Editorial: The state of nursing in the United Kingdom

Nursing has a long and noble tradition and has made a significant contribution to the health and welfare of the British public. Perhaps its epoch was in the Nightingale era. However, its illustrious years have been eclipsed recently to the point where it is losing its identity, status and respect: it certainly seems in danger of losing its way. The problems, although numerous, complex and inter-related, can be loosely located around ill-conceived roles and functions, limited career opportunities, out-moded education and training and poor leadership.

The term ‘Registered Nurse’ has become vague, meaningless and devalued and a plethora of new titles – (advanced) nurse lecturer/practitioner/specialist/consultant – has emerged without roles, boundaries and scope of practice being conceptualized or clarified (Thompson & Watson 2003). Advancing nursing practice depends to a large extent on contemporary societal healthcare needs and demands and its responsiveness to these, and yet practice per se is comparatively devalued even though it is the raison d'etre of nursing, and will remain so as long as teachers and managers are better rewarded. This is typified by the clumsy decision (pandering to the whims of politicians and policy makers) to introduce the Modern Matron (Watson & Thompson 2003).

The apparent shortage of nurses is mainly because of many displaying discontent in the way they have been valued and choosing not to work because of limited opportunities in terms of flexible careers or incentives. Recruitment and retention campaigns are often ill conceived with managers visiting underdeveloped countries to poach nurses and depriving these economies of already scarce resources. Moreover, there may be problems integrating Spanish nurses into the UK health system (Watson et al. 2003), so how much greater must the problems be for those from another continent?

The plethora of educational and training courses, often instigated at the whim of UK National Health Service (NHS) or workforce development confederations (WDCs) (Watson & Thompson 2000, 2004, Thompson & Watson 2001), is driven by trusts competing for what they consider they need: invariably the focus is on competency rather than education, thus, short-term training courses are favoured over long-term education programmes. This problem has been compounded by the shift in funding for university educated nurses from the higher education funding councils to the WDCs; the latter have simply bullied many universities into a module-based economy for nurse education which suits workforce development needs but militates against coherent education for pre-registration nurses. WDCs have now gone and the nurse education budget is within the remit of the UK Strategic Health Authorities. However, given the frequency with which the UK NHS is reorganized it is unlikely that these will exist much longer.

Certainly, education should be linked to practice, but this does not always need to take place in the classroom or the ward. Advanced skills laboratories and web-based clinical teaching are good alternatives. Improving partnerships between practice and education should not be a one-way process whereby universities are necessarily expected to produce what the service requires. Of course, this is not helped by universities offering a variety of programmes with different entry and assessment criteria and, indeed, different products. Perhaps it is time to revisit a national curriculum and examination for nursing Watson & Thompson 2005).

Research in nursing is in an even more perilous state (Rafferty et al. 2003, Thompson 2003) and not helped by WDCs who do not seem to recognize it as a legitimate activity, a fact exemplified by them advocating master's level education for assistant and advanced practitioners but without an emphasis on either research or a dissertation (Draper 2004).

Poor leadership is exemplified by senior nurses who appear invisible and to have exerted little if any impact on the profession or on the society that it serves. These managers assume titles that play down their nursing origins and many include ‘quality’ which should surely be part of everyone's agenda. Yet they are rewarded, financially and in the honours system, proportionately much more than nurses in practice, education, or research. So-called visionary initiatives, such as Making a Difference (DoH 1999), a new strategy for nursing launched with a major fanfare and heralded by the bureaucrats as revolutionary, have probably retarded the development of nursing to such an extent that it will be difficult if not impossible to reclaim ground. There is little evidence of vision, strategic direction, or a guiding coalition emerging from so-called nurse leaders. It is hard to identify nurses who are key decision makers or who represent nursing at the high table of policy making.

Nurses not only comprise the biggest occupational group but are also the main ‘front-line’ staff in the British healthcare system. They are vital for delivering safe and effective care. There is strong evidence that quality of nurses and quality of care are inextricably linked (Aiken et al. 2003). If nurses and nursing are to continue to have a significant impact on the design, organization and delivery of services, they must be included in decision-making.

Nursing does not operate in isolation or in a specific sphere and in an era of increasing specialization and cost containment, issues such as scope of practice and boundaries need to be clarified and standards established, and accountability and authority, including legal status, need to be determined. Challenges such as poor access to services and shortage and maldistribution of nurses (Cameron & Thompson 2005), demand that a responsive, flexible, knowledgeable and competent nurse is produced. It is important that universities and their partners work together with the common aim of producing nurses for tomorrow who are competent, thoughtful, critical and compassionate. Then the British people will have the nurses and nursing care they truly deserve.