The value of Master’s degrees for registered nurses Liz Clark, Debbie Casey and Sunita Morris
The value of graduates in the nursing workforce has been recognised in the move to all-graduate preparation of pre– registration nurses in England (Nursing and Midwifery Council, 2010). Increasingly, after registration continuing professional development programmes for nurses are being offered at Master’s level. However, there is limited evidence of the relationship between postgraduate study and improved patient outcomes. Evidence that does exist suggests that nurses who engage in postgraduate study are more likely to have improved critical thinking and decisionmaking skills, demonstrate leadership qualities to empower them to challenge poor practice, and have the skills needed for advanced clinical practice roles. This article explores these issues and makes recommendations for further work in this area. Key words: Students ■ Postgraduate ■ Decision making ■ Curriculum ■ Nurses
T
he value of higher education for nurses has been the subject of considerable debate over the last 30 years (Sturgeon, 2012). Issues of contention centre on the relationship between higher education and improved patient outcomes and quality of care. In recent years, nurse education and the nursing profession have been closely scrutinised by the media, government and the nursing profession itself, and a critique of nurse education, manifesting at times as anti-intellectualism, appears to have emerged. This includes the suggestion that education encourages nurses to disengage from caring in the ‘too posh to wash’ debate (Beer, 2013; Chapman and Martin, 2013). While these comments relate to undergraduate study, this critique has implications for the academic and professional development of all nurses, including programmes offered at postgraduate level. Moreover, there is increasing evidence that nurses who undertake degrees are more likely to have greater competence than non-graduates, and that learning experiences further develop these enhanced competencies (The King’s Fund, 2008). More importantly, a recently published cross-European study clearly demonstrated that an increased number of graduate nurses in the workplace Liz Clark, Principal Lecturer; Debbie Casey, Senior Lecturer; Sunita Morris, Senior Lecturer, Faculty of Health and Social Sciences, Leeds Beckett University, Leeds Accepted for publication: February 2015
328
resulted in a significant reduction in patient mortality (Aiken et al, 2014). This study supports similar work conducted in the USA (Blegan et al, 2013; Kutney-Lee et al, 2013) and, in the words of Professor Ieuan Ellis, former Chair of the Council of Deans of Health for the UK: ‘This research comprehensively rebuts the myth that degree-level education for nurses is a retrograde step.’ (Council of Deans of Health, 2014) The value of graduate nurses has been recognised in the move to pre-registration preparation in England being at first-degree level (Nursing and Midwifery Council, 2010). One corollary of this is that continuing professional development courses are increasingly being offered at postgraduate level.A clear relationship between postgraduate study by nurses and improved patient outcomes is to be expected. However, this appears to be an under-researched area as Gijbels et al (2010) note in their systematic review on the impact of post-registration nursing and midwifery education on practice. This article will explore some of the themes emerging from the literature on the potential value of Master’s-level study for registered nurses.
Advanced nursing practice In response to a range of political and professional drivers (Box 1), the value of developing advanced nursing roles in areas previously part of the doctor’s role, has been recognised (Dalton, 2013). Although there is no professionally recognised definition of the advanced nursing role, the Royal College of Nursing (RCN) definition is generally used to describe the role, with attributes such as a nurse who practices with a higher level of autonomy, and who can assess and manage patients with undifferentiated and undiagnosed problems, using highly-developed nursing knowledge and skills, including physical examination (RCN, 2012). These nurses often will have undertaken Master’slevel educational preparation. There is some evidence demonstrating the relationship between the higher level educational preparation of advanced nurse practitioners and improved patient outcomes. Examples include: ■■ Paediatric-nurse-practitioner-managed cardiology clinics are associated with high-quality patient care while earning high levels of patient satisfaction (Evangelista et al, 2012) ■■ The nurse-practitioner-run surgical spine consultations offer accurate and earlier assessment, facilitating a more timely diagnosis and management (Sarro et al, 2010) ■■ The diagnostic accuracy of nurse practitioners in breast care compares favourably with that of a consultant
© 2015 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2015, Vol 24, No 6
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.216.030.116 on May 16, 2015. For personal use only. No other uses without permission. . All rights reserved.
