Have we overqualified yet undertrained today’s nurses?

Contribution to 2020health’s recent report ‘Too posh to wash? Reflections on the future of nursing’  

By Maura Buchanan, BA RGN, PGDip, Clinical Neurosciences, PGDip Health law, Independent Nursing & Healthcare Adviser; Past President, Royal College of Nursing

Major criticism of nursing and nurses has come from a variety of sources, from CQC inspections, enquiries such as that undertaken into Mid-Staffordshire, the Patients’ Association and from patients and relatives themselves. Such wide ranging criticism cannot be dismissed as a few unfortunate experiences in a busy pressurised service, nor down to a few ‘bad apples’ that have let the service down in the way they have treated vulnerable patients.

That the nurses of today are accused of lacking in compassion or failing to deliver dignified care should be a matter of grave concern to all of us in the profession. Whether or not these criticisms are justified, the public perception of nursing is being shaped by these reports. The criticism of nursing is often targeted at nurse education as if to educate nurses, was somehow to reduce their ability, or desire, to deliver compassionate and dignified care. At this time when the profession is moving to all graduate entry by 2013 we need to reassure patients, public and the politicians that nurse education is not only compatible with caring, compassionate and safe practice but is it’s very foundation.

Our patients surely deserve well educated, informed and competent nurses who can assimilate complex information and make safe and effective interventions. To suggest otherwise would be to fail to recognise the complexity of decision making that is necessary for safe care in today’s healthcare environment.

It is not too many years ago that third year student nurses would be left in charge of wards at night. Today, with the complexity of surgical intervention and acuity of patients, this would be unimaginable, placing patients at risk and, indeed, could be considered negligent. Health care is an ever changing world and nurses need education that prepares them for the changes and challenges ahead. Yet, preparing nurses to become caring, competent practitioners requires much more than the acquisition of knowledge and skills gained through the formal years of education. It is the application of knowledge and the development of skills over years of practice in a supportive healthcare environment that leads to truly competent nurses. The visible demonstration of nursing is to be found at the interface with patient, be that at the bedside, nursing home or elsewhere. Perhaps that is where the problem lies, in that insufficient attention has been paid to the application of knowledge and skills at the point of care.

It is not sufficient to demonstrate clinical or technical knowledge and skills, but the ability to respond to a patient with dignity, respect, compassion and good communication are equally, if not more, important. These skills take time to develop and require good mentorship, good role models and exposure to a range of situations where learning can be applied and practice advanced. I would argue that the main responsibility for failing standards lies not with nurse education, rather, with the clinical practice environment for which employers must take blame. Over the years, as RCN President, I listened to students from across the country complain about inadequate or poor clinical placements. It takes time to properly support and mentor students throughout a clinical placement.

Yet, nowhere have I witnessed managers taking account of the increasing impact of students on workload when setting the ward establishments. In these times of financial constraint, low staffing levels, high levels of temporary staff and reduced skill mix, failing to provide a high quality learning experience for nursing students can have a disastrous effect.

The failures in the learning environment do not just occur in the undergraduate/pre-registration years but extend into the early years post registration. No other healthcare profession is expected to ‘hit the ground running’ in the way that is expected of newly qualified nurses. Midwives, for example, have a required period of supervised practice, immediately following registration, and doctors have very structured learning and supervision over their early careers. Whilst the NMC might well advise on a period of preceptorship for new registrants, there is no requirement for such a programme to be put in place by employers. For some newly qualified nurses, a week or two supernumerary practice is the extent of their preceptorship, before being expected to take on a caseload of patients, often with little or no supervision. A further consideration must be given to the significant proportion of nurses working in healthcare who originate from countries outside the UK. Provided their educational qualifications meet the standard for NMC registration or they undertake an appropriate period of adaption, they are registered and free to practice. Their practice may be clinically sound but some may have little knowledge of the cultural and social aspects of nursing in this country leaving them vulnerable to criticism and lapses in practice. In some other countries personal care, including feeding, is delivered by families, not nurses. The nurse’s main responsibility is to give out medicines and record clinical observations in accordance with medical directions. Again, there is a failure by employers here to provide proper induction programmes and mentorship to support cultural adaptation and understanding of the social context of care.

Nursing in today’s health care environment requires much more than proficiency in a set of tasks. Nurses now need to be able to assimilate information and make decisions in increasingly complex situations. This requires a sound educational base and experience in applying knowledge and skills to new and challenging circumstances. It is a continuous learning process.

In addressing a conference of military nurses a couple of years ago, a question arose about nursing as an all graduate profession. I was impressed by a statement from one of their leaders that ‘We train for certainty and educate for uncertainty’. How true is that comment when applied to the world in which nurses have to practice, now and in the future.

We do not train nurses; rather, we educate them for the increasingly complex and changing world of health care. But, we must never forget that nursing is much more than the application of clinical skills and knowledge, it requires caring compassionate practitioners to deliver the safe dignified care that our patients deserve.

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