We hold Dr. Ann Bradshaw in the highest esteem. Her long and distinguished career in university nursing have left their mark, especially on the history of the various changes that have taken place in the last century and the way nursing education is delivered. One of us reviewed her book The Project 2000 Nurse for Journal of Advanced Nursing in 2003, saying that it “deserves to be read widely and will serve as a ‘gold standard’ in the history of nurse education”.
Views were exchanged before on the value of graduate nursing following a previous article she wrote in the Daily Sceptic. Her work has also been referred to in TCW Defending Freedom where criticism of university educated nurses is lapped up by a readership largely ignorant of the evidence in favour of graduate nurses and unwilling to consider it.
Dr. Bradshaw surely cannot be unaware of the evidence on the value of a graduate workforce in nursing and also the fact that nursing students in university spend 50% of their time in practice. We wish to offer a rejoinder to her recent piece on fixing social care in the Daily Sceptic. Here the usual tropes about how nursing has gone to hell in the proverbial hand cart are rolled out, and all because nurses now go to university. In support she cites Left of centre journalist David Goodhart and one article in the Daily Telegraph reporting a case of sepsis allegedly contracted as graduate nurse did not swab an injection site prior to administering an injection.
Dr. Bradshaw is, we presume, aware, as described in a Cochrane Library review of 2018 that “there has been no clinical impact of using or not using alcohol swabs on infections and infection symptoms calling into question the practice of using it prior to all injections”. The link between what the Telegraph – another bastion of graduate nurse criticism – reckons and the purported outcome is a spurious one.
Claims linking poor nursing care with the development of graduate nursing education have a long history. Sadly, for the detractors of university level education for nursing students, this has not been an evidence-based approach. The first Willis Commission of 2012 searched in vain for such evidence.
On the contrary, copious evidence is available for the effectiveness of graduate nursing education. A long line of work at the University of Pennsylvania led by Professor Linda Aiken provided evidence so convincing that the Institute of Medicine in the United States recommended increasing the number of graduate nurses in 2011.
Aiken’s work is not confined to the United States. The RN4CAST project showed in 2014 in a study of 300 hospitals, 26,516 nurses and 422,730 patients in nine European countries that every 10% increase in bachelor’s degree nurses was associated with a decrease in the likelihood of an inpatient dying by 7%.
Work from a different team from Qatar has shown a direct and positive link between graduate nurses and patient outcomes. Whereas the link between nurses and outcomes in Aiken’s work is indirect, in the Qatar study the link was direct and made possible due to the unique electronic records system available in the organisation studied. The study, originally published in Journal of Advanced Nursing, was summarised in the Conversation. In short, it shows that greater exposure to graduate nurses during a patient stay in hospital leads to a greater likelihood of survival.
The effect of the admitting nurse was controlled for in another study published by the same group in International Nursing Review. It mattered not whether the admitting nurse was a graduate or non-graduate, demonstrating that the effect on survival was not the patient pathway, and further demonstrating that it was the subsequent exposure to graduate nurses which positively influenced patient survival.
We do not claim that all is perfect currently with nursing. One of us wrote about our own brush with the NHS earlier this year, after collapsing at home, in TCW Defending Freedom and the Catholic Herald. The ambulance staff were great, the consultant was as caring and competent as any medical professional could be. But the nurses were truly shocking. Much is wrong, but we have never understood and can find no systematic evidence that this is because of nurses being educated in university.
We are not graduate nurses; we are of the old school. But we recall shocking examples of care when we were student nurses: patients tied to chairs with blankets; tea, milk and sugar in the same pot being given to patients with learning disabilities; pressure sores that you could put your fist into and some incidences of terrible patient abuse.
It is so easy to look back on the good old days of nursing through rose tinted spectacles. It is also so easy, as demonstrated above, to make spurious links between every incidence of poor care these days to the fact that all nurses are graduates. The crucial point is whether we are going to make such comparisons based on evidence or prejudice. We conclude with a question to Dr. Bradshaw: in light of the link between graduate nurses and inpatient survival, would she rather, when ill, be admitted to a hospital with high proportion of graduate nurses or a low one?
Dr. Roger Watson is Academic Dean of Nursing at Southwest Medical University, China. He has a PhD in biochemistry. He writes in a personal capacity.
Professor Mark Hayter is Head of Nursing at Manchester Metropolitan University. He writes in a personal capacity.
Dr. Ann Bradshaw responds:
Thank you to Professor Watson and Professor Hayter for responding to my article. I fear they may have missed my point (or I was not clear?) in that I was writing about the crisis in social care and offering a solution.
In response to his defence of degree nursing (which is neuralgic to the nursing establishment), as I argued in Times Higher Education, the North American study he refers to does not define what is included in the nursing ‘degree’ in any country, so is irrelevant to survival rates. ‘Degree’ is just a label. In the U.K. the nursing degree is not a medical degree and is not standardised. Professor Watson has admitted to me in the past his regret that there is a lack of anatomy and physiology taught generally in U.K. university nursing departments. Also, unpaid supernumerary placements are not the same as paid full-time apprenticeship training.
In response to the authors’ last question, as to whether I would like to be nursed by a degree level nurse or not, I will give my story. Several years ago, while working on my allotment, I developed severe abdominal pain. My husband took me to our local teaching hospital emergency department, where I lay on the floor in pain until my turn came. The degree level trained nurse came with her paperwork, looked at my drip (not at me), inserted pain relieving suppositories into my rectum and left. I vomited, no nurse present, my husband found me a vomit bowl. I passed out the contents of my rectum on to the couch I lay on. No nurse came. My husband cleaned me up. The nurse came and reluctantly changed the sheet, as if it was below her station, but left me in the soiled hospital gown and with soiling on my skin. I was wheeled to X-ray in the gown and felt very humiliated. When I told this story to a Royal College of Nursing conference, the degree level trained nursing delegates did not want to hear it.
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