Response to ‘the Trojan horse of nurse education by Roger Watson and David Thompson’
Article Outline
Professors Watson and Thompson present a gloomy picture of the state of nursing in the UK. Inevitably with rhetoric there is a kernel of truth, but in common with recent events in political life in Westminster, much spin doctoring. They suggest there was once a halcyon period before integration of the health profession disciplines into the higher education sector in the 1990s. This was a time when a small elite grouping of universities with departments of nursing were engaged in the production of a few graduate, even fewer postgraduate, educated nurses and research scholarship in keeping with the traditional values of a University. These departments and their incumbents were unfettered by the responsibilities of mass production of a nursing workforce, were laudably focussed on the generation of knowledge to underpin the emerging discipline, and were left to get on with their work without any call to account by bureaucratic management. My reading of their argument is as follows: post integration the challenges of mass education, coupled with inadequately prepared academic staff, and the introduction of management has resulted in a poor quality higher education experience for students, an expanded and largely ill-equipped academic workforce and a less than research expert professorial leadership. Further, that these demands on the expanded number of departments of nursing in universities are in some way culpable for creating many of the challenges currently faced in the sector. These include widening participation and robust systems for accreditation of prior and experiential learning which (they imply) have wrought havoc on the very underpinning of what it means to be a university and so undermined the quality of education. The solution offered is that much of the business currently undertaken in the name of nursing in higher education should shift, and presumably the academic (teaching) staff, into the further education sector.
Those of us who have worked through the last two decades in nurse education have had to grapple with the competing and often confounding agendas that emerged from government. One of these issues – the integration of the education of nursing, midwifery and the other allied health professions into the higher education institutions – was not casualty free and some of the scars left after that re-organisation remain.
The shift fulfilled many of the frequently and heatedly expressed aspirations of those committed to academia as a route to professionalisation yet created human resource (HR) issues some of which remain unresolved. It also presented new and different challenges to staff whose main purpose hitherto had been teaching. As then, and for some still, research endeavour coupled with teaching may never form part of their academic profile. The question whether it should is not unique to nursing and one that generates much debate across the higher education sector as a whole. The tensions exerted by the requirement to deliver quality education, and participate in the UK Research Assessment Exercise (RAE) creates an urgent need to revisit the traditional roles and responsibilities of academic staff in higher education. Just as higher education institutions (HEIs) are themselves having to rethink their purpose linked to the teaching and research versus teaching or research debates that emerged from the publication of the recent white paper – Future of Higher Education (Secretary of State for Education and Skills, 2003). The HR management issue may not be comfortable but much needed if health professional disciplines are to develop and not implode under the workload demands; just as supposedly more mature higher education disciplines are able to continue to flourish.
These organisational and HR issues are made even more complex in the health professions where the traditional career trajectory of undergraduate degree, followed by postgraduate study, with tenure in a lectureship by mid 20s and a career undertaken solely in higher education is largely unknown. This traditional HE model is very different from that journeyed by qualifying health professionals who understandably wish to practice in health care before or alongside embarking on a research and/or teaching career. Thus postgraduate research training is often delayed by the imperative to gain practice experience. The redesign of roles in health care, the emergence of a career structure with the proposed Knowledge and Skills Framework (Department of Health, 2003a) coupled with the implementation of Agenda for Change (Department of Health, 2003b), will inevitably impact on recruitment to a sector that values different indicators of capability in its staff. Indicators such as production of quality publications in peer reviewed journals, research grant income, research activity that translates into national or international application, these are hard to achieve when meeting clinical demands and pursuing continuing professional or postgraduate education.
These capacity issues, together with the absence of a clear career trajectory for developing nurse academics does inevitably link with the calibre of the professoriate. The issue of title; whether a professor appointed to a department of nursing as a professor of nursing research, clinical nursing or indeed nurse education is minor in comparison to the imperative to develop leaders in research who can advance the discipline. The pressing need is for coherent thinking between the NHS and higher education institutions as to how to best facilitate the integration of clinical practice, education and research threaded within a career structure with appropriate remuneration and recognition.
The separate but equally thorny problem of developing the capacity of departments of nursing to perform in research terms whether that be by appointment of senior academic posts or by other means was recognised by the Higher Education Funding Council and other commentators following the 2001 research assessment exercise. Investment in capacity building is needed as much for the development of nursing as is a good diet if children are to perform according to their potential. Nursing is one of a number of emerging research disciplines and this has been rightly recognised. Hopefully the funding given to 3 and 4 rated departments (on a scale of 1–6 where 6 is best) entered in 2001 RAE will be a good investment and enable some aspirant research active academic staff to pursue the manufacture of knowledge through research, and in the current vernacular, transfer that knowledge in order to make it work. Likewise other initiatives such as the doctoral and postdoctoral fellowship schemes for developing research careers in nursing, midwifery and the allied health professionals funded by the Department of Health may go some way to producing future leaders, possibly even the next professoriate. No matter what level of investment, if the next generation of academics are to be able to deliver the education, research and entrepreneurial/commercial requirements of their institutions then the urgent task is reconfiguring academic roles and accepting that one specification might not fit all. In the health professional disciplines that cannot be done without engagement with the broader health community so that clinical career advancement is clearly linked with that in higher education.
