An Overview of Policy Perspectives

The idea of degree education as a minimum entry requirement for nursing practice began many years ago in developed countries and was envisaged, by global health organisations, as a strategy for future nursing (Smith, 2010). It is therefore important to give an overview of the policy, the background effort and the perspective of global organisations to improve nursing education. This section will analyse the specifics of this policy, newly implemented in SA.

Nurse education has seen important changes throughout the 20th and early 21st centuries (Klainberg & Dirschel, 2010). Prior to 2009, global standards for nursing developed in a random manner with no orientation towards standardisation of skills and training (Almadani, 2015). Since then, the development of global standards for the initial education of Nurses and Midwives has taken place in a more organised and integrated manner, led by the World Health Organisation (WHO) and Sigma Theta Tau International (WHO, 2009). The principles articulated at this stage were that nursing education should be based on developing competencies, evidence-based learning and life-long learning, interaction between client and nurse, and inter-professional collaboration (Klainberg & Dirschel, 2010).

32 minimum level for nurse training would be at Bachelor degree level (NMC, 2010). The impetus for this came from the belief that nurses’ need to have a high level of knowledge and skills, commensurate with the requirements of a profession meeting the needs of complex care delivery. Additionally, the changes were intended to safeguard the interests of the public through quality nursing education, providing equal opportunities to nursing students and to create learning opportunities through practical training. (Donley & Flaherty, 2008) suggest that new and emerging issues need to be dealt with by a qualified workforce. For example, the majority of the nurses still lack essential education in certain areas such as health promotion, which is linked to the prevention and treatment of illness, a shortfall in nursing education that could easily be covered in a nursing degree programme, but unlikely to be covered properly through ‘on the job’ experience (Almadani, 2015). In the post-war period, significant developments in nursing degree education were made. Across the policies reviewed in this chapter, these developments have been inspired by the relevant social and economic considerations of the time. Of these the most significant has possibly been the 1965 proposal by the American Nursing Association (ANA), which inspired similar efforts to implement a degree education policy in the UK and other countries (Reiter, 1965; Donley & Flaherty, 2008). The ANA published an early paper about degree-based entry into nursing practice in 1965, advocating that a Bachelor degree should be the minimum level for entry into nursing practice (Reiter, 1965). The reasons for this proposal included a need to strengthen a nursing education system to meet the current and future needs of healthcare (Donley & Flaherty, 2008; Smith, 2010). The Bachelor degree would provide the necessary foundation from where nurses could pursue either practitioner training or research work. According to Smith (2010), during that time only one state (North Dakota) implemented degree education as an entry requirement for nursing practice because it had the power to introduce such a change through its own nursing regulatory board.

The American Association of Colleges of Nursing (AACN), (the national voice for baccalaureate and graduate nursing programmes in the US), believed degree education has a significant impact on the knowledge and competencies of all qualified health care providers (AACN, 2016), and nurses with Bachelor degrees are well prepared to meet the demands of the current and future health care system. Smith, (2010: P3) summarised that

33 the rationale underlying the ANA position paper of 1965 addressing entry to practice;

“the changing role of government, especially its investment in nursing education and manpower training; the changing pattern of education in the US; the increasing availability of collegiate education for women; the expansion of science and technology and its impact on health and healthcare; and the new insights into human health problems”.

Despite the limited success in North Dakota, other states in the US and other countries continued to experiment with the policy and implement it in their unique context (Smith, 2010).

Historically, in the UK two failed attempts were made to introduce the policy in the 20th century, but were met with resistance. The reluctance in adopting the policy has been due to concerns from nurses already in the profession, patients, Trade Unions, universities and the government (Brooks & Rafferty, 2010). There were concerns that making nursing a degree only profession would create a hierarchical environment, making the profession more academic, stripping the field of its compassion, kindness, common sense, communication and caring skills (Brooks & Rafferty, 2010). Furthermore, there were concerns from many that nurses would be too busy dealing with paperwork to be providing the services required from a nurse (Almadani, 2015). For example, some believed that highly educated nurses would be reluctant to meet the personal needs of patients, such as bed bathing. This was evident from the opinions voiced by some trade unions who opposed the policy, suggesting degree educated nurses will generate a segment of the workforce ‘too posh to wash’ though this has been refuted by the Willis Commission (Willis, 2012). The government did not want the extra financial burden of making the policy work and funding it (Brooks & Rafferty, 2010).