■ Economic ■ Junior
doctors’ hours/ European Working Time Directive obligations organisation of health service delivery ■ Consumer demand and approval for nursing role development ■ Better educated workforce ■ Enabling legislation—amendments to Medicines Act 1968 ■ Patients have increasingly complex healthcare needs ■ Changing
Box 2. Failings at the Mid Staffordshire NHS Foundation Trust ■ Confused
view of responsibilities focus on systems not outcomes ■ Those who received care were not listened to ■ Staff disengaged from the process of management ■ Insufficient attention to professional standards ■ Lack of support for staff ■ A weak professional voice in management decisions ■ A failure to meet the challenge of caring for the elderly and the vulnerable ■ A
surgeon (Osborn et al, 2010). Williamson et al (2012), in their study of advanced nurse practitioners in a ward setting, recognised that nurses drew on their considerable expertise, networks and insider knowledge of health care to develop a pivotal role facilitating nursing practice. This includes enhancing communication and practice, acting as a role model and facilitating the patient’s journey (Williamson et al, 2012). This suggests that postgraduate education may have a role beyond defined specialist or advanced practice skills. These wider characteristics are transferable to a broader nursing context, in particular for those who have responsibility for leading clinical practice and ensuring compassionate, competent care.
Postgraduate study and empowerment of nurses The Francis Report (Francis, 2013) on the failings at the Mid Staffordshire NHS Foundation Trust (Box 2) clearly outlined the consequences of a lack of clinical leadership. Francis suggested this was a significant factor at board and middle-management level, and crucially, for those leading wards (Francis, 2013). The evidence seems to suggest that effective leadership skills are more likely to be seen in nurses who have undertaken postgraduate study. Drennan (2012) evaluated leadership and management abilities of Master’s-level nurses and found that there were some gains in these when assessed objectively compared to their skills on commencing the programme, as a result of their higher degree. This mirrored previous work by Whyte et al (2000) and Ashworth et al (2001) and suggests that investing in clinical leadership education at postgraduate level for nurses may be appropriate in terms of developing the advanced capabilities required in today’s challenging healthcare environment. These capabilities are likely to include complex problem solving, change management and relationship development. This concurs with the outcomes of postgraduate studies as detailed by the Quality Assurance Agency for Higher Education (QAA), 2008). Its descriptors state that the
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outcome for all Master’s-level graduates is that they will have the qualities needed for employment in circumstances: ‘Requiring sound judgement, personal responsibility and initiative, in complex and unpredictable professional environments.’ (QAA, 2008: 20) This QAA outcome around judgement and responsibility for actions links closely to the notion of professional accountability. This is a particularly important concept as it may be that recognition of individual personal accountability for practice standards is the most important factor in protecting the public from poor practice. The relationship between these Master’s-level outcomes and empowerment to raise concerns about standards of practice needs further examination. Certainly, these outcomes appear to have a particular currency today given the concern about care standards. Dixon et al (2012) stated that front line professionals: ‘Are first-hand witnesses when things go wrong and often have ideas about how the quality of care could be improved. It is vital that they are able to speak up and empowered to act to prevent failings in care.’ (Dixon et al, 2012: 2) The failings at Mid Staffordshire NHS Foundation Trust clearly illustrate a lack of empowerment to escalate concerns about care standards by nurses and other health workers. The role of occupational socialisation in perpetuating poor care standards is worth considering. This is when nurses may compromise the quality of care as a result of peer pressure. Personal and professional values are lost if nurses conform to the cultural norms of the workplace that are detrimental to patient care, or do not promote best practice. This has been acknowledged in research looking into the work conflicts of newly qualified nurses, where ‘covert rules’ of the ward were identified, such as ‘fit in and don’t rock the boat’ (Maben et al, 2006). This inability to challenge and acknowledge personal and professional responsibility for raising concerns about standards of practice may stem from a lack of professional confidence. Indeed, Gallagher (2010) has suggested that whistleblowers embody the characteristics of professional wisdom, courage and integrity. These characteristics seem particularly important in the current healthcare environment with the pressures and challenges facing professionals today, in particular the potential tensions between value-based practice as espoused by professional ethical codes, and the increasing focus on value for money and achieving targets. The role of postgraduate education in supporting the development of increased confidence and self-esteem among nurses is clearly highlighted in Cotterill–Walker’s literature review on postgraduate education and its effect on patient care (Cotterill-Walker, 2012). This included an increase in confidence to question care decisions after undertaking postgraduate study. A study by Ellis and Nolan (2005) suggested that Master’s-level programmes can also have a positive impact on nurses’ attitudes, and aid the development
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Box 1. Drivers for advanced practice roles