This takes me to pre-registration nurse education, which in England, unlike the three UK Celtic fringe countries, remains largely at sub degree level ([advanced] diploma in higher education). The non-graduate status of nurses at the point of qualification after three years continuous higher education is something that has been debated at length and there is no need to rehearse the arguments justifying the case for an all graduate profession here. In England the issue of graduateness is not one of capability but of bursary. Indeed the divisive nature of financial support for nurse preparation could be viewed as a form of oppression by exclusion. Those involved in recruitment for nurse education will no doubt be regularly faced by candidates who have worked in health care settings as a care worker, undertaken National Vocational Qualifications (NVQ) training to level 3, often successfully undertaken an access course but will not be able to accept a place on a programme unless they can be supported by secondment from their employer and local Workforce Development Confederations. Similarly candidates often having achieved two or three ‘A’ (Advanced General Certificate of Education) levels, who for financial reasons cannot apply for a degree programme due to the prohibitive financial burden it places on parents and partners and the inevitable student debt.
A separate, yet important, issue is the demand placed on resources by the diverse learning needs of individuals in any cohort of a diploma level nursing programme. This can be challenging for staff and the support needed to facilitate those with specific learning needs such as dyslexia, English as a second language, and to develop, refresh and enhance academic skills acquired before admission puts an enormous load on the system from the sheer volume of numbers. Just because it is challenging to provide quality learning and teaching to meet the needs of a wide ability range is not a good enough reason to propose that the correct setting for nurse education is further education. That said, many of the skills and expertise traditionally associated with supporting learning and teaching in further education are required by staff in higher education so that we can better assist those students who enter less well prepared for the challenges, or who flounder for want of the right sort of support.
That is different from the wholesale movement of the student and academic (teaching) workforce who are beginning fully to establish their rightful place in higher education. Other issues such as the failure of nursing students fully to engage with student life may be better resolved by timetabling measures (traditionally Wednesday afternoon free) that enable participation in university student activities and sports. These are more likely to enhance the student experience than removal from the sector. Further education as a solution would merely serve to distance nursing from the other graduate health disciplines and prevent the cross fertilisation and enrichment of the educational experience that comes from location in higher education. The professorial solution offered by Watson and Thompson would not only be retrograde but permanently disable nursing as a maturing academic discipline.
Lastly, to the tale of the Trojan horse as captured in the title of the editorial. This mythical tale centres on the fate of Helen; the woman who was said to have such beauty her face launched a thousand ships. Helen is the by-product of the seduction of her mother, Leda, Queen of Sparta, by Zeus, Father of the Gods, who in keeping with mythical traditions had taken the form of a swan. To cut a long story short, when married to King Menelaus, Helen eloped with Paris, son of Priam, the King of Troy. This was the catalyst for the Trojan war where the Greeks laid siege to the city of Troy for ten years in order to bring about the reunion of a reluctant Helen with the cuckolded Menalaus. The war ended when the Greeks invaded the embattled city of Troy. They had built a large hollow wooden horse and presented it as a gift outside the wall of the city and then left in their ships. The Trojans brought the horse into the city and then set about celebrating. Greek soldiers hidden in the belly of the horse emerged during the celebrations, opened the gates of the city thereby providing access for the then returned remaining Greek forces. They set about slaughtering the male population and putting the women and girls into bondage. Helen was returned to her husband and Sparta.
So what does this have to do with predicament of nursing in higher education? My reading of the editorial is that Watson and Thompson liken Troy to old-fashioned higher education and Helen to real nursing characterised by long standing departments who host the proper home of graduate nursing and real professors. The horse is the gift given to higher education with the integration of Colleges of Health (Schools of Nursing). The Greek invaders are the oppressors of higher education – who destroy the real purpose of academic life and put what remains in bondage by widening participation and accrediting experiential learning. This is an interesting analogy but one that fails to take into account that Helen, despite her great beauty, her tantalising enigmatic qualities and the much-contested thirst for her hand in marriage is frequently characterised as fickle, flirtatious and brazen (see Euripides). Homer in the Iliad presents Helen as maligned by the citizens of Troy although respected by King Priam. Whatever the rights and wrongs of her behaviour or character, according to the myth it led to death, destruction and slavery. Taking a lesson from the story let us hope that Helen (nursing) remains safely at home in Sparta (modern higher education) and is not tempted to run away with a good looking but rather ineffectual suitor despite the support of a well meaning father in law (further education) thereby avoiding war.
References
- Secretary of State for Education and Skills, 2003. Future of Higher Education CM5735 London, Department of Education and Skills
- Department of Health, 2003a. The NHS Knowledge and Skills Framework (NHS KSF) and Development Review Guidance – Working Draft London, Department of Health
- Department of Health, 2003b. Agenda for Change Proposed Agreement London, Department of Health
PII: S0260-6917(04)00003-6
doi:10.1016/j.nedt.2004.01.002
© 2004 Elsevier Science Ltd. All rights reserved.
