Friday, 4 April 2014

Student Nurse Perspective: More Education is not Less Care

Male Nurse Action Figure
The Conversation recently published an article that made my ears (and eyes) prick up a little bit. The article was titled "More Education and Lower Workload for Nurses Patient's Lives Saved". Doesn't quite roll of the tongue and it is one of those "No shit, Sherlock" articles for myself. And I thought it would be for others but when I did mention it what I got was "Well I don't agree, because in my opinion..." and then I started thinking a little about the resistance in the UK when they decided to make all future Nurses course degree level. This articles was written following a Cross-European study published in The Lancet. It is by no means the only study done in regarding staffing levels on hospital wards, but not so much regarding education level. For those who don't know most of the universities in the UK used to run two nursing courses side by side. Diploma of Higher Education which had set up as part of a very ambitious project called "Project 2000" and Bachelor of Science degree in Nursing. "Project 2000" was a very important step in validating nursing as an evidence based profession. Though it took a some time to find a balance between University education and actual work experience, quite frankly I would say that that is one of those balances that would never be found and no one would be 100% satisfied with. Lots of people with little understanding would always complain that there wasn't enough time spent in clinical settings, which quite frankly is bovem de stercore. The idea was at the end of the day was to make sure that the nurses practice was safe and evidence based. There is this concept that nursing is purely a vocational career, that all you need to be a good nurse is to be good at heart. What this study showed quite strongly was that while being good at caring it also helps to be well education in order to recognize sign of deterioration for example, it helps to hone the decision making process of a nurse. As it states in the findings:
An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7%, and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7%.  ¹
Regarding teaching nursing to a degree level I was always a bit astounded that it took such a long time to do in the UK. They were practically running two courses side by side with different University qualifications but both would end up in the same job with the same pay. If you did DipHE you'd have less educational workload and also more financial support and if you did the Degree you'd get more educational workload and student debt. All for the same job, with the same wage. Whereas most countries in Europe have made it a standard that nurses are educated to a degree level.

Evidence Based Nursing
So as I said before there was quite a bit of opposition when it was decided that all nurses should be educated at a degree level, people were writing to newspapers and nursing magazines, often saying that nursing students these days don't know enough about caring. Which to put it bluntly is a load of equum stercore. This is just a variation of the "Good Old Days" fallacy.  Now just to make it clear, I am not saying that you don't need to be caring to be a nurse it is still a very important part of it. What I am saying that getting an education will not kill the caring attitude that a person has. Anyone who enrolls into a nursing course without a caring attitude should, and hopefully do, quit and let someone else take their place. But a caring attitude will only get you so far, it won't help making an informed decision. There were lots of letters written to nursing publication denouncing this idea of nurses needing degrees to work, and that we'd lose out as good care can't be taught in a classroom, but that is why the nursing course is generally 50% university based and 50% clinical setting based. In some Universities they've taken in a step further and based their course on 60% in clinical settings. At the end of the day if nurses want to be taken seriously as a profession they have base their work on evidence, not where their heart will take them. This is not me saying that caring as a nurse is next to useless, this is me saying that good education can only enhance those qualities. As this article puts it rather beautifully the qualities that make a good nurse are: Caring, Communication Skills and Responsible. But it's the education that makes the biggest difference, especially in life and death circumstances. You don't have to take my word for it, but the evidence is fairly conclusive.
Each 10% increase in the proportion of nurses with higher degrees decreased the risk of mortality and of failure to rescue by a factor of 0.95, or by 5%, after controlling for patient and hospital characteristics. This adjusted OR of 0.95 (95% confidence interval, 0.91–0.99) is a multiplicative parameter. ²
This study also challenged the notion that experience is better than education. Experience is of course important, but you do need the education to make sense of that experience. So as The Conversation added it has to be both.

The common complaint I hear, especially from people who are not nurses, is why student nurses have to write essays. Well one for thing it will prepare us for the oodleplex of paperwork that we'll have to do as soon as we qualify and that is a good point, we have to learn how to write a good concise daily record, reports, handovers and such like. Even before we become fully fledged nurses we have to be sure that we know how to write a CV or supporting statements for job applications. But the main reason is because writing and essay coerces students to do a lot of reading. What some people also don't realise is that it is about the research done around the essay, and the essay can work as evidence of what we have read, what we have learned and in some cases how we can incorporate that into our professional career. Along side this it should also teach students how to evaluate evidence because, and I can't stress this enough, if we want to be taken seriously as a profession that is what we have to base our actions and decisions on evidence. But then you have these people who then complain that some students and some nurses are too posh to wash, well to be honest, yes you do meet them, but very very rarely. Students have to spend half (or as I said before 60%) in clinical settings, they learn that personal care is integral in good care. Those who sign up for nursing only to find out that they have to do chores like that generally quit very very early in the course.

The other important point that this recent study pointed out was the rather obvious statement that the lower workload also saves lives. The RCN had been advocating for some time that the maximum caseload per nurse should be 8 patients. This is something that every nurse and their dog knew, without having to read the daily's. But it seems like the people in power refuse to listen until something big happens. Again this is something that is supported by several studies and hopefully something that NICE will have a say about.
Our results imply that had the proportion of nurses with BSN or higher degrees been 60% and had the patient-to-nurse ratio been 4:1, possibly 3810 of these patients (725 fewer) might have died, and had the proportion of baccalaureate nurses been 20% and had staffing uniformly been at 8:1 patient-to-nurse ratios, 5530 (995 more) might have died. ²
Of course there would be better care if there are more staff around. But at the same time that is why this law that the current Minister of Health, stating that all wards should publish what the staffing levels are, is such a big red herring. It is all very well to publish how many staff there are working at any one point, what it doesn't tell you is what the skill mix is, how many nurses there are working, how many health care support workers, how many associate practitioners and so on and so forth. But as this report from the RCN states it is not only beneficial for the patient that we have a higher nurse to patient ratio, it is also a cost-saving mechanism. A survey done for the BMJ in 2012, this involved around 2917 nurses over 401 hospitals wards had this to say:
Most nurses (86%) reported that one or more care activity had been left undone due to lack of time on their last shift. Most frequently left undone were: comforting or talking with patients (66%), educating patients (52%) and developing/updating nursing care plans (47%). The number of patients per registered nurse was significantly associated with the incidence of ‘missed care’ (p<0.001). A mean of 7.8 activities per shift were left undone on wards that are rated as ‘failing’ on patient safety, compared with 2.4 where patient safety was rated as ‘excellent’ (p <0. 001).
 It might not look like it in the short term but the long-term benefit of having better educated nurses and more of them as well would lead to more effective care that is given. A meta-analysis done in 2007 concluded that an increase of registered nurses employed was positively associated with "decreased hospital related mortality and adverse patient related events". It would also help to raise the morale of an already spent workforce that has been kicked and tossed around and used as scapegoats for political gains. As Peter Carter said:
“The Francis report [into failings at Mid Staffs trust] showed that on some occasions there were two nurses on 34 bedded wards for elderly people,” said Carter. “The two nurses could have been Florence Nightingale, but with that ratio you simply cannot provide quality care.”  
So is it lack of staffing or lack of education that is the problem? Both. It shouldn't be a question of one over the other. When the research shows that it is a lack of both leads down a dark path.

¹ "Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study"

² "Educational Levels of Hospital Nurses and Surgical Patient Mortality"

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