tag:theconversation.com,2011:/global/topics/nursing-education-9142/articlesNursing education – The Conversation2021-12-13T13:25:27Ztag:theconversation.com,2011:article/1711022021-12-13T13:25:27Z2021-12-13T13:25:27ZThe US doesn’t have enough faculty to train the next generation of nurses<figure><img src="https://images.theconversation.com/files/434267/original/file-20211128-17-elh123.jpg?ixlib=rb-1.1.0&rect=0%2C11%2C7935%2C5238&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some nursing programs had to turn away students because of a shortage of faculty and clinical sites. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/nurse-attending-to-patients-needs-during-covid-19-royalty-free-image/1257336821"> FatCamera/E+ Collection via Getty Images</a></span></figcaption></figure><p>Despite a national <a href="https://theconversation.com/amid-a-raging-pandemic-the-us-faces-a-nursing-shortage-can-we-close-the-gap-149030">nursing shortage in the United States</a>, over <a href="https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/24802/2020-survey-data-student-enrollment">80,000 qualified applications were not accepted at U.S. nursing schools</a> in 2020, according to the American Association of Colleges of Nursing. </p>
<p>This was <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">due primarily</a> to a shortage of nursing professors and a limited number of clinical placements where nursing students get practical job training. <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">Additional constraints</a> include a shortage of experienced practitioners to provide supervision during clinical training, insufficient classroom space and inadequate financial resources.</p>
<p>Although the 80,000 <a href="https://www.ncsbn.org/LTL_Fall2021.pdf#page=17">may not account</a> for students who apply to multiple nursing schools, it clearly suggests that not all qualified students are able to enroll in nursing school. </p>
<p>I am a nurse researcher, <a href="https://health.usf.edu/nursing/faculty-staff/directory/raynaletourneau">professor of nursing</a> and founding director of <a href="https://health.usf.edu/nursing/partnerships/wires">WIRES</a>, an office at the University of South Florida that focuses on the well-being of the health care workforce. I’ve found that the nursing shortage is a complex issue that <a href="http://healthworkforcestudies.com/news/state_of_the_nursing_workforce_paper.pdf">involves many factors</a> – but chief among them is the shortage of faculty to train future nurses.</p>
<h2>Growing demand for nurses</h2>
<p>There are not enough new nurses entering the U.S. health care system each year to meet the country’s <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm">growing demand</a>. This can have serious consequences for <a href="https://psnet.ahrq.gov/primer/nursing-and-patient-safety">patient safety</a> and <a href="https://doi.org/10.1093/restud/rdaa082">quality of care</a>. </p>
<p>Nationally, the number of jobs for registered nurses is <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6">projected to increase by 9% between 2020 and 2030</a>. </p>
<p>Some states project an even higher demand for registered nurses because of their population and their needs. Florida, for example, will need to <a href="https://projectionscentral.org/Projections/LongTerm?AreaName=&AreaNameSelect%5B%5D=12&Name=nurse&items_per_page=10">increase its number of registered nurses by 16%</a> over the next decade.</p>
<p>The U.S. Bureau of Labor Statistics estimates there will be about <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm">194,500 openings</a> for registered nurses each year over the next decade to meet the demands of the growing population, and also to replace nurses who retire or quit the profession. This means the U.S. will need about <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm">2 million new registered nurses</a> by 2030.</p>
<p>In addition to a shortage of registered nurses, there is also a shortage of nurse practitioners. Nurse practitioner is identified as the <a href="https://www.bls.gov/emp/images/growing_occupations.png">second fastest-growing occupation</a> in the next decade, after wind turbine technicians, with a projected increase of 52.2%. Nurse practitioners have an advanced scope of practice compared with registered nurses. They must complete additional clinical hours, earn a master’s or doctoral degree in nursing, and complete additional certifications to work with specific patient populations. </p>
<p>The COVID-19 pandemic has exacerbated the <a href="https://nursing.osu.edu/news/2021/09/23/new-study-examines-association-between-nurses-well-being-workplace-wellness">health and wellness problems of the nursing workforce</a>. Despite these problems, student enrollment in nursing schools <a href="https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/24802/2020-survey-data-student-enrollment">increased in 2020</a>. The pandemic has not turned people away from wanting to pursue a career in nursing. However, without enough nursing faculty and clinical sites, there will not be enough new nurses to meet the health care demands of the nation. </p>
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<img alt="Women in red scrubs hold signs encouraging people to get vaccinated" src="https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Student enrollment in nursing schools increased in 2020 amid the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/indiana-university-nursing-students-hold-signs-encouraging-news-photo/1235910444">Jeremy Hogan/SOPA Images/LightRocket via Getty Images</a></span>
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<h2>Need for more nursing faculty</h2>
<p>Currently, the national <a href="https://www.aacnnursing.org/Portals/42/News/Surveys-Data/2020-Faculty-Vacancy-Report.pdf">nurse faculty vacancy rate is 6.5%</a>. This is slightly improved from the <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">2019 rate of 7.2%</a>. More than half of all nursing schools <a href="https://www.aacnnursing.org/Portals/42/News/Surveys-Data/2020-Faculty-Vacancy-Report.pdf">report vacant full-time faculty positions</a>. The highest need is in nursing programs in <a href="https://www.aacnnursing.org/News-Information/News/View/ArticleId/25043/data-spotlight-august-2021-Nursing-Faculty-Shortage">Western and Southern states</a>. </p>
<p>Nursing education in clinical settings requires smaller student-to-faculty ratios than many other professions in order to maintain the safety of patients, students and faculty members. Regulatory agencies recommend at least one faculty member to <a href="https://www.ncsbn.org/ga_chapter410.pdf">no more than 10 students</a> engaged in clinical learning.</p>
<p>The faculty shortage is also affected by the fact that many current nursing faculty members are <a href="https://doi.org/10.1016/j.outlook.2017.03.003">reaching retirement age</a>. The percentage of full-time nursing faculty members <a href="https://www.nursingoutlook.org/article/S0029-6554(16)30314-1/fulltext">aged 60 and older</a> increased from roughly 18% in 2006 to nearly 31% in 2015. </p>
<p>The American Association of Colleges of Nursing reports the <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">average ages</a> of doctorally prepared nurse faculty members at the ranks of professor, associate professor and assistant professor were 62.6, 56.9 and 50.9 years, respectively.</p>
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<p>Another factor that contributes to the nursing faculty shortage, and the most critical issue <a href="https://www.aacnnursing.org/Portals/42/News/Surveys-Data/2020-Faculty-Vacancy-Report.pdf">related to faculty recruitment</a>, is compensation. The salary of a nurse with an advanced degree is much higher in clinical and private sectors than it is in academia. </p>
<p>According to a survey by the American Association of Nurse Practitioners, the <a href="https://www.aanp.org/about/all-about-nps/np-fact-sheet">median salary of a nurse practitioner</a>, across settings and specialties, is $110,000. By contrast, the AACN reported in March 2020 that the <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">average salary for master’s-prepared assistant professors</a> in nursing schools was just under $80,000. </p>