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Critical thinking and decision making in practice The notion of critical thinking is defined by Drennan (2010) as encompassing: ■■ Problem solving ■■ Decision making ■■ Inference ■■ Evaluative thinking ■■ Reasoning. Drennan’s (2010) study demonstrated higher critical thinking scores on completion of a postgraduate nursing programme. While the gains in critical thinking were ‘relatively modest’, they should be considered as a potential positive outcome of Master’s-level education and practice. An early piece of work by Girot (1995) acknowledged that there was a growing recognition of the strong relationship between decision-making skills and the ability to think critically. Certainly, critical thinking appears to be an essential requirement for nurses to engage in safe, competent and autonomous practice. In the authors’ opinions it could also be argued that the ability to apply critical thinking to clinical decision making is what distinguishes health professionals from non-professional support workers. Cotterill-Walker’s literature review found a correlation between Master’s-level graduates and improved critical analysis of care, clinical judgment and improved diagnostic reasoning and problem solving (Cotterill-Walker, 2012). Perhaps more significantly, a systematic review by Gijbels et al (2010) found evidence that this translated to benefits for patients and carers, including a reduction in symptoms, length of stay, and patient satisfaction with nurses’ knowledge, skills and personal qualities. This suggests there are benefits of critical thinkers as practitioners and is supported by research exploring the experience of mental health nurses qualifying with a Master’s degree (Stacey et al, 2010). Stacey et al (2010) found that the criticality and decision-making skills gained from postgraduate study were maintained and accepted by others when the former students became staff nurses. However, there is a need for further research in this area. Indeed Cotterill-Walker’s (2012) literature review identified only three studies that focused on clinical practice outcomes,
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and all of these had significant limitations. These included, for example, small sample sizes and were related to a specialised clinical area only. The lack of robust evidence is not an indication that outcomes are not improved, but indicative of an under-scrutinised area.
Expert nursing practice In addition to possessing fundamental knowledge of patients’ healthcare needs and the skills and abilities required for entry-level nursing practice, today’s nurses are called upon to take part in and lead organisational initiatives aimed at improving the quality, safety, and efficiency of care delivery (NHS England, 2013). Nurses are also increasingly at the forefront of care coordination and prevention as a result of more care being delivered in the home, the community, and remotely (NHS England, 2013). In order to support changing roles and increased responsibilities, a Master’s qualification has been viewed as a tool for legitimacy of nursing as a professional occupation, strengthening the clinical credibility and confidence in a nurse (Gerrish et al, 2003). This is important to acknowledge as the nursing role has moved away from that of the stereotypical handmaiden to the doctor towards a more autonomous, accountable practitioner (Dalton, 2013). For example, Gerrish et al (2003) suggested that: ‘Clinical capability attributed to the nurse [as a result of a Master’s qualification] … has been interpreted as leading to an increase in the authority commanded by the expert professional.’ (Gerrish et al, 2003: 103) Morrison and Symes (2011) undertook a literature review on expert practice in nursing which revealed some common characteristics across the breadth of nursing specialties and work settings, including knowing the patient, intuitive knowledge, reflective practice, risk taking and skilled knowhow. These skills clearly require education and training that develops an in-depth knowledge base beyond the professional body requirements at the point of registration. Expert nurses must be able to demonstrate insight and originality in the application of this knowledge, which in turn should have a positive influence on patient outcomes. Watkins (2011) looked at the influence of Master’s education on nurses and reported changes in their way of thinking and, in particular, how information was analysed and synthesised. Watkins (2011) found improved cognitive functioning and, importantly, enhanced evidence-based practice skills. The potential for Master’s-educated nurses to contribute to developing and leading expert nursing practice therefore needs to be considered. Advanced academic knowledge and application of theory related to clinical practice is usually a requirement of any Master’s nursing programme; indeed, most programmes require the student to undertake a small research project. It is desirable that the focus of this is practice or service development in line with the QAA outcomes of postgraduate study which include the requirement for research to be aligned with the professional field (QAA, 2008). However, this may not always the case and educational institutions and sponsoring organisations
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of, for example, assertiveness skills. While there appears to be a lack of empirical work demonstrating an association between whistleblowers, empowerment and educational background, it is difficult not to draw conclusions that if the skill set of Master’s-level nurses includes increased confidence and awareness of professional and personal accountability, then these practitioners would be more likely to challenge unacceptable care and to accept responsibility for escalating concerns. Another under-researched area appears to be the nature of what is studied on Masters programmes. Some Master’slevel programmes for nurses may focus on research skills or generic personal and professional development rather than the acquisition of advanced clinical skills or practice roles. It is unclear if this makes a difference to improved patient outcomes such as identifying poor practice and advocating for patients and service users.
