11 January 2010

On the education of nurses (in the USA) --and parallels

I know that some readers are in nurse education, so you might be interested in this new report from the Carnegie Foundation for the Advancement of Teaching, in the USA [link from post title]. It parallels in some respects the plan for nursing to become an all-graduate profession in England by 2013. That proposal has been met with some scepticism in the UK.

It does seem that what Etzioni (1969) called the "semi-professions" have been making strenuous efforts in the latter half of the last century to enhance their status. As the citation below shows, he identified teachers, nurses and social workers as the main semi-professions, although since he was writing there are many more candidate occupations. I used to teach social workers, and more recently I have been teaching teachers, among whom have been nurses taking what the Nursing and Midwifery Council terms a "Recordable Teaching Qualification"--so I have a certain amount of knowledge in the area.

When I first taught in a primary school in the early sixties, some of my colleagues had only one year's training, or indeed higher education; they were known as "Emergency Trained" in a scheme developed in the aftermath of WW2 particularly to replace the large numbers of male teachers lost to the occupation. The norm was two years (although there was one teacher on the staff, apart from myself, who was quite untrained). Graduates did not have to be trained.

The first social work course I taught on was just a year long, with no specific entry requirements other than at least six months experience in residential child care. When I moved on from social work education, the Diploma in Social Work was just two years long, but in practice only taken by mature people (in age, at least) with some prior experience. The standard qualification has only been an undergraduate degree for a few years. Strangely at my former institution it is a Bachelor of Science award. Recently, (December 2009) the Social Work Task Force has reported, recommending the equivalent of a probationary year for newly-qualified staff, with extra support and supervision and the estbalishment of a National College for Social Work (presumably to replace the National Institute for Social Work which was closed in 2003...)

And nursing is now either a Diploma or Degree qualified profession, in both cases following a three year course. It moved from being work-based training with study blocks to coming under the auspices of universities in a programme called "Project 2000" from 1992 onwards. This was itself influenced by practice in the USA.

So what?

The first point is that as the fully-qualified staff have moved up the professional scale in each occupation, much of what they used to do has been taken over by lowlier and less-trained people. So much of the routine activity in nursing (and crucially the long-term and continuing patient contact) is now undertaken by Health Care Assistants, whose basic qualification is at National Qualifications Framework (NQF) level 3. Classroom Assistants have become increasingly important in schools, they may have minimal training or be relatively well-qualified with a Foundation Degree; from being primarily concerned to help children with special educational needs, their roles have become broader to the extent that the may be asked to "deliver" lessons using material prepared by a "proper" teacher. And social work has always relied heavily on an army of poorly-paid residential or domiciliary care assistants, nursery nurses and others often with very basic National Vocational Qualifications. So a caste division is established.

Of course, the fully-qualified staff cease to be direct practitioners--they become supervisors and managers. And because of the  institutional anxiety engendered by the fact that direct "user" contact is increasingly undertaken by under-qualified staff, the quality assurance procedures have to be tightened which means that the qualified staff spend even more time in their offices dealing with paperwork... There is also a view which may or may not be legitimate that the new generations of highly-qualified staff are coming to see direct contact, particularly of a routine and even menial kind, as "beneath them".

And... Many commentators have made the point that raising the bar for the final qualification is likely to entail raising entry requirements and thereby excluding  many potential candidates from under-represented groups. I'm not entirely convinced by this argument. Further and higher education institutions are in practice going out of their way to create ladders through sub- and para-professional qualifications to full professional recognition. And--purely on the basis of prejudicial respect for dozens of people I have had the privilege of guiding to that recognition--I need actively to be persuaded that people following this route are not the very best all-round practitioners in their fields. Their commitment, stamina, and practical experience (tempered perhaps by their toleration of being taught by prats like me--putting up with that is not  a commendation)! ...does not merely add--it multiplies their practice wisdom.

But. From a different angle--

What is happening to those left behind?

Policies of social mobility which encourage able people to transcend their origins are great. Up to a point...
  • in a norm-referenced world, for everything which goes up, something must go down.

  • Gramsci (1971) (Italian marxist theorist imprisoned by Mussolini) was concerned about the development of "organic intellectuals" among the working class. Roughly, "traditional intellectuals" are people who think of themselves as such; organic intellectuals are people who undertake intellectual work without recognising themselves or being recognised by others. Gramsci argued that organic intllectuals were a by-product creation of the ruling classes, but that they also had counterparts "embedded" as we should now say within the working classes, in voluntary and community groups, in unions, in churches (not sure where he stood on religion) and families. In his view it was vital that they be enlisted to lead the revolutionary struggle.

  • The problem from this perspective is of course that educationally-promoted social mobility may be seen as "creaming off" the working-class organic intellectuals, thereby leaving working-class communities leaderless and even more disenfranchised than before; hence, it may be argued, "sink estates" and so-called "broken Britain" (and perhaps vulnerability to right-wing demagoguery), as opposed to Hoggart's account of pre-WW2 working-class life in "The Uses of Literacy" (1957).

  • The rise of the semi-professions fits into this argument because of their accessibility to aspirants.
Push the argument further (perhaps too far?) and it suggests that raising the bar for the semi-professions does not enhance but undermines not only the quality of the service they offer, but also the quality of life of a large proportion of the population...

Discuss!

    Etzioni, A. (1969) The Semi-professions and their Organisation: Teachers, Nurses and Social Workers, New York: Free Press


    Hoggart, R (1957) The Uses of Literacy; Aspects of Working Class Life London; Chatto and Windus

    3 comments:

    1. James Morris4:46 pm

      Hi James, top stuff as always.

      I too raised an eyebrow at the Graduate Nurses thing when I first heard it. I'm not sure it's a good plan either, and will probably exclude many potentially excellent future nurses.

      I think I'll blame the government for this one (it's usually either them or television that's at the root of any problem). In the desire (and expectation) to constantly raise standards, we've reached a stage where nobody can get a job without first papering their entire body with certification. There was a time when having no O-levels didn't mean you couldn't get a job, it just meant you got an unskilled job. Now there is a qualification for everything, and this paper becomes a suit of armour in an increasingly litigious society.

      The upshot of this is the segment of the population who used to go straight to nursing college now falls within the 50% of people who are supposed to go to University, so I can sort of understand it.

      There are several underlying, intertwined rants here, forming a Venn diagram of vitriol as it were, but I'll spare you them for the time being. Plus, I'll miss my bus.

      James

      ReplyDelete
    2. Is it pure chance that all three semi-professions mentioned are professionalised versions of traditional female roles?

      ReplyDelete
    3. Isn't this a modern parallel of the mediavel guilds? "all industry in the hands of the guilds who limited freedom of competition to protect their own warm little world" (from Garrett's review of Hilaire Belloc's "The Servile State". Is society well served by this government interference, I wonder?
      And here's the economist Menger on guilds:The guilds sought, by various means, to limit the number of artisans as much as possible (by long apprenticeship, by prohibition of more than a certain number of apprentices, etc.). All these measures were correct from a monopolistic standpoint, since the quantities of the several monopolized commodities reaching the market were regulated in a manner favorable to the monopolists, or to the corporations of monopolists. When freer trade, the emergence of factories, and other influences prevented the guilds from regulating independently the quantities of goods entering the market, the entire guild organization became ineffective so far as its monopolistic character was concerned. Monopolistic fines and similar measures directly influencing price formation at once gave way before the impact of the larger quantities of goods brought to market.

      ReplyDelete

    Comments welcome, but I am afraid I have had to turn moderation back on, because of inappropriate use. Even so, I shall process them as soon as I can.