<figure class="align-center ">
<img alt="Two people wearing face masks and scrubs fill a syringe" src="https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=442&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=442&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=442&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=556&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=556&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=556&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A registered nurse, at right, helps a nursing student prepare a dose of the COVID-19 vaccine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/western-university-of-health-sciences-master-nursing-news-photo/1300409969">Will Lester/MediaNews Group/Inland Valley Daily Bulletin via Getty Images</a></span>
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<h2>Fixing the faculty shortage</h2>
<p>Innovative strategies are needed to address the nursing faculty shortage. The <a href="https://www.congress.gov/bill/116th-congress/house-bill/728">Title VIII Nursing Workforce Reauthorization Act of 2019</a> was a start. The act provides funding for nursing faculty development, scholarships and loan repayment for nurses, and grants for advanced nursing education, nursing diversity initiatives and other priorities.</p>
<p>The Build Back Better Act that <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376">passed the U.S. House of Representatives</a> in November 2021 includes funding to help nursing schools across the country recruit and retain diverse nursing faculty and enroll and retain nursing students. The act is now before the U.S. Senate.</p>
<p>In addition to national strategies, individual states are addressing the shortage at the local level. Maryland, for example, awarded over <a href="https://mhec.maryland.gov/Pages/6-3-20.aspx">$29 million in grants</a> to 14 higher education institutions with nursing programs in Maryland to expand and increase the number of qualified nurses.</p>
<p>Finally, offering faculty salaries comparable to those in clinical settings may attract more nurses to use their expertise to train and expand the next generation of health care workers.</p><img src="https://counter.theconversation.com/content/171102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rayna M. Letourneau receives funding from philanthropic supporters to build programs to recruit and retain competent nurses and nursing students into the profession. </span></em></p>The US has a growing demand for nurses. Yet nursing schools are turning away many qualified candidates.Rayna M. Letourneau, Assistant Professor of Nursing, University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1570542021-04-28T20:08:28Z2021-04-28T20:08:28ZMy partner or my degree: a choice that exposes how students battle gender inequity<figure><img src="https://images.theconversation.com/files/396953/original/file-20210426-13-1an4puy.jpg?ixlib=rb-1.1.0&rect=0%2C20%2C6720%2C4446&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lazy-husband-sitting-couch-using-phone-1779932177">Shutterstock</a></span></figcaption></figure><p>The current focus on gender equity has meant universities are promoting and investing in strategies to overcome gender-related factors known to hinder women academics’ success. While these are positive steps, female university students burdened by gender inequities have been largely overlooked. <a href="https://doi.org/10.1080/03075079.2020.1861597">Our research</a> explored the impacts of traditional societal expectations of women’s domestic roles on mature-age nursing students. More than one in four separated from their partners, with most indicating they did this so they could complete their studies. </p>
<p>All our research participants were living with a male partner. In these relationships, traditional gender responsibilities associated with “being female” can threaten their ability to engage and achieve at university. At the same time, the stability of their family unit is undermined. </p>
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Read more:
<a href="https://theconversation.com/how-covid-is-widening-the-academic-gender-divide-146007">How COVID is widening the academic gender divide</a>
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<p>Women students are <a href="https://theconversation.com/yes-women-outnumber-men-at-university-but-they-still-earn-less-after-they-leave-142714">in the majority</a> in Australian higher education. In undergraduate nursing they account for <a href="https://www.voced.edu.au/content/ngv%3A57229">90% of enrolments</a>.</p>
<p>Nursing degrees are steadily losing favour with school leavers but are <a href="http://dx.doi.org/10.1515/1548-923X.2334">increasingly attractive to older women</a>. Many of them are considering a career for the first time after having children. The <a href="http://hdl.voced.edu.au/10707/384852">rise in the average age</a> of nursing students means more are living with a partner than ever before. </p>
<h2>‘Women’s work’ hinders study</h2>
<p>For <a href="https://doi.org/10.1080/03075079.2020.1861597">our research</a>, we conducted 52 in-depth interviews with 29 participants across the degree journey at an Australian university nursing school. Analysis of their responses identified the influences on their studies off traditional societal expectations of women’s roles and responsibilities. </p>
<p>Every participant took main or sole responsibility for childcare and housework before they began their degree. This reflects commonly reported <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0%7E2016%7EMain%20Features%7EEmployment%20Data%20Summary%7E67">divisions of domestic work</a> in Australian households.</p>
<p>The unequal division of duties continued during their time at university – the woman’s study commitment or the time each partner spent in paid work made no difference. Partners remained unwilling to share the domestic load. </p>
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<p>“No he never compromised. To him all he really had as a responsibility was his work.” (Lauren*, 32).</p>
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<strong>
Read more:
<a href="https://theconversation.com/covid-forced-australian-fathers-to-do-more-at-home-but-at-the-same-cost-mothers-have-long-endured-154834">COVID forced Australian fathers to do more at home, but at the same cost mothers have long endured</a>
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<h2>University practices add to the problem</h2>
<p>Aspects of the degree curriculum and its delivery made the women’s situation worse. Most notable was the university’s practice of allocating clinical placements without consulting students. Some placements were far from home. </p>
<p>In addition, hospital placement providers often gave students minimal notice of shift patterns. They were left to struggle to reorganise paid work arrangements and secure childcare. </p>
<blockquote>
<p>“Practical placements are horrendous when you’ve got a young family and you don’t get your shift roster until a week and a half before you go. I mean some hospitals, you get it on the day you turn up there.” (Candice*, 40).</p>
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<img alt="Tired nurse completes notes in ward" src="https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Work placements far from home, often made with little notice or consultation, add to nursing students’ difficulties.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/overworked-nurse-wrinting-on-clipboard-working-1931087729">Shutterstock</a></span>
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<p>Much-needed student academic and digital support workshops tended to be planned outside the curriculum. This made sessions, especially those held in the early evening, less accessible to these time-poor students. The almost ubiquitous initial lack of digital literacy among the women in this study meant online workshops were similarly inaccessible.</p>