However, some of the arguments for the adoption of the policy from nurses already in the profession have centred on degree-educated nurses having more medical knowledge in an ever-evolving field (Donley & Flaherty, 2008). A degree will give nurses more autonomy and will enhance the characteristics of nursing as a profession (AACN, 2016). With an increase in population and a global increase in the shortage of medical staff, degree educated nurses will have the capability to develop the skills necessary to ease the burden

34 on healthcare systems (Smith, 2010). For example, nurses in the US can progress their degree education and skills acquired to become practitioners with prescribing powers (non- medical prescribers) which could allow better health care delivery and more readily meet the needs of the patients (Scrafton, McKinnon, & Kane, 2012; Black & Dawood, 2014; Carberry, Clements, & Headley, 2014). This shift in policy of degree nurse education supporting research in the field has already encourage nurses to have greater involvement in the development of nursing education, practice, policies, and changes in the work environment, among other calls for demonstrating how the change has already given nurses autonomy (Varjus et al., 2011).

Traynor and Rafferty (1999) proposed some of the reforms needed to make such a policy work in the UK and globally. The authors described three sets of conditions required for the transition in making degree education mandatory in nursing; context, convergence and contingency. Traynor and Rafferty (1999) describe context as the need to create positive opinions or pressurise the need for change; convergence is described as the merger of professional and government opinions; and contingency as the need to provide a plan to deal with unforeseen events following implementation, resulting in evolution of the policy. Following the uptake of the degree education policy, graduate nurses have been successful in the work force according to initial results despite fears that the quality of care would be compromised (AACN, 2016).

The duration of the pre-registration programme in developed countries may vary, likewise the Bachelor of Nursing programme is a three to four-year education programme administered at university level leading to professional entry into nursing practice (Smith, 2010). The WHO, (2009: P18) for the initial education of nurses and midwives, stated that

“Nursing or midwifery schools have entry requirements that meet national criteria for higher education institutions including, but not limited to, completion of secondary education.”

Conversely, university admissions in SA have entry requirements to study nursing including, but not limited to, completion of secondary education, the General Aptitude Test

(GAT) and the Standardized Achievement Aptitude Test (SAAT) administered by the National Centre for Assessment in Higher Education, named QIYAS, and meeting the national criteria for MoHE (Siddiek, 2011). The five years’ duration of the BSN

35 programme in SA is considered a long-term period comparing with the developed countries (Almadani, 2015). For example, in Canada, Australia and the US state of North Dakota, the four-year Bachelor of Nursing qualification is currently required as a standard for entry to practice (WHO, 2009). However, compared to the more common 3-year programme, the 4-year programme inducts students at a more basic level and provides the requisite foundation for formal nursing education. Since 2013, the biggest change era, only degree level pre-registration nursing programmes have been offered in the UK (Willis 2012).

Nevertheless, the Bachelor programme for nurses’ contrasts with the Diploma. It includes course work taught in associated degree and diploma programmes, but at a higher level of knowledge that appraises the skills of nurses in critical thinking, research based knowledge, leadership, case management and health promotion (Hendricks et al., 2012). These skills are vital to the performance of evolving nursing roles given the dynamic context where technological development and sophisticated health care practices are creating a complex environment.

In essence, the previous discussion shows how the initial proposal by the ANA to introduce the degree policy was a starting point to bring structure to nursing education. It documents the initial resistance on the part of health care professionals, the difficulties experienced by the educational authorities and the slow progression of the policy in developed countries.

2.5

Summary and Conclusion

This chapter has provided an overview of nursing profession in Islam, history of nursing education, and the nursing workforce in the Saudi context. It has reflected on the concern that the Saudi Heath system is dependent on foreign educated nurses, recruited from different countries, even though the Gulf War in 1990 led to the country facing difficulty recruiting foreign nurses and resulted in severe shortages in the non-Saudi nursing workforce. Despite this fact, the number of Saudi nurses remains too small to meet the national workforce needs and it has been that it would take the country 25 years to build up a qualified national nursing workforce to meet 30% of healthcare services needed in Saudi Arabia (Abu-Zinadah, 2007). This is a key issue, considering that globalisation and

36 education are highlighted as significant indicators of the rapid socio-economic developments in Saudi context. There has been consideration of education delivery and entry requirements by nursing organisations globally and the wealth of information SA has access to from this field has been discussed in order to relate to developing its own healthcare system and manage its workforce, making it fit for the 21st century. The advantage of studying countries that have already implemented the policy to make degree level education a minimum requirement for nursing have been noted as particularly valuable, offering SA the opportunity to consider the positives and negatives of implementing such policies to shape its own policy. This initiative was driven by the need to reform nursing education as the world entered the 21st century, and to address the global impetus to reassess old policies and standardise education, that could more readily meet diverse nursing roles and the global migration of nurses from one country to another. Furthermore, other health related fields were already one-step ahead in offering and making degrees’ mandatory for practice such as physiotherapy, pharmacy and social care. The next chapter will review the current literature in two different sections. The first section will provide an overview of the global and local trends in the nursing workforce, and the second section will use a systemic review of global literature to explore the effectual impact of degree education on patient outcomes in relation to professionalism, education, and experience.

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