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PROFESSIONAL ISSUES need to promote and support this focus on nursing practice and service development. The authors believe that the contribution of nurses undertaking Master’s degrees to the quality of care delivered by health organisations is currently under-acknowledged and under-used. Difficulties in the logistics of identifying these nurses may be one factor impacting on this. The lack of any frameworks for regulating and recording practice beyond registration may be an issue, and it makes it imperative that employers actively identify and target how they will use expert nurses to enhance service delivery and support the achievement of organisational objectives. There is an argument that expertise can be achieved through experience alone. Certainly the seminal work of Benner (1984), based on the Dreyfus model of skills acquisition, suggests that practitioners move through five cognitive stages to become an expert nurse. The novice relies on abstract principles and the application of rules to guide his or her practice. The expert performer, however, no longer relies on analytical principle to connect his or her understanding of the situation to an appropriate action. Having engaged in a range of practice experiences, pattern recognition enables the nurse to demonstrate an intuitive grasp of situations and make an accurate and quick assessment of the problem, appearing to bypass lengthy reasoning processes (Benner, 1984). Benner suggests that this results from experience. It seems likely that this intuitive assessment of clinical situations is based on a deep, tacit understanding of their area of practice that starts with an underpinning knowledge base. However, the authors suggest that this comes from a synthesis of both experience and ‘taught’ knowledge, and the integration of both practice and classroom learning is the basis for expertise. This ability to recognise context, without conscious consideration of a wide range of alternative diagnoses and solutions, is allied to the skills of the critical thinker, and potentially links to the outcomes of postgraduate study.
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Conclusion The recurring themes in the literature suggest that there are some positive gains for nurses who successfully complete Master’s degrees that in turn may lead to improved care delivery and/or improved patient outcomes. There may be a relationship between Master’s-level study by registered nurses and critical thinking and leadership skills that is likely to positively influence nursing practice. However there is a need: ■■ To develop measurable and observable criteria against which Master’s level educational outcomes can be evaluated within nursing practice ■■ To ensure the content and curriculum of Master’s programmes meet the requirements of stakeholders through robust and specific educational commissioning processes ■■ For higher educational institutions to further engage with stakeholders to develop appropriate Master’s programmes ■■ To articulate the benefits of employing Master’s nurses and the contribution they could make to improving organisational performance The Shape of Caring review of pre- and post-registration education for nurses and midwives in England that is being
British Journal of Nursing, 2015, Vol 24, No 6
KEY POINTS n There
is some evidence on the relationship between postgraduate study and improved patient outcomes but further research is required
n Evidence
exists suggesting that critical thinking development, empowerment to challenge poor practice and improved decision making are outcomes of Master’s-level study for nurses
n Further
work is needed to develop measurable criteria that demonstrate the value of postgraduate study on clinical outcomes
led by Lord Willis (Health Education England, 2014) is considering some of these recommendations. The evidence suggests that there is a relationship between postgraduate study for nurses and improved patient outcomes. Exploring the potential of increasing the number of nurses with Master’s qualifications is pivotal to developing future nursing practice, and this may have significant benefits for patients, BJN employers and the wider community. Conflict of interest: none Aiken LH, Sloane DM, Bruyneel L et al (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 383(9931): 1824–30. doi: 10.1016/S0140-6736(13)62631-8 Ashworth PD, Gerrish K, McManus M (2001) Whither nursing? Discourses underlying the attribution of master’s level performance in nursing. J Adv Nurs 34(5): 621–8 Beer G (ed) (2013) Too Posh to Wash? Reflections on the Future of Nursing. 