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<p>
<em>
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Read more:
<a href="https://theconversation.com/its-not-about-you-how-to-be-a-male-ally-158134">'It's not about you': how to be a male ally</a>
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</em>
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<h2>Compromise and sacrifice</h2>
<p>The stress of the competing demands of the women’s studies and their private lives coupled with the lack of domestic support from partners created tension in their relationships. </p>
<p>Partners resented the time the women took away from the family to study. They often withdrew emotional support over time. Some women described partners as “obstructive” to their academic progress. Most described periods of relationship conflict. </p>
<blockquote>
<p>“It was anger and verbal abuse … He would just put me down as far as my study goes … in a way of demeaning the study, like it doesn’t really matter about my nursing degree at the end of the day.” (Jennifer*, 46). </p>
</blockquote>
<p>The women described how they made compromises to remain at university and appease their partners. Some sacrificed sleep and socialising with friends and family. Most consciously lowered their personal achievement expectations. </p>
<blockquote>
<p>“I had to base my course around my family. I think if I did have more time, more freedom to choose […] [it] would definitely have increased my grades.” (Georgia*, 23).</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-arent-better-multitaskers-than-men-theyre-just-doing-more-work-121620">Women aren't better multitaskers than men – they're just doing more work</a>
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</em>
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<p>More than a quarter of the women separated from their partners later in their studies. Most of them indicated this had been a conscious decision to enable them to complete their degree. </p>
<blockquote>
<p>“I realised something needs to give and it’s not going to be my degree. It just wasn’t going to work so I gave him the flick.” (Charlotte*, 30).</p>
</blockquote>
<h2>Implications for nursing and an ageing society</h2>
<p>The heterosexual intimate relationship can act as a direct challenge to women nurse students’ progression and achievement. With women studying nursing later in life, this has serious implications for nurse education and the supply of fully prepared graduates to the workforce. </p>
<p>The <a href="https://www.aihw.gov.au/getmedia/19dbc591-b1ef-4485-80ce-029ff66d6930/6_9-health-ageing.pdf.aspx">rise in the nursing needs</a> of Australia’s ageing population compounds the problem of a <a href="https://www.voced.edu.au/content/ngv%3A57229">projected shortage of nurses</a>. These trends heighten the significance of nursing students’ situation. </p>
<p>More widely, the implications of relationship breakdowns on the mental and financial health of those affected should not be forgotten. </p>
<h2>What can universities do?</h2>
<p>The idea of the nurse student as a single autonomous agent who can prioritise the university over “traditionally female” domestic roles at home is at odds with reality. Universities need to acknowledge the substantial impacts of gendered expectations and responsibilities on women students. </p>
<p>Universities are notoriously reluctant to pry into students’ private lives. They see this as outside their remit. In reality, universities can improve engagement opportunities for their women nurse students in many ways. </p>
<p>Some universities are beginning to offer workshops that prepare students for the digital requirements of study at the start of the degree. They are also embedding academic literacy support across the curriculum. </p>
<p>There is still more they can do. Simple strategies include involving students in clinical placements to ensure these are accessible, providing placement information in good time, and providing accessible childcare that meets the ad hoc and changing needs of students. Training of university counsellors could also be expanded to support students in relationship crisis.</p>
<p><em>* Pseudonyms have been used to protect study participants’ privacy.</em></p><img src="https://counter.theconversation.com/content/157054/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Andrew does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nursing students are 90% female, often mature-age students who are still expected to carry most of the housework and childcare load while they study. Something has to give.Lesley Andrew, Course Coordinator, Postgraduate Public Health, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1255382020-05-11T20:27:03Z2020-05-11T20:27:03ZRecognizing history of Black nurses a first step to addressing racism and discrimination in nursing<figure><img src="https://images.theconversation.com/files/333793/original/file-20200509-49546-yjxbvz.jpg?ixlib=rb-1.1.0&rect=351%2C0%2C4536%2C3246&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Black nurses meet a number of barriers in health-care practice.</span> <span class="attribution"><span class="source">(Hush Naidoo/Unsplash)</span></span></figcaption></figure><p>During the coronavirus pandemic, nurses are among the nation’s front-line workers. Over the years and to this day, the contributions of Black nurses are hard-fought, unrecognized and under-appreciated.</p>
<p>Nurses are essential in care delivery, policy directives and in shaping the health-care system. <a href="https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020">The year 2020 is the year of the nurse and midwife</a>. Yet, Canada’s history of racism and segregation has contributed to residual anti-Black racism that remains present in Canadian nursing. </p>
<p>Nursing, as a profession, was established on <a href="https://doi.org/10.1891/1062-8061.17.129">Victorian ideals of “true womanhood”</a>, including notions of <a href="https://doi.org/10.1111/jan.12289">dignity, purity, morality and virtue</a>. Think: white caps and pristine white smocks.</p>
<p>Historically, people who did not meet these “ideals” were prevented from practising nursing. It was believed that Black women did not possess these ideals of “true womanhood” and in turn, were prevented from <a href="https://doi.org/10.1891/1062-8061.17.129">pursuing nursing as a career</a>. Many of these unconscious biases and stereotypes about nursing are still believed today, with evidence showing that the exclusion of Black folks and anti-Black practices persist in nursing.</p>
<h2>Beginning with oppression</h2>
<p>In Canada, the first nursing training facility <a href="https://www.casn.ca/wp-content/uploads/2016/12/History.pdf">opened in 1874</a> in Ontario. The first baccalaureate nursing program started in 1919 at <a href="https://www.questia.com/read/88917918/legacy-history-of-nursing-education-at-the-university">the University of British Columbia</a>. </p>
<p><a href="https://utorontopress.com/ca/moving-beyond-borders-4"><em>Moving Beyond Borders</em></a>, Karen Flynn’s 2011 account of the racial segregation in Canadian nursing, vividly describes the experiences of Canada’s earliest Black nurses.</p>
<p>As Flynn notes, Black folks were not permitted to attend nursing programs. Instead, prospective Black nurses in Canada were <a href="https://www.jstor.org/stable/40034391">told to go to the United States</a>. American schools began <a href="http://doi.org/10.2307/2294691">allowing Black folks into nursing in the 1870s</a> while Canada continued to restrict admissions to Black folks until the 1940s, granting admission only after pressure from community groups and organizations. </p>
<p>Ruth Bailey and Gwennyth Barton were the first Black nurses to earn a nursing diploma in Canada from the Grace Maternity School of Nursing in Halifax, graduating in 1948 — <a href="https://www.jstor.org/stable/40034391?seq=1#metadata_info_tab_contents">almost three-quarters of a century after the first school opened</a>.</p>
