Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Nurses, degrees, and the workforce crisis

BMJ 2019; 365 doi: (Published 19 June 2019) Cite this as: BMJ 2019;365:l4224
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

The biggest threat to the NHS’s existence is its workforce crisis. And, although modern healthcare is a team venture reliant on interdisciplinary working, nursing is the NHS’s most numerous, visible, and trusted clinical workforce group. One with a workforce crisis even more pressing than that in medicine.1

Against this backdrop, the zombie trope I’ve mentioned before in this column2—that “overeducated nurses” lead to declining standards of care—has made an unwelcome return in parts of the media. It seems a peculiarly British obsession, as graduate nursing is established in most developed nations—but it’s hard to kill off.

In a 2014 study in nine European countries, every 10% increase in degree educated nurses was associated with a 7% reduction in patient mortality. England had one of the lowest percentages of graduate nurses in its bedside workforce.3 Then we have the immense (and growing) contribution to patient care by advanced nurse practitioners educated to masters level, in services throughout the NHS.4

Lines of argument

Yet last month saw a series of posts by the journalist Harriet Sergeant, who has criticised nursing degrees on and off for years, claiming that “the rot set in” in nursing care with the introduction of bachelors degrees as standard—that this somehow worsened care (though with no evidence beyond anecdotes) and that it deterred potential applicants with the right skills.5 Letters appeared in the Times6 and the Telegraph7 from readers banging the same drum. The lines of argument are ill informed about modern healthcare and nursing roles, the complexity and acuity of patients, the range of technologies, the pressure on services, and the growth in evidence for practice. Different eras require different approaches.

In essence the correspondents argue that, by requiring degrees, we’ll exclude people with the right skills from becoming nurses. What nurses mostly need, they say, are innate values of compassion, caring, and common sense, for what should be a vocation, not a profession: nursing degrees somehow render nurses incapable of compassion and empathy, uninterested in practical, hands-on care, despite graduate nurses throughout the NHS delivering precisely this.

We hear calls to “bring back” old-style training based on paid ward work with a classroom component, although modern nursing degrees, contrary to mythology, have a standard requirement for over 2000 hours training in clinical practice.8

Despite our understanding that improving quality and safety9 requires flat hierarchies, teamwork, an open and just culture, and an awareness of human and system factors—and despite a move away from regimented, institutionalised care—many still long for an era when “matrons were feared” and nursing could magically be reduced to nutrition, pressure sore prevention, spotless environments, and crisp uniforms.

We don’t see these wholly unevidenced arguments or assumptions made about doctors or a range of allied health professionals: behind them lies an unhealthy dose of covert snobbery and sexism. And a move to nursing degrees needn’t be some kind of insult to nurses in an era when degrees weren’t required. Professional training moves on.

Proposed solutions

Several factors are driving the workforce crisis in nursing. These include removing nursing study bursaries10; deliberate decisions to cut funding, staffing, and CPD budgets for Health Education England11; insufficient availability of student clinical placements and their funding12; immigration visa13 and English language test rules,14 which put off applicants trained overseas; and the workload terms and conditions, falling morale, and burnout that mean more nurses leaving the workforce or choosing less than full time working.1915 Some solutions are proposed in the Closing the Gap report1 and the preliminary NHS People Plan.16 And NHS England is investing in more flexible routes to degrees, including apprenticeships and new nursing associate roles,17 which partly address some of the “back to the future” calls.

Whatever’s causing our problems in nursing, they won’t be solved by giving people less education and training—an argument that should surely have had its day.