Opinion

Is it time to turn our back on graduate-only entry to nursing?

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Undoubtedly, major challenges face the healthcare sector – an ever-growing older population, improved diagnostic techniques leading to often-lengthy and expensive treatment, a more medically educated and discerning public, a critical media and government and scarce financial, material and human resources. On top of these issues, I see the most immediate challenge being the chronic shortage of qualified nurses. It is this problem that needs urgent attention.

High-profile failing hospitals, over-stretched emergency departments and exposure of poor care practices in health and social care have forced a commitment to increase the number of nurses recruited to deliver clinical care. The problem is that no nurses can be found. Along with the NHS and care home operators, NHS clinical commissioning groups (CCGs) are racing to recruit from Spain, Portugal and other European countries. Historically, South Africa, Australia and the Philippines were the countries of choice but more relaxed controls over workforce movement, mutual recognition of professional qualifications in Europe and comparatively weak economies now make the recruitment from EU countries a more attractive proposition.

Far from being a panacea however, these practices raise a number of other problems namely language, cultural adaptation and social pressures that must be balanced against the immediate relief of filling vacancies.

There is a tendency to believe that there is a root cause to every problem. In my discussions about nurses in the social care sector however, one common theme keeps surfacing: Project 2000.

Introduced in the 1990s, Project 2000 was supposed to transform a vocation into a profession, recognising a changing population and that medical treatments were becoming more complex and hence nurses needed to be better trained. This may have had merit, but simplistic thinking resulted in the baby being thrown out with the bathwater.

The reality is more complex. At a time when society was looking to build greater respect for those delivering care, the idea of introducing a single academic nursing qualification (a diploma as opposed to the previous certificate) as the entry point to nursing seemed the way to go. To allow those with only two years vocational training (enrolled nurses) to call themselves nurses would only dilute the professional image, so the argument went. But to take an analogy, I wonder what our army would look like if the only entry point was Sandhurst?

What seems to have happened is that nurses were regarded as a homogenous resource, and therefore there should be one nursing qualification (RGN) demonstrating the same level of training whoever holds the title.

The reality is that there needs to be a variety of nurses with different qualifications and skills, able to perform different functions and aspire to different careers. Nurses in care homes, for example, need certain basic skills – wound dressing, drugs administration, venepuncture, PEG feeding, and so on, pretty much the skills that state enrolled nurses with two years of on the job training would have had.

Today, the academic entry qualification for entry to the Nursing and Midwifery Council register is a degree, effectively barring entry to many with a genuine desire and capability to nurse.

This situation also makes it difficult for mature candidates, particularly those with dependents, to qualify. As the new graduate-only system takes hold, new registrants will increasingly be largely young people with little life experience or insight into the travails of the increasingly older patient population.

It is worth noting that the first year drop-out rate for nursing courses of around 40% suggests that graduate-only entry may be worth a reconsideration. So can we and should we turn back the clock?

There is absolutely no doubt that there is a shortage of nurses. The rush to recruit from Spain, Portugal and Eastern Europe is testament to that. There have also been suggestions that today’s nurses are not always the most compassionate, often prioritising process before the person.

Looked at objectively, does every role and task that requires a qualified nurse genuinely need someone with a degree level qualification? During my years in adult social care, I have found that the resource most valued by patients in care homes and being supported in their own homes, is human contact. Insisting on qualified nurses puts financial pressures on the NHS, CCGs and care homes.

When resources are stretched, spend on what in some instances is an over-qualified and unduly expensive resource can lead to overall staff numbers being cut to compensate and patient contact time greatly reduced.

I would contend that the system does not necessarily need changing but a role comparable to the enrolled nurse of previous decades should be reintroduced. Maybe this role could be named the social care nurse (SCN). Then managers can assess where a SCN or a RN is needed and staff hospitals and care homes appropriately.

About the author

Tony Stein is a chartered accountant and founder and chief executive of Healthcare Management Solutions (HCMS)
Twitter: @tony27nine

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