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<h2>Black nurses in Canada</h2>
<p>Overall, Black nurses are largely absent from leadership positions and specialty practice areas such as intensive care. Instead, Black nurses are often streamlined into areas that are <a href="https://cws.journals.yorku.ca/index.php/cws/article/viewFile/6316/5504">more physically demanding and strenuous</a>. At the same time, Black people are concentrated in entry-level positions, non-specialty roles or in non-licensed clinical roles <a href="https://doi.org/10.1111/j.1365-2834.2012.01442.x">such as personal care workers</a>. </p>
<p><a href="https://doi.org/10.1111/jocn.14505">Beyond physical challenges and visibility</a>, Black nurses are subjected to micro-agressions and racism from patients, colleagues and superiors.</p>
<p>Gender and class have a substantial impact on Black women nurses <a href="https://doi.org/10.1111/j.1755-618X.1996.tb02457.x">with the nursing profession having successfully racialized gender and class discrimination</a>. Men who enter nursing usually ride the glass escalator: <a href="http://doi.org/10.2307/3096961">leadership, higher wages and other substantial advantages</a>. </p>
<p>It’s a marked contrast to Black women who do not encounter a glass ceiling but rather they hit a concrete wall from simultaneous racism and sexism; <a href="https://books.google.ca/books?id=ufpyDwAAQBAJ&dq=Our+Separate+Ways:+Black+and+White+Women+and+the+Struggle+for+Professional+Identity&source=gbs_navlinks_s">their existence is invisible, yet their mistakes and flaws are amplified</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333794/original/file-20200509-49573-1q84mpf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Unlike their white male colleagues, Black nurses are less likely to be in leadership roles or to receive higher wages.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<h2>Racism reinforced through nursing education</h2>
<p>In 2013, I proudly graduated from a nursing program with more than 10 Black soon-to-be nurses. At that time, there were designated seats for qualified Black applicants <a href="https://doi.org/10.2202/1548-923x.1111">resulting in a 100 per cent increase in enrolment for Black students</a>. </p>
<p>After the removal of these designated seats, the program now graduates far fewer Black nurses each year. I hear similar findings from nursing graduates at other universities. Yet, despite evidence regarding <a href="https://www.ubcpress.ca/the-equity-myth">inequity amongst faculty appointments</a> in universities, most Canadian institutions <a href="https://www.universityaffairs.ca/opinion/in-my-opinion/universities-serious-data-gap-race/">do not collect nor publish race-disaggregated data related to the student population</a>.</p>
<p><a href="https://brighterworld.mcmaster.ca/articles/black-students-still-face-major-hurdles-getting-into-university/">Multiple barriers</a> limit access to post-secondary education for Black students. However, issues within nursing education go beyond admissions. </p>
<p>Considering what is taught in nursing school, <a href="https://doi.org/10.1016/s0020-7489(99)00051-6">we see stark examples of anti-Black racism embedded within a curriculum</a> that not only reinforces the invisibility of Black nurses but also exacerbates health inequities. </p>
<p>What is taught is largely void of the contributions to nursing made by Black pioneers. For example, nurses are not taught about Bernice Redmon, who was refused admissions to Canadian nursing programs, trained in Virginia before returning to Canada in 1945. Redmon became <a href="https://rnao.ca/sites/rnao-ca/files/Pages_from_Jan-Feb_Pres_View_0.pdf">the first Black nurse appointed to the Victorian Order of Nurses in Canada</a>. </p>
<p>The nursing curriculum continues to be riddled with <a href="https://www.bbc.com/news/blogs-trending-41692593">colonial, anti-Black, heteronormative and hegemonic content</a>. For most of nursing’s history, aspiring nurses have been taught how to care for white, straight and gender-binary patients. If this is not you, even a <a href="https://doi.org/10.1016/j.jnn.2010.03.002">routine hair, skin or health history assessment can pose a challenge</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/333501/original/file-20200507-49546-ixxah6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/333501/original/file-20200507-49546-ixxah6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333501/original/file-20200507-49546-ixxah6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333501/original/file-20200507-49546-ixxah6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333501/original/file-20200507-49546-ixxah6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333501/original/file-20200507-49546-ixxah6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333501/original/file-20200507-49546-ixxah6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Black nurses are still trained to work with white patients in mind, posing a challenge for attending to many racialized patients’ needs.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Anti-Black racism in nursing is detrimental to Black nurses and to the health of all Canadians, especially since Black folks suffer from high rates of chronic illnesses including <a href="https://doi.org/10.1503/cmaj.071279">diabetes, high blood pressure and mental illness</a>. These health inequities are worsened by an undertone of mistrust towards a health-care system that does not have health-care workers who <a href="https://cjnr.archive.mcgill.ca/article/view/2069/2063">look like you nor who understand your health needs</a> — <a href="https://doi.org/10.1073/pnas.1516047113">leading to misdiagnosed or undertreated conditions</a>. </p>
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Read more:
<a href="https://theconversation.com/study-racism-shortens-lives-and-hurts-health-of-blacks-by-promoting-genes-that-lead-to-inflammation-and-illness-122027">Study: Racism shortens lives and hurts health of blacks by promoting genes that lead to inflammation and illness</a>
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<h2>Towards an anti-racist profession</h2>
<p>There are successful initiatives in place. The Faculty of Medicine at <a href="http://applymd.utoronto.ca/black-student-application-program">the University of Toronto</a> has made great strides in combating anti-Black racism through the Black applicant stream and the collection of race-disaggregated data. </p>
<p><a href="https://www.dal.ca/faculty/law/indigenous-blacks-mi-kmaq-initiative.html">At the Dalhousie Schulich School of Law</a>, a successful program established in 1989 has increase the representation of indigenous Black and Mi’kmaq students in the legal profession. Select universities, like Dalhousie, offer entrance scholarships for Black students as a means to alleviate financial barriers.</p>
<p>Nursing can learn from these bold, innovative ideas and work towards adopting anti-racist frameworks in education and practice. This begins by actively recognizing, appreciating and celebrating Black nurses and their contributions in nursing. </p>
<p>Despite the persistence of anti-Blackness in society, nursing education and health care, Black nurses continue to provide care. Now, more than ever, we must recognize and celebrate their contributions.</p><img src="https://counter.theconversation.com/content/125538/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keisha Jefferies receives funding from Vanier Canada Graduate Scholarship, Killam Trust, Research Nova Scotia, Johnson Scholarship Foundation and Dalhousie University. </span></em></p>Anti-Blackness lingers in nursing and continues to limit access for Black folks, especially within nursing schools.Keisha Jefferies, PhD Candidate, Nursing, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1342422020-04-01T05:16:22Z2020-04-01T05:16:22ZUsing nursing assistants to fill coronavirus gaps brings risks if they’re not up to the job<figure><img src="https://images.theconversation.com/files/324483/original/file-20200401-66109-l7q7hc.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7877%2C4443&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/Have a nice day Photo</span></span></figcaption></figure><p>The number of people going to hospital with the coronavirus is expected to rise, putting a strain on our health and aged care services and their workforce.</p>
