Should nursing be a four-year degree?

Some healthcare leaders argue that undergraduates need an extra year of study. Three experienced nurses share their views. Compiled by Linda Belardi.

Nursing is a four-year program in many parts of the world but remains a three-year undergraduate degree in Australia and New Zealand. Proponents argue a fourth year could advance the skills of nurses, promote leadership development and place them on par with other health professionals.

A dip in the graduate job market and increasing patient expectations are also cited as potential drivers. However, limited clinical training opportunities continue to act as a handbrake on expansion, and honours and post graduate options are already available to nurses.

The risk of narrowing the pool of graduates or locking out others from the profession altogether could create new concerns. Welcome to the debate.

In favour

Education linked to fewer deaths; By Adjunct Associate Professor Kim Ryan, CEO Australian College of Mental Health Nurses and chair of the Coalition of National Nursing Organisations.

The education of nurses needs to be closely linked to practice, both in delivery and planning.

The increasing body of knowledge, expanding scopes of practice, development of technology, advances in nursing science and research, along with changing demographics and complex healthcare needs place pressure on education facilities to prepare nurses for practice into the future.

They also place significant demands on organisations that need to invest in ongoing training and education of staff. It is vital that the foundation education upon which this type of investment is made is comprehensive and contemporary, and that it reflects the changing contexts and environments in which nurses practise.

Clinical education is an essential component of education and training for a practice-based profession and is needed to ensure the quality of new professionals and specialist nurses. Research suggests that registered nurses are confident and competent within six months of graduation. However, the transition from completion of degree to commencement of work has been problematic; the lack of access to high quality clinical practice may be responsible.

Many countries such as Sweden, Portugal, Canada, Korea, Iceland, Brazil, the Philippines and Greece already require a four-year undergraduate degree to practise nursing.

Studies have shown an inverse relationship between the number of nurses who have completed a four-year degree and the mortality of hospitalised patients, that is, as the number of four-year degree registered nurses increases, patient deaths decreased - highlighting the link between nurses’ education levels and lower levels of patient mortality.

The community has a right to competent, quality nursing care and nurses need to feel confident in their chosen profession. Economy and expediency should not influence nursing education. A four-year degree would provide the basis for this confidence, competence and provision of quality care.

Putting the patient first; By Dr Barbara Newman, academic, registered nurse clinician and researcher.

The three-year bachelor of nursing program came into being more than 20 years ago. Whilst several states within Australia argued for a four-year program, the deciding vote rested with NSW at the time who elected to go with a three-year program.

The support for a three-year program was not made on evidence but purely on financial and economic reasons; the reasoning being that the need for nurses was acute and the number required to meet industry needs was enormous. This indeed, in my view, is hardly a justification for an educational program which holds the health of consumers in its hands.

It is the responsibility of nurses to maintain the trust and confidence of the public by applying skills, knowledge and attitudes that reflect competence, especially as patient demands for higher standards of care increase.

In a three-year degree there is little time to develop fully the educational attributes required by generalist nurses so that all speciality areas and needs of the industry are met. Rural and remote nurses are mostly generalists, however, in many curricula only lip service is given to primary healthcare knowledge and understanding.

If nurses feel competent and have a sound grounding in theory they will be more likely to advance their practice and achieve more job satisfaction. The mandate from industry, that is the employing agencies, has been to produce novice practitioners.

A three-year program limits the achievement of students to think critically and have time for reflection, plus it puts nurses out of sync with other health professionals in the multidisciplinary team. Nurses need to receive an equitable education to physiotherapists, occupational therapists, teachers, social workers and rehabilitation counsellors, who all undertake a four-year bachelor program.

The complexity of technology and care required by patients and consumers of healthcare means that nurses require enhanced knowledge and skills. If each nurse was a four-year graduate they could become involved in improved patient care and actively seek the development of a stimulating and innovative environment through leadership and advancement in practice.

Today, many curricula adopt an elementary framework, rather than pushing to develop a nursing curriculum that is reflective of a wonderful profession full of opportunities and critical thinking. Part of why students become disenchanted with nursing as graduates and ultimately leave is because they do not receive the job satisfaction they should, because at best, they have a superficial understanding of the basics without being pushed to critical thinking.

The current three-year bachelor of nursing is inadequate and inappropriate for 2012 and beyond. Leadership in nursing is desperately required to recognise the true value of nurses and their contribution to the lives of so many individuals within the community.

Against

A utopian dream; By Associate Professor Tracy Levett-Jones, deputy head (teaching and learning) school of nursing and midwifery, University of Newcastle.

While a four-year undergraduate bachelor of nursing program may be ideal, there are a number of pragmatic constraints to this utopian dream.

Foremost amongst these is the recurrent problem of accessing sufficient numbers of quality clinical placements. This issue would be exacerbated should we have a fourth year which would primarily be an extended period of clinical practice.

Pressure would be exerted to access appropriate clinical placements for these soon-to-be registered nurses and also to retain an adequate number of placements for first-, second- and third-year students. With the complexity and acuity that characterises contemporary healthcare this seems to be both impractical and unfeasible.

Coupled with this are the needs and preferences of the undergraduate nursing students themselves, many of whom struggle with the competing demands of study, work, families and finances.

Given that the nursing cohort has a higher than average number of mature-age and socio-economically disadvantaged students, this issue needs to be taken into account in decision making related to program length.

Additionally the requirements of the Australian Qualifications Framework which govern many of the decisions related to length of university programs and nomenclature, need to be acknowledged. Four-year degree programs, structured to align with this framework, often include an imbedded or end-on honours program.

Currently, many bachelor of nursing programs offer a fourth year as an honours program to students who have demonstrated academic ability and who wish to undertake a period of clinically relevant research. It is these students who may well become the shining lights of the nursing profession, demonstrating commitment to changing practice through research, often while working as beginning practitioners, and seeking to question the status quo rather than just adapting or conforming to it.

While a four-year bachelor of nursing program may not be feasible or desirable for all graduates, it is often those who undertake a fourth year as an honours program who emerge as nursing leaders.

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