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Oh nurse, your degree is a symptom of equality disease

One of the government’s sillier initiatives was its announcement last week that in future all NHS nurses must have a university degree. From 2013, all would-be nurses will have to have taken a three- or four-year university course to enter the profession. The disastrous consequences of this ought to be obvious to the meanest Whitehall intelligence. All sorts of people who might make excellent nurses will be put off, and lost to nursing: anyone who is not particularly academic; anyone who — frankly — is not particularly bright; anyone who has a vocation to care for patients without wishing for the most high-tech training; anyone who is unable to take on a mass of student debt on a nurse’s poor pay; any late entrants — and this at a time when the NHS is desperately short of nurses. Rare though it is for me to agree with any trade union, I believe the nursing unions Unison and Unite are right when they say that there is no “compelling evidence” that degrees for nurses would improve patient treatment. I have come across a great deal of anecdotal evidence quite the other way: that nursing degrees on a university campus with too little practical hospital experience have recently been producing graduates who are all too often, in the words of one consultant, “a liability on the wards” — not necessarily “too posh to wash” but often not much good at it, or at the important clinical observations that go with it. To say this is not to dismiss the value of demanding degree courses for any would-be nurse who is suited to intense academic and technical study. Such nurses should be able to take degrees and already can, though one might argue about the nature of the present courses: more than 25% of nurses already hold a degree. However, not all would-be nurses are suited to a university degree; just as people vary hugely, so do nurses, so do the nursing roles they are fitted for and so does the training that suits them best. Plenty of the best bedside nurses are not academic, and much essential nursing work does not depend on the dizziest heights of training. There is more than one way to be a “supernurse”, and a degree is not enough. As the nursing unions said last week, “The emphasis should be on competence, not on unfounded notions about academic ability.” The health minister, Ann Keen, has been making predictable noises about providing higher-quality healthcare, but the real motivation beneath all this, quite explicitly, is the desire of the Royal College of Nursing and the nursing establishment to raise the status of nursing, and to end the stigma of the “doctor’s handmaiden”. Nurses — or rather those who claim to represent them — want to have the status of professionals, on a level with doctors, and part of being a professional is having a degree. So nurses must have degrees. All of them. What’s particularly depressing is that this obsession with status is not unique to the nursing establishment; it has become a national obsession, of which this is just one expression. It’s what explains the feeling that everyone must go to university now and the government’s determination to turn 50% of all school-leavers into undergraduates, regardless of the consequences. (There have been some suggestions that the government welcomes the idea of sending all nurses to university because it will effortlessly bump up the student numbers closer to the promised 50%.) When I was a child only very few people, and only those of supposedly high learning and intelligence, called themselves professionals and had concomitantly high social standing. Now, increasingly, everyone is described as a professional, even journalists occasionally. This unthinking pursuit of professional status and distinction has been hobbled from the first by the uncritical pursuit of equality, as if there were no real differences between people; it is hard to proceed in both directions at the same time. If, in the name of equality, at least half the country, rather than a tiny academic elite as before, must have a degree, degrees must become easier, to suit a wider range of intelligence, and universities must accept a greater number than before of students who are less bright. If half of all sixth-formers need good A-levels to get to university, A-levels must become easier. If in the name of social justice more people ought to get upper seconds and firsts, degrees will have to become easier. But, quite inevitably, a degree that is easier is also by definition less professional. And a degree that is held by many is a degree that by definition has lost some of its status. You cannot have both equality and professional status: the attempt leads to some strange absurdities. A few years ago, when I was visiting a small day centre for young adults with marked learning disabilities, a member of staff proudly showed me some artwork and some typed pages produced by three young women as part of their submission for an NVQ certificate. Having just met these girls, I knew they could barely communicate, and certainly could not read or write, so I asked how they could have produced such written work. Their tutor admitted that they had done so “with support” and when I expressed doubts, she overrode them firmly, saying she thought “everyone has the right to a qualification”. Clearly she felt — she can scarcely have thought — that social inclusion in the form of a qualification was more important than the objective value of that qualification. That is the reductio ad absurdum of the muddled thinking that has overtaken us. Few would go so far, even in the disability lobby. However, it is not quite as remote as it might seem from public policy. For if, as many people think, 50% of the population should have university degrees, why not 75%? And why stop there? After all, that would be discriminatory. Why not degrees for all? And so — why not for all nurses? Tony Blair once declared that we are all middle class now, despite all the evidence to the contrary; these days he could almost as well say we are all professional now. Such has been the collapse of standards and the debasement of language and thought under his new Labour experiment.