<p><a href="https://www.canberratimes.com.au/story/6701301/student-nurses-to-join-health-ranks-in-the-battle-against-covid-19/">Australian undergraduate student nurses</a> and those <a href="https://www.afr.com/politics/federal/student-nurses-could-be-a-great-asset-when-virus-peaks-20200318-p54bdz">health workers here on visas from overseas</a> are being encouraged to work as nursing assistants during this COVID-19 pandemic.</p>
<p>This is in keeping with the worldwide trend of employing more nursing assistants in health and aged care services.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/supplies-needed-for-coronavirus-healthcare-workers-89-million-masks-30-million-gowns-2-9-million-litres-of-hand-sanitiser-a-month-134786">Supplies needed for coronavirus healthcare workers: 89 million masks, 30 million gowns, 2.9 million litres of hand sanitiser. A month.</a>
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<p>But <a href="https://www.acn.edu.au/wp-content/uploads/white-paper-regulation-unregulated-health-care-workforce-across-health-care-system.pdf">questions remain</a> about the differences in training of nursing assistants compared to regulated nurses (registered and enrolled nurses) and the tasks they are able to undertake.</p>
<h2>An unregulated workforce</h2>
<p>As nursing assistants are unregulated, their training and clinical practice is not controlled by professional bodies or governments.</p>
<p>Training is certainly recommended, but it is not compulsory, and content between training organisations can be different. Therefore, <a href="https://doi.org/10.1111/jan.14354" title="A systematic review of activities undertaken by the unregulated nursing assistant">nursing assistants working in hospitals and residential aged care facilities</a> may have completed an on-line course, a <a href="https://www.aqf.edu.au/aqf-qualifications">Certificate III</a> qualification, completed one year of undergraduate nursing studies or have a nursing qualification from overseas. They may have had no training at all.</p>
<p>Visa holders can work as a nursing assistant while their overseas nursing qualifications are being assessed by the <a href="https://www.nursingmidwiferyboard.gov.au/Registration-and-Endorsement/International.aspx">Nursing and Midwifery Board of Australia</a>.</p>
<p>It is these last two examples, undergraduate nursing students in Australia or overseas trained nurses, that the <a href="https://www.smh.com.au/national/visa-work-restrictions-lifted-on-20-000-international-student-nurses-20200318-p54bfz.html">Prime Minister Scott Morrison recommends</a> organisations seek to recruit.</p>
<h2>What a nursing assistant can do</h2>
<p><a href="https://www.health.nsw.gov.au/workforce/Documents/AIN-acute-care-position-description.pdf">Nursing assistants can work</a> under the supervision of a registered or enrolled nurse to help provide basic nursing care such as showering, hair, skin and mouth care. They can assist with activities essential for daily living including helping people with dressing and feeding. </p>
<p>They may also perform simple wound dressings, transport stable patients or residents between beds or wards, and undertake nursing observations such as pulse, temperature and respiratory rates.</p>
<p>Using student nurses and current visa holders seems like a potential solution to a possible staffing crisis. But is it?</p>
<p>For student nurses, there is considerable variation in the course structure offered by universities, who each write their own curricula within the boundaries of the <a href="https://www.anmac.org.au/about-anmac/about">Australian Nursing and Midwifery Accreditation Council</a>.</p>
<p>This means not all students will have had the same clinical experience or completed the same content by a given point in their course. Therefore they may not have equivalent knowledge or skills before working as a nursing assistant.</p>
<h2>Patients at risk?</h2>
<p>This variation may be a problem and there is a lot of evidence that a higher number of unregulated nurses and a lower number of regulated nurses increases the risk of <a href="https://theconversation.com/replacing-registered-nurses-isnt-the-answer-to-rising-health-costs-25739">patient infections</a> and other <a href="https://www.sciencedirect.com/science/article/pii/S0020748916301559" title="The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: An analysis of administrative health data">adverse events in hospitals</a>) and the <a href="https://theconversation.com/our-ailing-aged-care-system-shows-you-cant-skimp-on-nursing-care-115565">aged care</a> sector.</p>
<p>For example, nursing people with an infectious disease requires scrupulous attention to detail and meticulous use of Personal Protective Equipment (PPE) to prevent further spread.</p>
<p>There are <a href="https://theconversation.com/why-singapores-coronavirus-response-worked-and-what-we-can-all-learn-134024">correct ways to apply</a> and remove a mask and gown. A tiny slip-up can put the wearer and others at risk of contamination.</p>
<p>Working as nursing assistants can provide undergraduate students with valuable clinical experience. Our recent <a href="https://doi.org/10.1111/jan.14354" title="A systematic review of activities undertaken by the unregulated nursing assistant">research</a> shows most nursing activities performed by nursing assistants are those personal care activities described above.</p>
<p>But we found around one-third of tasks they performed require a higher level of skill and knowledge and should therefore be performed by regulated nurses.</p>
<p>This may explain why the rate of adverse events increases with more unregulated nurses. With the projected increase in patients who may need intensive care, experienced qualified nurses who can work without supervision will be needed.</p>
<h2>Can retired nurses help?</h2>
<p>Some have recommended recruiting <a href="https://theconversation.com/how-well-avoid-australias-hospitals-being-crippled-by-coronavirus-133920">retired nurses</a> to help staff intensive care units. Again, this is fraught with problems. </p>
<p>Working nurses are ageing – the average age is about 45 – with two out of five aged <a href="https://www.aihw.gov.au/reports/workforce/nursing-and-midwifery-workforce-2015/contents/who-are-nurses-and-midwives">50 and over</a>. So most retired nurses are likely in their 60s or older.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-the-time-of-coronavirus-donating-blood-is-more-essential-than-ever-134541">In the time of coronavirus, donating blood is more essential than ever</a>
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<p>The two age groups – the over 50s and the over 60s – are precisely those at risk of a severe response to the coronavirus, which could make staffing shortages and the demand for beds much worse. </p>
<p>Perhaps a more effective and sustainable solution would be to use Australian Defence Force nurses who are all regulated, presumably fit and who have been prepared to deal with emerging crises at short notice.</p>
<p>Australia is clearly going to need innovative ways to ease pressure on the health workforce over the coming months. If we’re going to recruit student nurses and current visa holders, we need to make sure all have been trained and assessed to the same standard.</p><img src="https://counter.theconversation.com/content/134242/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Blay is a member of the Australian College of Nursing </span></em></p><p class="fine-print"><em><span>Christine Duffield receives funding from the Australian Research Council.
