as ammunition against an all graduate nursing profession.

Sue Howard is education adviser at the Royal College of Nursing.

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