The Sunday Times | Sunday, November 15, 2009


Sadly, the university or college degree has become a commodity of the "education industry" rather than evidence of true education. Candidates wind their way through a maze of standardized courses so that all have the same foundation instead of learning, hands-on, from a broad array of experiences directly related to their chosen career field.

Here in the States, and in the UK I presume, the requirement that one have a degree has become a tool for "sameness," not a hallmark of professional quality.

Please give me an experienced practitioner any day over one who only read the instruction manual!

Posted by: Lamar Green | 1 Dec 2009 01:43:56

I suggest that Ms. Marrin pull her head out of the 19th century when she discusses nurses' job responsibilities. The professionals who study nursing need a solid foundation in the science behind the work they do in managing medications, monitoring patients' conditions with a variety of diagnostic tools, and dealing with the interpersonal and administrative side of patient care. As a practicing physician I thank God daily that there are four-year nursing degrees, and that those who are "not too bright" are encouraged to find other ways to help peopls.

Posted by: S. Fitzgibbons MD, FACP | 14 Dec 2009 19:25:23

Dear Miss Marrin,

It is amazing that journalists with as little knowledge about the healthcare system as yourself have the guts to make such unqualified comments. As a college educated women yourself, not to support the education of mostly female nurses is telling me you have no respect for other women. Attacking the UK government's plan to require that all nurses have a three- or four-year university degree by 2013, with arguments that the plan would have "disastrous" effects primarily because it would exclude those who would make "excellent" nurses even though they are "not particularly academic" or "not particularly bright" supports my perception.
You are not suggesting this to physicians, that they should get a 2-year degree and stay that way because they are not too bright for the rest of their career. Any clue why, did your work on the ethics board for the Royal College of Obstetricians & Gynecologists teach you a thing or two?

As a nurse and nurse educator for the last 25 years, I am appalled that you think that extending university education to more people, inhibits good nursing. Your column is so full of uninformed disrespect that it's hard to know where to begin a response. But I'll try to be professional about it. Nursing is an autonomous profession with a distinct scope of practice built on scientific knowledge. The vast majority of U.S. nurses have college degrees that require three or four years of training, and hundreds of thousands have graduate degrees (i.e., at least six years of university training). A large body of evidence shows that higher levels of nursing education improves patient outcomes. Unfortunately, you have not read any of it and therefore cannot make any informed comments. This speaks again to the quality of your writing. New physicians have little practical experience after they graduate from medical school, but no one argues that their formal training is wasted. The argument against nursing education is based on the false assumption that nursing is mainly about physical labor and hand-holding. But in an increasingly complex care environment in which physicians and others have graduate degrees, nurses cannot provide expert direct care or advocate effectively for patients without advanced training. Nurses are held accountable for all of their actions and the not so bright nurses are hopefully soon a picture of the past. They deliver antiquated care, have little knowledge why they continue certain practices and certainly no knowledge of how to improve their actions. Not a particular safe environment for you and your family if you need expert nursing care.

You have two choices:
1. Abstain in the future from polluting the news with comments about a profession for which you obviously have no respect and even less knowledge about.
2. Join to make the efforts of nursing a priority, join the professional, educational and health policy debates and become an informed activist and supporter.

The choice is yours!

Posted by: J. Voss | 14 Dec 2009 20:59:35

Dear Ms. Marrin:

I am writing in response to your Sunday Times columns of November 15, 2009, "Oh nurse, your degree is a symptom of equality disease."

It seems that you believe having to earn a degree would exclude those who would make "excellent" nurses even though they are "not particularly academic" or "not particularly bright." It seems your belief is that degrees inhibit good nursing, because they produce nurses who are not necessarily "too posh to wash," but who are not much good at it, with their heads full of all that irrelevant theory. You seem to think that nurses are not "professionals." This is offensive to nurses and illogical from a safety standpoint. As a fragile patient in an intensive care unit, would you want to be cared for by someone who is "frankly--not particularly bright?" Would you feel better while you were coding to know that you had excellent maid service, but no one at the bedside who could think critically?

As a preceptor and assistant clinical professor, I have seen how the degreed nurses do initially face challenges in clinical practice at the bedside. Usually, these deficits involve task-oriented activities, which require practice and experience. After proper orientation however, there is an integration of knowledge that allows these nurses to far surpass the skills, judgment and overall competence of those who do not hold a degree. They make better nurses, leaders, and advocates for their patients.