Fellow of the Australian College of Nursing</span></em></p><p class="fine-print"><em><span>Michael Roche has received funding from the Australian Research Council. He is a member of the Australian College of Nursing. </span></em></p>We need to make sure those brought in to help cope with the pandemic have adequate training to avoid any risks in patient care.Nicole Blay, Research Fellow - workforce, Western Sydney UniversityChristine Duffield, Professor, Nursing and Health Services Management, Faculty of Health, University of Technology SydneyMichael Roche, Associate Professor Mental Health Drug and Alcohol Nursing, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/823372017-09-07T12:50:39Z2017-09-07T12:50:39ZNot all nursing students make the grade but mentors need more support to fail them<figure><img src="https://images.theconversation.com/files/185051/original/file-20170907-8341-lob90w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-female-nurse-hospital-corridor-360888332?src=vJAHWeXlACBHzB-WBcrWZQ-1-6">Syda Productions/Shutterstock</a></span></figcaption></figure><p>How would you feel if dentists did not measure up to scrutiny as they were about to turn on the drill? Or if doctors did not have the skills to diagnose as they walked on the ward? We need to feel confident that people in positions of trust are knowledgeable and can provide proficient services. One way that this happens is through mentors, who nurture and teach new members of staff and students on the job.</p>
<p>Yet there is evidence of a culture of “<a href="https://www.ncbi.nlm.nih.gov/pubmed/27428804">failing to fail</a>” – where students are allowed to pass despite not meeting the required standard – across several professions for a number of years. And our <a href="http://onlinelibrary.wiley.com/doi/10.1111/jan.13292/epdf">newly published research</a> has found that the nursing profession is no less prone to it. </p>
<p>In the UK, nursing students work in clinical practice where they are assessed by <a href="https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-to-support-learning-assessment.pdf">nurse mentors</a>. In total, students must spend 2,300 hours in a hospital, surgery or other practice before they can qualify. However, some students – particularly those on the borderline of achievement – are not meeting the expected standards on these placements. Despite this there is still the potential for them to be passed by their mentors, and then for them to register and work.</p>
<p>Given the alarming number of nursing vacancies <a href="https://www.nursingtimes.net/news/workforce/more-experienced-nurses-quitting-profession-warns-rcn/7020630.article?blocktitle=...1%2525-pay-cap&contentID=25819">across the country</a>, it is paramount that safe staffing is not just about the number of nurses employed, but about ensuring their skills and competence. </p>
<h2>Competence and controversy</h2>
<p>The nurse mentor role is essential to gate-keeping professional standards, but we found that some mentors’ assessments can be compromised by a number of personal, professional and organisational pressures. A sense of lone accountability, the emotional burden of failing someone, resource limitations, and lack of recognition of their assessing role, can all influence their decisions.</p>
<p>Interestingly, nurse mentors often have to still be encouraging to student mentees even when there is not much chance of them passing. They invest time and effort in nurturing students’ development to the point where it is difficult for them to know when to let students down. </p>
<p>The mentors feel personally responsible for a failing student’s lack of progress, and find it extremely difficult to explain their reservations about failing students, particularly in writing. These concerns mean that they may be tempted to give a student the benefit of the doubt. As Fay, one of the nurse mentors in our study, said: “You need the student to be there with you – especially when they are not up to the mark – but you don’t always have the time or the staffing levels to be able to do that.”</p>
<h2>Supporting mentors</h2>
<p>Our findings show how failing nursing students raise the stakes of mentorship to extraordinary levels of emotion and commitment. This is quite different from usual educational relationships where students and mentors/teachers equally contribute to a shared learning experience.</p>
<p>However, we discovered that the emotional turmoil of mentors could be reduced where assessment decisions are not viewed as a lone responsibility, and teams agree on a level of competence needed for a student to pass. There also needs to be recognition of the mentor’s emotional effort in any difficult circumstances, and an acknowledgement of the work that was put into failing mentor/mentee relationships.</p>
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<img alt="" src="https://images.theconversation.com/files/185052/original/file-20170907-8355-1191pyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/185052/original/file-20170907-8355-1191pyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185052/original/file-20170907-8355-1191pyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185052/original/file-20170907-8355-1191pyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185052/original/file-20170907-8355-1191pyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185052/original/file-20170907-8355-1191pyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185052/original/file-20170907-8355-1191pyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Teaching, encouraging, learning.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-nurse-teaching-junior-293664350?src=XkD_ZxCT2tcpO8wYVyAJag-1-14">Samrith Na Lumpoon/Shutterstock</a></span>
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<p>In addition, nurse mentors are more likely to trust their own assessments of failing students when their decisions were listened to and acted on by others involved in the student’s education. When mentors feel there is a wider acknowledgement of their role in assessing failing students, they feel more authorised to act, and so there is less potential for the student to pass when they should not have. </p>
<p>Likewise, the way failing students are supported by their educational institution and the healthcare organisation they are training with has a crucial connection to mentors’ perceptions about professional standards. Ideally the mentor role should be made more official, and seen as central to gate-keeping professions, rather than potentially as a tick-box exercise. As another nurse mentor, Mary, said:</p>
<blockquote>
<p>It’s about thinking of the greater good. I mean if you don’t bring concerns to the fore the student won’t ever change.</p>
</blockquote>
<p>High quality learning and assessment is fundamental to maintaining professional nursing standards, not least because there is evidence that <a href="https://theconversation.com/youre-more-likely-to-survive-hospital-if-your-nurse-has-a-degree-61838">reduced mortality occurs</a> in services with more graduate nurses.</p>
<p>The UK Nursing and Midwifery Council is currently consulting on a new <a href="https://www.nmc.org.uk/education/education-consultation/">mentorship framework</a> with final standards to be published early in 2018. This model will separate the supervising and assessing roles of a mentor, and there will be more of a practice team approach to assessing students. Already there have been some promising signs that a whole team approach to assessment will help to alleviate the issue.</p>
