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Moving Towards an All-graduate Nursing Profession

Published online by Cambridge University Press:  01 August 2009

Pat Smedley
2009 President Elect
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Guest Editorial
Copyright © British Association of Anaesthetic and Recovery Nursing 2009

First, to all those members who do not know me, I would like to introduce myself to you as your new President. I well remember, back in 1992, being asked by Rose Bailey (then Chairman), if I would join the BARNA committee. I confidently agreed, as long as I would not have to do much! I had no idea at the time just how many roles I would take on in the intervening years and certainly would never have dreamt that I would one day be President. As with most things in life – the more you put in, the more you get out. Over the years, my commitment to BARNA has strengthened: it has given me freedom to develop professionally in a way that is just not possible within the confines and constraints of working in the National Health Service (NHS). I have met fantastic nurses both at home and abroad. We have a great deal to work for in BARNA, as anaesthetic and recovery nurses are still largely underdeveloped in the UK. I will be cutting down on my commitment to teaching perioperative modules at Kingston University from September and I hope to have more time to commit to BARNA.

I am writing this at a time when once again, major changes to nurse training in the UK are just round the corner. On 3rd September 2008, the Nursing and Midwifery Council (NMC) ratified the proposal to make nursing an all-graduate profession. By 2015, the minimum academic award for pre-registration nursing will be a degree. The move follows widespread consultation by the NMC over the future of nursing and is part of the Modernising Nursing Careers initiative. The change is highly controversial: the Royal College of Nursing (RCN) voted for, and Unison against the proposal. The Nursing Times website reveals the strength of feeling among nurses. One entry sums up frustration well:

‘Having a degree does not make you a better nurse! What about those who have been nursing for years without one – many of us have wealth of experience – ask the patients what they think – most won’t care as long as the nurse is caring, compassionate and knows what they are doing. You cannot learn how to run a busy ward in a university and other degree professions are usually paid much more than the average nurse!’

Having trained back in the 1970s, when apprentice style nurse training was remarkably efficient in preparing skilled, caring, efficient nurses, capable of running a ward on day one post registration, I have some sympathy with the above statement. However, it really reflects a ripple of discontent dating back to the early 1990s, when the real shake up to nurse training took place. During this period, nurse education switched from Schools of Nursing to Higher Education Institutes, and student nurses were replaced on the wards by Health Care Assistants (HCAs). Most importantly, the academic Diploma replaced the Certificate as the minimum standard for registration. The focus of debate now is more discrete and centres around how will the degree, as opposed to the diploma impact on nurse recruitment, training and career prospects. How will it affect patient care? I want to examine these questions in relation to the perioperative domain.

What is the essential academic difference between graduate, diploma and certificate level? Simply put, certificate level (RGN: Level 4) requires descriptive writing. Diploma (Level 5) requires the ability to analyse and discuss evidence. Degree (Level 6) necessitates the ability to critically analyse evidence and evaluate research reports as well as conducting a research dissertation using statistical tools where appropriate. I have been teaching both Level 5 and 6 post-registration perioperative nurses now for 5 years. When I first heard about the oncoming changes, my heart sank. At some stage leading up to 2015, I will have to up the game and somehow empower all students to succeed at Degree level, as the Diploma level will soon become redundant. Would this necessarily lead to a ‘dumbing down’ of standards I wondered. On reflection, I have changed my mind and think a common pathway towards the Degree will simplify my work.

The current mix of post-registration diploma and degree students is, in many ways artificial. In my current PACU module, I teach each core topic (airway/breathing/circulation) along the lines of risk analysis/planning and evaluating care. This involves critical thinking for Diploma and Degree students. All are examined on a detailed scenario, which requires them to critically appraise the patient for potential and actual complications and then treat appropriately. There is often no distinction between the diploma and the degree student’s answers, and often the diploma students perform better. The critical element is fundamental to informed decision-making in PACU for all practitioners. I guess the bottom line is: can we prepare the less ‘gifted’ students at Degree level? Certainly they need more time, more one-to-one tuition, but is it feasible? The sadness is, that if they do not make the grade, there will be no niche for them to perform as registered practitioners.