Let's hope that you never find yourself in need of a highly-skilled nurse, but if you do, pray that he or she is a competent, educated professional, rather than a brainless angel of mercy, who is good with a washcloth and follows orders without questioning whether your plan of care is safe and effective.

Anyone can be trained to make a bed or fluff a pillow. It takes an informed professional to intervene in the plan of care a physician wants implemented. Sometimes the plan isn’t safe. Sometimes the patient will be unable to comply. Sometimes, quality of life is an issue that has been overlooked. Sometimes the patient needs more education, or there is an easier way for the patient to achieve the desired outcome. Sometimes, the correct limb should remain intact. Any of these scenarios can happen, and they happen all the time.

It takes a competent educated individual to collaborate credibly and effectively in order to maximize quality of patient care. And that’s what good nursing practice is: Using evidence based knowledge to collaborate as equals with other professionals on the team for the ultimate good of the patient. Sometimes that involves soap and water, sometimes it means knowing when to carry out an order and when to question it. Being an effective nurse always requires that we use our education, experience and critical thinking to assure we are providing the best care. All three of these components are critical to ensure that the person at your bedside is a competent professional and not the maid you so vehemently argue him or her to be.

Before you give your opinion about the nursing's quest for quality improvement, get educated yourself about why higher education is critical to the profession. Your flawed thinking is unfortunately a status quo that places every patient at risk.

Thank you.

Posted by: S. Green, MSN, APRN, BC | 14 Dec 2009 21:48:07

I am writing in response to your Sunday Times columns of November 15, 2009 ("Oh nurse, your degree is a symptom of equality disease") and August 30, 2009 ("Fallen angels: the nightmare nurses protected by silence").

Although nursing allows for individuals to begin with a 2 or 3 year period of study there are increased demands for nurses to have higher education in order to provide increasingly complex care needed by patients. This care is provided in a variety of settings – now not just in hospital settings but a host of autonomous places of practice -- and requiring more specialization.

The nursing profession involves technical, specialized and highly skilled work often referred to as "professional expertise." Education for this work involves obtaining degrees and professional qualifications without which entry to the profession is barred. Education also requires regular updating of knowledge and skills that facilitates the incorporation of this new knowledge in order to maintain expert competence and public safety. This is accomplished through continuing education, meeting requirements for certification and by advanced degrees.

The International Council of Nurses (ICN) best defines nursing “as a profession that encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.” These roles require highly skilled and knowledgeable nurses delivering the care.

I would encourage you to learn more about nursing. I can guarantee that if you or a family member is faced with a critical illness requiring highly specialized skills, a chronic illness requiring expertise in your disease and its management or need hospice or palliative care you will want to have the nurses who are the brightest and most educated providing the care. The research shows that you will have better outcomes.

Posted by: Polly T. Barey, RN, MS | 14 Dec 2009 22:21:41

I am writing about your article about nursing education.

Someday you will be hospitalized. Do you really want someone who is not very bright to be responsible for your blood transfusion, medication management, prevention of medication interactions or to explain what the physician said in the 5 minutes s/he spends with you in the very early morning?

I encourage you to rethink your stand and invite you to learn more about the profession of nursing.


Susana Serna

Posted by: Susana Serna | 15 Dec 2009 00:54:24

From your comments in Sunday Times of November 15, 2009 ("Oh nurse, your degree is a symptom of equality disease") and August 30, 2009 ("Fallen angels: the nightmare nurses protected by silence") it appears to me that you neither know what nurses do nor the history of medicine. You seem to be stuck in the eighteenth century! (Or when Florence Nightingale lived!) Even so, if it was not for her brain and planning Britain and her soldiers would not have survived. Do you think she was dim?
Do you know that about a hundred years ago most doctors did not hold a degree? Was it because they were dim? And now every legally practicing doctor has a degree. At some point they were required to have a degree, so they got one. 50 years ago very few people, possibly your own family did not hold a degree. 50 years ago many people did not know what a computer was, but now even our grandmothers depend on computers. Ms Marrin, the world is changing, if you have not noticed! Human beings with brain like others with brain to care for them. And one way to ensure that, is to educate the caregivers- be they doctors or nurses or pharmacists or therapists! And it is only fair that those who acquire knowledge, be acknowledged.
The dictionary meaning of nursing is not the same as the the profession of nursing. Human beings are advancing, and there are standards set for various professions. And, nursing as a profession is totally different from other professions in that nurses think of the whole person and not just the diseases or treatments. It is an amalgamation of medicine, pharmacy and caring! People want to be treated and cared for by those who know what they are doing, not by those who just follow orders! Would you take your car to a mechanic who knows what the engines actually do and how they work or to a mechanic who has no clue about how the engines work? The chances are that if they know what they are doing, you can hold them responsible, your car has fewer repairs and better longevity! After all, lives are more precious than automobiles. At least I hope they are, even in the UK!
As you might have noticed, I am not from the UK. I am used to listening to the BBC and hence I have developed lot of respect for the reporters of the BBC, but I was too naive to think most people in the UK are like those at the BBC. Because, if you were responsible, you would have been better informed! You remind me of the joke about the third person reporter (who never went any where but reported from hearsay and gut-feelings)! I hope New Year brings you enlightenment and to those who work with you, hope!