<p>Ultimately, the credibility of mentor assessments is pivotal to public confidence in the nursing profession, and in the way that nurses are taught under the degree system. There is extensive evidence that working towards a degree and being a competent, compassionate nurse is <a href="https://www.nursingtimes.net/Journals/2012/11/02/j/c/c/Willis-Commission-report-2012.pdf">entirely possible</a>. Now, we just need to make sure that the mentor system supports both teachers and students to achieve the high standards required.</p><img src="https://counter.theconversation.com/content/82337/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Coffey has received research funding from National Institute for Health Research, Health and Care Research Wales, and Research Capacity Building Collaboration Wales. He is a member and past chair of the Mental Health Nurse Academics UK group.</span></em></p><p class="fine-print"><em><span>Fiona Murphy and Simon Cassidy do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nursing students are passing placements when they shouldn’t be.Simon Cassidy, Practice Education Facilitator, Swansea UniversityFiona Murphy, Professor of Clinical Nursing, University of LimerickMichael Coffey, Associate Professor, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/476132015-09-16T11:01:37Z2015-09-16T11:01:37ZNursing shortage: if we let them come will they be able to stay?<p>The <a href="http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf">Francis Report</a> into the malpractice at the Mid-Staffordshire NHS Foundation Trust marked a defining moment concerning nurse staffing. The report contained much about governance and management but it was its attention to quality assurance and staffing that were seminal. </p>
<p>The message was that rigour and responsiveness are necessary <a href="http://www.rcn.org.uk/__data/assets/pdf_file/0018/541224/004504.pdf">in determining safe nurse-staffing levels</a> and their neglect produces the inevitable failings that arose at Mid Staffordshire. The view of Francis on the development, sustenance and reporting of safe staffing levels was <a href="https://www.gov.uk/government/publications/berwick-review-into-patient-safety">universally endorsed</a> across the health and care sector.</p>
<p>The mounting vacancy rate in nursing is self-explanatory: the country is not training sufficient students to replace losses of qualified staff for reasons including retirement or a change of career, or moving abroad – more nurses are now moving abroad than are coming to the UK to practice. </p>
<p>The result is failed provision of appropriate quality care and defective patient safety. The extent of insufficient recruitment to training is also plain. In this fiscal year 2015-2016, training places <a href="http://www.nuffieldtrust.org.uk/media-centre/press-releases/nuffield-trust-responds-nurse-shortage-warning?gclid=CMvIoOit7scCFcRAGwodAFML7g">increased by 989 to just under 23,000</a>. Given that it is estimated that the NHS faces <a href="http://www.nursingtimes.net/nursing-practice/specialisms/management/nhs-to-face-chronic-nurse-shortage-by-2016/5059871.article">having 48,000 fewer nurses than needed by 2016</a> this represents a clear shortfall.</p>
<p>Retaining nurses once they are qualified is a contentious matter that <a href="http://www.ncbi.nlm.nih.gov/pubmed/17184373">has been widely debated</a>. But despite there being no shortage of interest in <a href="http://www.rcn.org.uk/nursing/work_in_health_care/become_a_nurse">nursing careers</a> by applicants, most of whom are British and more occasionally from the EC area, they are being rejected because funded places on pre-registration nursing courses <a href="https://www.rcn.org.uk/__data/assets/pdf_file/0016/482200/004332.pdf">has been reduced</a> to contain costs. Ironically, this compels individual NHS trusts to seek remedies through <a href="https://theconversation.com/nhs-needs-agency-staff-but-it-must-manage-them-better-42866">exorbitantly priced agency nursing services</a> that <a href="http://www.theguardian.com/society/2014/nov/01/nhs-spending-agency-nurses-cuts">just burn a big hole</a> in their budgets. And employers have also sought to bring in migrant labour to fill their vacancies.</p>
<p>Attrition from training is also an issue – and Health Education England, the national leadership organisation for education, training and workforce development in health, has recognised this. It <a href="http://hee.nhs.uk/wp-content/blogs.dir/321/files/2014/04/Workforce-plan-UPDATE-interactive.pdf">promises self-sufficiency by 2017</a>, claiming more nurses will be produced than ever before. But the immediate matter taxing managers is the current and pressing nursing shortage.</p>
<h2>The foreign workforce</h2>
<p>An obvious means to refresh the undeniably depleted workforce is to look overseas and this trend is already well established in the UK. Indeed it is maintained that NHS is facing such a chronic shortage of British nurses that <a href="http://www.theguardian.com/society/2015/apr/04/nhs-recruits-one-in-four-nurses-from-abroad">one in four had to be recruited from abroad</a> last year.</p>
<p><strong>Foreign nurses in the UK by country of origin, 2015</strong></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95012/original/image-20150916-11989-yk47ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95012/original/image-20150916-11989-yk47ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=286&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95012/original/image-20150916-11989-yk47ln.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=286&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95012/original/image-20150916-11989-yk47ln.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=286&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95012/original/image-20150916-11989-yk47ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=359&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95012/original/image-20150916-11989-yk47ln.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=359&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95012/original/image-20150916-11989-yk47ln.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=359&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">Nursing and Midwifery Council</span></span>
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<p>The reduction in pre-registration nursing courses means migrant labour is seen as one way of helping with the staffing problem. Yet <a href="http://www.bbc.co.uk/news/health-34191123">prominent NHS trust leaders warn</a> that Home Office rules on immigration are so “stringent” as to prevent them securing the overseas labour they so much need. Ten managers and their support organisation, NHS Employers, recently wrote to the home secretary, Theresa May, warning of the risk to patients – long waits on trolleys and cancelled operations – simply because they are unable to employ overseas staff due to immigration restrictions.</p>
<p>More worryingly, the Home Office does not class nursing as a profession with staff shortages. The dispute concerns the number of admission places the Home Office will permit. NHS Employers claim they have recruits who want to work but are not allowed into the country, that another 1,000 places are needed within six months and that many existing migrant applications have been rejected by the Home Office. In return the Home Office has argued that the NHS <a href="http://www.bbc.co.uk/news/health-34191123">has not used the places</a> already allocated to it.</p>
<h2>Government up against the profession</h2>
<p>This discord between the Home Office and the NHS is an intransigent and recurring theme. In February, the Royal College of Nursing (RCN) <a href="https://www.gov.uk/government/organisations/migration-advisory-committee">responded to news</a> that the <a href="https://www.gov.uk/government/organisations/migration-advisory-committee">Migration Advisory Committee</a>, the non-departmental public body that advises the government on migration issues, had declared that nursing roles were not on its shortage list for recruitment overseas. The college said it was deeply disappointed that the committee had significantly misrepresented its position to claim that there was no shortage of nursing staff. </p>
<p>Then in June <a href="http://www.bbc.co.uk/news/health-33201189">the RCN annual conference heard</a> that the threat may no longer be just about whether migrant nurses should be admitted but whether they might even be allowed to stay. Under new immigration rules, non-European workers will have to earn at least £35,000 within six years in order to remain in the UK. While the Home Office said this would reduce demand for foreign labour, RCN general secretary Peter Carter warned that by 2017 more than 3,300 overseas NHS nurses could be deported. </p>