What remains vital in this reshuffle will be extended provision for Diploma/Certificate nurses who want to top up their academic qualifications. This is important to maximise the potential of so many non-graduate experienced nurses who will still be delivering care as graduate nurses are coming off the assembly line. It is amazing to witness how empowering academic study is for the experienced certificate nurses who are so often needlessly modest about their academic potential. Maturity, life skills as well as clinical expertise invariably hone their critical analytical powers, which they easily assimilate into their academic studies. Acquiring academic merit empowers them to new heights in their professional lives. For all-graduate nursing to succeed, it is vital to offer user-friendly ways to top up and accredit previous experience and prior learning for all experienced non-graduate nurses. Let us hope that this will be built into the plan.

Just as important as extending opportunities in Higher Education Institutes (HEIs) for top up qualifications, so is reviewing the current provision of bursary’s and grants. While the Diploma students are better supported on a bursary, the graduate, on a means tested grant so often has to take on part-time work to fund themselves through college. This can put many off the Degree entry. So often they make up experience and funds by working weekends and all too often being supervised by non-registered practitioners. Research demonstrates that while nurse graduates’ practical skills may not match those of the old certificate nurse, in time they catch up. The new provision for all-graduate nursing recommends a period of protected mentorship on qualifying, in order for these nurses to consolidate their practical experience. I wonder how much pressure this will put on the qualified staff on the wards that already have so much supervision of non-registered staff on a daily basis. Had we retained apprentice style training and combined it with appropriate study in Higher Educational Institutes, this problem would not exist. Whatever the solution, we owe it to undergraduate nurses to prepare them thoroughly in basic nursing skills and in developing clinical decision making by the bedside.

How will all-graduate nursing affect the experience of the pre-registration student allocated to theatre/post anaesthetic care units (PACUs)? The highly specialised perioperative domain can be a frightening experience for the novice. Here, students rely on the expertise of all experienced nurses, no matter what grade, as well as ODPs to help them gain the most from their brief allocation and hopefully return as graduates. I do not think the undergraduate status of the student will prove challenging any more than the current more general Diploma trainee for the mentors/assessors in this area.

The opportunities presented by the prospect of an all-graduate nursing force within perioperative practice are exciting. For one thing, post-registration modules will automatically include research projects leading to Master’s Degrees as the basic nursing degree that will have been attained. Compared to other critical care specialities, perioperative nursing in the UK is largely under-researched. The potential for changing practice via this means is compelling. It should not only be ‘specialist/advanced practice nurses’ who effect these changes, but all qualified, graduate nurses should be contributing to developing practice in their units. Especially in the PACU, where work comes in and out in waves, there is no excuse not to engage!

This remains a very complex issue especially set against a rapidly changing health care provision driven by demographics, medical/surgical advances, work force directives, consumer demands and, of course, national politics! Certainly work force directives govern patient care provision and I have not addressed the crucial debate about how to best prepare the non-registered health care practitioners who deliver so much basic care in the NHS, and who are being introduced increasingly into the perioperative domain. For the all-graduate nursing scheme to gain public and professional support, I think it is vital that resources are allocated into more extensive training of HCAs both within and without the perioperative domain, and to enable skilled HCAs to progress quickly up the KSF ladder to qualify for entry into academic education. Failure to achieve this will surely create a two-tier profession, one more radical that the old SRN (state registered)/SEN (state enrolled) split. It took years for the profession to facilitate SEN top up training to fully registration. These questions, however, are so important and there are simply no easy answers because it is so difficult to accurately forecast the future and life is changing so fast.

If you have any comments for Pat Smedley, please contact her via e-mail;

PS Since writing this editorial a major report on the ‘cruel and neglectful care of one million NHS patients’ was published by the Patient Association [August 2009]. As usual nurse leaders responded by stating that this situation was unacceptable but that is was not a representative picture across the NHS. Nowhere did I read any intelligent discussion about why this situation has arisen. However nurses are trained: to certificate: diploma or graduate level, if nurses do not deliver excellent bedside nursing care, and take responsibility for the standards of unqualified staff, respect for nursing by the public will diminish and the ‘degree’ badge of honour will be tarnished.

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