Posted by: Victoria Cryer | 15 Dec 2009 06:17:06

In these columns you attack plans to require that all U.K. nurses have university degrees, which you say would exclude those who would make "excellent" nurses even though they are "not particularly academic" or "not particularly bright." These practitioners may be good technicians, they are not necessarily good NURSES. You also argue that degrees inhibit good nursing, because they produce nurses who are not necessarily "too posh to wash," but who are not much good at it, with their heads full of all that irrelevant theory. This irrelevant theory is what often stands between a patient and excellent outcomes vs. adequate "care".

Please try to learn what nursing actually is before you make further statements that serve only to mislead the public about the nature and value of the profession.

Posted by: K. Mahler | 15 Dec 2009 16:14:57

I am writing in response to your Sunday Times columns of November 15, 2009: "Oh Nurse, Your Degree is a Symptom of Equality Disease".

It's just a matter of time before you or a family member of yours is hospitalized. When that occurs, please remember what you have written about the education of the nurses who make the decisions that affect the life (and potentially the death) of the hospitalized person. Remember how nursing professionals are somehow arrogantly driven by "equality disease" rather than a desire for the latest scientific knowledge on the best care of infirmed persons.

The nursing competence you describe in your column comes from evidence based practice meaning firstly, a foundation of learned knowledge on many subjects including: medical diagnoses and treatment, a vast array of pharmacological knowledge, human anatomy and physiology, microbiology, patient safety(ergonomic and limited mobility issues, infection and contagious disease control, etc.), healthcare policy, legal aspects of providing care, sociology and human interaction, human growth and development, cultural aspects of providing care, existence and availability of adaptations for handicapped persons, and many, many other subjects. This extensive knowledge is garnered through a sound university education.

On this nursing knowledge, nursing experience is built so that a competent nurse is an intelligent, educated individual. Excellent care may be rendered by this person in accordance with the best research evidence available based on individual patient’s symptoms, social circumstances, physical ability, and other factors. Decisions made in this regard require a great deal of knowledge gained through education. We're not talking trained monkeys here.

I'm sorry that the very excellent work of Dr. Linda Aiken (a nurse) has not reached you. Her 2003 research did show a significant reduction of post-surgical patient deaths and complications when people were cared for by nurses with 4 year baccalaureate degrees rather than 2 year associate degrees, or "hospital diploma" training alone. Please read "Education Levels of Hospital Nurses and Patient Mortality" found in the 2003 Journal of the American Medical Association (JAMA), volume 290, pages 1617-1623 before writing your next article denouncing the education of nurses as unnecessary and a problem of "equality disease".

Frankly, I found your column both ignorant of the facts regarding nursing education and haughty. Hopefully when you do one day become hospitalized you will be blessed with a well educated and competent nurse rather than one who is “not particularly academic” or “not particularly bright”.

Posted by: Dee RIley | 29 Dec 2009 05:51:47

I am a nurse without a degree and I am throughly good at my job, I have a firm grasp of the evidence behind all nursing procedures and the science behind nursing. I am diploma trained not because I am not very bright, but because I could not afford to undertake a degree. The comments made regarding this article are offensive, do you really think the diploma course is that much different to the degree? This may suprise you all but nurses with diplomas are not sent out to the wards with a limited knowledge of how the body works or the evidence that underpins nursing practice, if we did not have a firm grasp of these things we would not qualify and its as simple as that. The only difference between the degree course at our university and the diploma is an evidence based practice module in which the degree students must write a research proposal, this does not contribute to how we assess or treat our patients!!!!!

Posted by: Nurse M McCartney | 12 Mar 2010 11:59:43