The Politics of Nursing and Nurse Education

I’ve recently participated in two review consultations to present a commentary on the recent proposals by Health Education England to introduce a new support role on the back of the Shape of Caring review. In both of these review meetings the context of the proposals and potential implications of the wider context of recent changes to nursing and nurse education, in particular, was a common focus. I’m going to outline these here and voice the kinds of predictions that have been made by both groups about what the future of nurse education looks like.

So if we review the changes that have been happening across both the current Conservative government and the previous Coalition government we can see a number of interventions happening. Firstly in relation to nursing education, we have the establishment of £9,000 tuition fees amongst many Universities wherein the Liberal Democrats ditched their election pledge to not raise student’s fees. The impact of this has been a decline in undergraduate student numbers as quoted verbatim here from the Universities UK 2014 report in conjunction with the HESA (Higher Education Statistics Agency) on the Patterns and Trends in UK Higher Education.

“In 2012–13 there were 140,000 more students studying at UK higher education institutions than in 2003–04, an increase of 6.4%. However, the rate of change fluctuated across the period: 2009–10 saw the largest year-on-year increase, of 4.1%; between 2009–10 and 2011–12 numbers remained stable at around 2.5 million, and then in 2012–13 numbers decreased by 6.3% (156,000 students). First-year undergraduate student numbers increased by 13.7% from 2003–04 to 2009–10, followed by a 22% decrease between 2009–10 and 2012–13.” (Universities UK, 2014; p6). The devil is in the contextual details when it comes to monitoring student numbers – depending on which year we start measuring from and which subset of students get included in the counting.
This should be considered also in light of the upcoming proposals to move away from a student bursary for nursing students to a student loan arrangement. This led to a considerable outcry, protest, a professional and parliamentary debate about the relative merits and potential harms of such a move. It is worth considering that research indicates that in over 40% of such existing loan schemes in HEI institutions in 44 different countries the recovery of such loan monies is  40% or less (Shem and Ziderman, 2009). It’s also worth mentioning that bursaries for Social Workers are being mooted as next on the government’s agenda.

Nurse revalidation “to strengthen the … registration renewal process and increase professionalism” (NHS Employers, 2016) was introduced as one of the measures following the Francis Report (2013). I would argue that whilst this has been ‘spun’ as a way to strengthen nursing and validate our professionalism what has actually been taken away and implemented from the 290 recommendations is in places far removed from this. Whilst the report indicates a number of individualized failings and also managerial shortcomings amongst others the whole of the nursing profession has been made effectively, tacitly to accept as a professional group the responsibility for these failures.

For example, the Francis Report made recommendations regarding ‘safe-staffing’ that the government promised to implement by commissioning NICE to review this independently. They’ve already back-peddled on this and now it is in internal NHS/DOH hands and is only now at the time of writing starting this work picking up from NICE’s previous analysis.

We also now have the government led work-force development plan to create a ‘nursing associate‘ role that Health Education England (HEE) says is intended to sit between care-assistants and qualified nurses . Several issues spring out of this – if the intention is to improve the quality of care (as is alluded to in the HEE documentation and subsequent discussions) then what is the evidence that such a role would do so? (It’s worth noting that when looking at patient mortality rates from acute myocardial infarction in the States studies have shown lower mortality rates when the nursing staff ratio had higher proportions of RN’s and higher mortality rates when nursing staff ratios had higher proportions of LPN’s (Licensed Practitioner Nurses) – a role very similar to that proposed as the nursing associate Person et al. 2004).

HEE also intends that ‘nursing associates’ would form another career-pathway towards nursing qualification then the existing graduate-pathway. Exactly how this would work, and how we could be certain that this more apprenticeship style route would have equivalency in terms of the education delivered is highly contentious. What we would have in the interim however is a new tier of work-force that registered nurses would have to take responsibility for – more management and less hands-on nursing from qualified staff then – that decreases patient safety. Nursing associates will not for instance be putting together care-plans, so that’s a job left to the RN. Another consequence I see of this workforce change is that we have cheaper care and less of it directly in the hands of RN’s.  I would argue further that we also get less consistency in terms of how nursing education is delivered through the introduction of a new career pathway.

There is also the matter of the use of the word nursing in the job-title. Registered Nurse is a protected term, whereas ‘Nurse’ is not. Nursing associate implies the practitioner is of the nursing persuasion, and yet clearly they are a new tier of health-care support worker – not regulated by the NMC. I wonder if the average patient receiving care is going to appreciate what and who this new level of practitioner is and what their expectations will be of what nursing associates can and can’t do?

Once more we have poor work-force planning, not backed by evidence of improved quality of care, that is politically-led and austerity driven. This is coupled with the hanging of responsibility on nursing and education for the complex systemic and individual failings highlighted in the Francis Report. Alongside this we have changes pushed through to student nursing bursaries and graduate fees that will undoubtedly change the landscape of recruitment into the profession.

So, bottom line predictions: the move to a nursing associate will create a new pathway to a nursing qualification. This cheaper for employers option with an ‘earn as you learn’ sales pitch will compete and even become the dominant route into the profession. Regulate nursing associates in the NMC and we have a new two-tier nursing with employers recruiting for more nursing associates into their rotas because, well it’s cheaper. RNs will have an increased clinical-supervisory/managerial role as a result and decreased hands on care. Care quality will be threatened as a result. Nursing isn’t teaching with its attractive golden hello, TV marketing campaign and decent starting salary. Without a bursary a proportion of nurses that would train by the graduate route will go elsewhere or into the NA route instead. We will have less diversity in our workforce as a result. Having axed bursaries the government will turn to social work and claw back funds from there to shore up some other aspect of the incessant goal towards nullifying our countries deficit. To the cost of an already beleaguered health and social care system.