Intensive and Critical Care Nursing
Volume 24, Issue 6 , Pages 327-328, December 2008

Moving to all-graduate nursing in England—Implications for the nursing workforce

University of Manchester, Manchester, United Kingdom

Article Outline

 

The decision by the Nursing & Midwifery Council (NMC) to move nursing in England to an all-graduate profession in September 2008 heralds a new way forward and an historic landmark for improving the education of the workforce (NMC, 2008). It marks the end of a protracted period of debate about whether or not English nursing should make this step (Burke and Harris, 2000, Greenwood, 2000, UKCC, 1999, DH, 1999); however, it also comes amid continued ambivalence of higher education for nurses, from both inside and outside the profession (Robinson et al., 2006). Degree level education for nursing is in evidence globally and there is evidence that this trend is on the increase (Cowin and Hengstberger-Sims, 2006). Whilst countries such as Australia and New Zealand have established all-graduate nursing, up to this point England was the only remaining country within the United Kingdom and Ireland not to have introduced all-graduate nursing programmes. Indeed the United Kingdom (UK) as a whole has, until recently, offered alternative education qualifications that lead to registration as a nurse (Lusk et al., 2001) and this position persists in the United States of America (USA)—though an all-graduate workforce is expressed as a preference (Lusk et al., 2001). So what have been the deciding factors in changing minimum education standards at the pre-registration level in England and in increasing graduate level education for nurses globally? Furthermore, what might the implications be, particularly in dynamic care settings such as the critical care environment?

One of the key considerations relates to demographic changes in patterns of health and disease which have modified societies’ expectations for healthcare provision. There have subsequently been changes in healthcare policy and reforms in the way in which health professionals’ practice (in England for example, see Macleod Clark, 2007), especially in terms of inter-professional practice. Perhaps most significantly there has been a mammoth growth in health-related information, knowledge and knowledge management systems, which the professions have had to contend with. In nursing this has provided the impetus to argue that, like all other health professional groups, there is a greater need for nurses with higher order intellectual skills that can be applied to clinical judgment and decision-making, policy implementation, leadership, research and change management (Macleod Clark, 2007). In critical care the focus on nurses’ intellectual clinical problem-solving processes are arguably put to the test more acutely than most hospital and primary care settings because of the need for skilled personnel to make rapid clinical decisions based on sound assessment and clinical judgment, often in highly stressful, noisy and hurried environments.

Yet whilst the arguments in favour of raising the education level of nurses has strengthened amid such change, until recently, there has been no empirical evidence that links the education level of nurses directly to positive patient outcomes. A study from the USA by Aiken et al. in 2003 changed this; Aiken et al. examined the relationship between the numbers of graduate level or above nurses with risk-adjusted patient mortality and ‘failure to rescue’ events (described in the study as surgical patient deaths from serious complications). They used cross-sectional data from a previous study (Aiken et al., 2002) on 232,342 surgical patients discharged from 168 hospitals in Pennsylvania and survey data from 10,184 nurses (between 1998 and 1999). Although there were limitations including a low response rate to the survey and the fact that the research was conducted in one state only, Aiken et al.'s findings have had a high impact on the debate about all-graduate nursing internationally because they were able to show that a 10% increase in the proportion of graduate nurses was associated with a 5% decrease in the likelihood of patients’ dying, or failure to rescue events, within one month of admission to hospital. Since then other studies have emerged in Canada which endorse Aiken et al.'s (2003) findings (Tourangeau et al., 2007, Estabrooks et al., 2005). Although this evidence-base is hitherto small, it nevertheless provides a compelling argument of the benefits of higher education for nurses that could be tested in other parts of the USA and in countries across the world.

The implications of all-graduate nursing in England though, and of special interest to this editorial, for critical care environments in particular, are wide-ranging. For students, whilst institutions of higher education might provide the foundation for technical and academic skills development, it is the workplace environment where nurses develop both technical and intellectual competence in the context of their ability to provide appropriate care. It will therefore fall, more than now, to practitioners to guide undergraduates in their critical thinking and other intellectual ability in relation to clinical problem-solving. For the existing workforce it entails consideration of how skills’ development and on-the-job experience can be accredited towards the award of a degree. Interestingly in this regard, higher order skills associated with critical analytical thinking, complex problem-solving and decision-making are among traits which are attributed to graduate outcomes internationally (Billing, 2003). They are also traits that are considered for measuring skills’ acquisition in environments such as critical care, through application of models such as Dreyfus & Dreyfus (1980—in Benner 2004), applied to nursing by Benner (2004), which show how an individual can move from novice, to advanced beginner, to competence and finally to proficiency and expertise. So for both pre-registration and post-registration skills development associated with the development of graduate attributes, workplace learning initiatives will become an increasingly important resource for the successful transition to an all-graduate workforce.

If nursing care can improve patient outcomes when it is provided by degree nurses, as is shown in Aiken et al.'s (2003) research then all-graduate nursing has to be considered a very positive step forward, and one which should be adopted internationally. Nursing however, needs to be clear about what graduate nurse attributes are of value to the workplace and then consider how these attributes will be recognised, nurtured and measured for existing and future workforces.

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References 

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PII: S0964-3397(08)00093-1

doi:10.1016/j.iccn.2008.10.001

Intensive and Critical Care Nursing
Volume 24, Issue 6 , Pages 327-328, December 2008

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