<p>The impact of this on all health and social care agencies will be profound and additionally render pointless, the costly recruitment programmes launched by many NHS trusts overseas.</p>
<p>Clearly the RCN is determined to make political capital out of this muddle and predicts chaos. But what this argument with the Home Office does expose most sharply are the deficiencies in strategic coordination at senior ministerial level. It is with some justification, then, that the RCN points out that when it comes to overseas recruitment, NHS managers are as confused as Adam on Mother’s Day.</p><img src="https://counter.theconversation.com/content/47613/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Bradshaw does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There aren’t enough nurses and predicted shortfalls but the government is determined to cut opportunities for foreign nurses.Peter Bradshaw, Emeritus Professor in Health Policy, University of HuddersfieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/436732015-06-23T10:45:47Z2015-06-23T10:45:47ZImmigration reform will starve NHS of healthcare workers<p>Thousands of foreign nurses could be <a href="http://www.bbc.co.uk/news/health-33201189">forced out of the UK</a> under new immigration rules, the Royal College of Nursing has warned. Changes to immigration policy under the government’s attempt to drive down migrant numbers mean that those earning less than £35,000 a year will have to leave the UK after 6 years. This means <a href="http://www.rcn.org.uk/newsevents/news/article/uk/rcn-report-shows-immigration-rules-will-cause-chaos-and-cost-the-nhs-millions">up to 3,365 nurses</a> currently working in the UK, whose recruitment cost more than £20m in total, could be affected.</p>
<p>The Royal College has warned the consequences of an exodus of foreign nurses would be serious and could jeopardise the ability of the country’s National Health Service (NHS) to function. In London alone, nearly a quarter of doctors and half of nurses <a href="http://collections-r.europarchive.org/tna/20100104184804/http://www.cabinetoffice.gov.uk/media/cabinetoffice/strategy/assets/migrationreport.pdf">are from abroad</a>.</p>
<p>This comes at a time when the NHS needs to change to meet the healthcare needs of a growing, ageing population and when the government is pushing for seven-day primary care services. <a href="http://www.cfwi.org.uk/publications/future-nursing-workforce-projections-starting%20the%20discussion">Researchers estimate</a> the demand for nurses is already outstripping supply by nearly 50,000 for the period between 2010 and 2016.</p>
<p>This problem is made worse by nursing’s high rate of turnover. An estimated 10% of the nursing workforce are <a href="http://hee.nhs.uk/wp-content/uploads/sites/321/2014/05/Growing-nursing-numbers-Literature-Review-FINAL.pdf">seriously contemplating leaving</a> for various reasons including burn-out. Nurse turnover rates tend to be higher in teaching trusts, in specialisms such as mental health and elderly care, and in inner cities – especially in London, where turnover rates can be as high as 38%. </p>
<p>This high turnover can reduce the quality of patient care and affect the ability of the NHS to meet demand. But it also costs the NHS a significant amount of money as turnover costs can cost up to double the salary of the nurse that left. </p>
<p>There has been at times <a href="http://www.dailymail.co.uk/news/article-2881469/The-REAL-reason-young-Britons-t-jobs-nurses-year-shipped-7-000-abroad.html">unfair tabloid reporting</a> that foreign healthcare workers take local jobs, draw on local benefits, offer substandard practice and take money out of the system. The reality is that many do jobs in areas that home-grown healthcare workers do not want. Many face a <a href="http://careers.bmj.com/careers/advice/view-article.html?id=20017542">degree of discrimination</a> and career glass ceilings, despite often being highly skilled. The fact of the matter is that foreign healthcare workers help keep the NHS going.</p>
<h2>International competition</h2>
<p>But there is also a much wider issue: that of the <a href="http://www.bmj.com/content/324/7336/499">globalised trade of healthcare workers</a>. It is estimated that around 53% of <a href="http://www.who.int/bulletin/volumes/86/1/07-041681/en/">Indian medical graduates</a> and up to half of <a href="http://www.safpj.co.za/index.php/safpj/article/download/1152/1546">South African</a> medical graduates emigrate to developed countries. Similarly, more than 150,000 <a href="http://www.globalization101.org/the-case-of-the-philippine-nurses/">Filipino nurses</a> and 18,000 <a href="http://www.ncbi.nlm.nih.gov/pubmed/16083467">Zimbabwean nurses</a> emigrate to countries where pay and conditions are significantly better.</p>
<p>This is not a new phenomenon. Indeed, a previous survey carried out by the British General Medical Council in 2002 reported that 58% of newly registered doctors in the UK were <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC516656/">trained abroad</a>. This situation has improved somewhat, according to <a href="http://www.gmc-uk.org/doctors/register/search_stats.asp">2015 statistics</a> which show that international medical graduates account for just over a quarter of all newly registered doctors. That said, the overall number of international medical graduates in the UK has been fairly static in the past decade. </p>
<p>There is also an issue of global inequity. Many of the countries that export doctors and nurses to high-income countries themselves face staffing shortages in the health sector and can ill afford to lose them. For example, India has just 171 registered nurses per 100,000 people and yet it exports many of the nurses it trains to the UK, which has nearly <a href="http://gamapserver.who.int/gho/interactive_charts/health_workforce/NursingMidwiferyDensity/atlas.html">five times as many nurses</a> (880) per 100,000 population. The healthcare brain drain deskills the donor health systems of other countries and threatens their viability. Ultimately this contributes to global health inequalities.</p>
<p>What’s more, not only are the countries of origin losing a valued and skilled human resource, but they are also losing the upfront investment costs required for training them. For example, each emigrating African doctor represents a loss of more than <a href="http://www.bmj.com/content/324/7336/499">US$184,000 (£116,000)</a> to the continent.</p>
<h2>Cheap solution</h2>
<p>In the UK it costs around £70,000 to train a nurse from scratch, £479,000 for a general practitioner, and £725,000 to <a href="http://www.pssru.ac.uk/project-pages/unit-costs/2013/index.php?file=full">train a hospital consultant</a>. It is therefore not surprising that the UK health economy makes a considerable saving in recruiting foreign staff that are already trained. But there is an ethical dimension to international health worker recruitment and migration. It could be argued from a moral standpoint that high-income countries which recruit international healthcare workers – such as the UK – should recompense the countries of origin.</p>
<p>The NHS relies heavily on foreign staff and it is unlikely that it can wean itself off this need in the near future. Undoubtedly, the long-term solution will be to train more home-grown health care staff. But this strategy will come with significantly long lead times and require considerable investment in health education and training. </p>
<p>Careful cross-departmental planning by the government is essential to ensure a smooth and safe transition. Until such a time is reached when the UK is self-sufficient in healthcare staff, foreign workers will continue to be needed. This creates problems for an immigration policy that aims to prevent their arrival and might even send them home.</p><img src="https://counter.theconversation.com/content/43673/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lee does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Foreign-born nurses working in the UK do a vital job in the face of discrimination, but their recruitment helps entrench global healthcare inequality.Andrew Lee, Senior Clinical University Teacher & Consultant in Communicable Disease Control, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.