2020health (online) 28 January. http://tinyurl.com/pphektk (accessed 23 February 2015) Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park Blegen MA, Goode CJ, Park SH,Vaughn T, Spetz J (2013) Baccalaureate education in nursing and patient outcomes. J Nurs Adm 43(2): 89–94. doi: 10.1097/NNA.0b013e31827f2028 Chapman J, Martin D (2013) Nurses told ‘you’re not too posh to wash a patient’: Minister orders student nurses back to basics to improve compassion in NHS. Mail online (26 March). http://tinyurl.com/mbnxn34 (accessed 23 January 2015) Cotterill-Walker SM (2012) Where is the evidence that master’s level nursing education makes a difference to patient care? A literature review. Nurse Educ Today 32(1): 57–64. doi: 10.1016/j.nedt.2011.02.001 Council of Deans of Health (2014) New study shows degree level nursing education cuts unnecessary hospital deaths. http://tinyurl.com/pmycr5q (accessed 23 February 2015) Dalton MA (2013) Perceptions of the advanced nurse practitioner role in a hospital setting. Br J Nurs 22(1): 48–53. doi: 10.12968/bjon.2013.22.1.48 Dixon A, Foot C, Harrison T (2012) Preparing for the Francis report: how to assure quality in the NHS. The King’s Fund. http://tinyurl.com/n77f58l (accessed 23 February 2015) Drennan J (2010) Critical thinking as an outcome of a Master’s degree in Nursing programme. J Adv Nurs 66(2): 422–31. doi: 10.1111/j.1365-2648.2009.05170.x Drennan J (2012) Masters in nursing degrees: an evaluation of management and leadership outcomes using a retrospective pre-test design. J Nurs Manag 20(1): 102–12. doi: 10.1111/j.1365-2834.2011.01346.x Ellis L, Nolan M (2005) Illuminating continuing professional education: unpacking the black box. Int J Nurs Stud 42(1): 97–106. doi: 10.1016/j.ijnurstu.2004.05.006 Evangelista J-AK, Connor JA, Pintz C et al (2012) Paediatric nurse practitioner managed cardiology clinics: patient satisfaction and appointment access. J Adv Nurs 68(10): 2165–74. doi: 10.1111/j.1365-2648.2011.05901.x Francis R (2013) The Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry. http://tinyurl.com/anb9zme (accessed 23 February 2015) Gallagher A (2010) Whistleblowing: what influences nurses’ decisions on whether to report poor practice? Nurs Times 106(4): 22–5 Gerrish K, McManus M, Ashworth P (2003) Creating what sort of professional? Master’s level nurse education as a professionalising strategy. Nurs Inq 10(2): 103–12 Gijbels H, O’Connell R, Dalton-O’Connor C, O’Donovan M (2010) A systematic review evaluating the impact of post-registration nursing and midwifery education on practice. Nurse Educ Pract 10(2): 64–9. doi: 10.1016/j.nepr.2009.03.011 Girot EA (1995) Preparing the practitioner for advanced academic study: the development of critical thinking. J Adv Nurs 21(2): 387–94 Health Education England (2014) The Shape of Caring Review. http://tinyurl.com/ mojlp4f (accessed 23 February 2015) The Kings Fund (2008) Moving to an all-degree nursing profession at registration: How might the nursing workforce and quality of care be affected? Policy + Issue 14. http:// tinyurl.com/lvx8foj (accessed 23 February 2015) Kutney-Lee A, Sloane DM, Aiken LH (2013) An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Aff (Millwood) 32(3): 579–86. doi: 10.1377/hlthaff.2012.0504 Maben J, Latter S, Clark JM (2006) The theory-practice gap: impact of professional-
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bureaucratic work conflict on newly-qualified nurses. J Adv Nurs 55(4): 465–77. doi: 10.1111/j.1365-2648.2006.03939.x Morrison SM, Symes L (2011) An integrative review of expert nursing practice. J Nurs Scholarsh 43(2): 163–70. doi: 10.1111/j.1547-5069.2011.01398.x NHS England (2013) Transforming urgent and emergency care services in England. Urgent and emergency care review—End of Phase 1 report. http://tinyurl.com/prx9qtg (accessed 23 February 2015) Nursing and Midwifery Council (2010) Standards for Pre-registration nursing education. http:// tinyurl.com/6f443py (accessed 23 February 2015) Osborn GD, Jones M, Gower-Thomas K, Vaughan-Williams E (2010) Breast disease diagnostic ability of nurse practitioners and surgeons. J Adv Nurs 66(7): 1452–8. doi: 10.1111/j.1365-2648.2010.05291.x The Quality Assurance Agency for Higher Education (2008) The framework for higher education qualifications in England, Wales and Northern Ireland. http://tinyurl.com/n2n5taa (accessed 23 February 2015) Royal College of Nursing (2012) Advanced nurse practitioners. An RCN guide to the advanced nursing practice, advanced nurse practitioners and programme accreditation. http://tinyurl.
com/24xsm3 (accessed 23 February 2015) Sarro A, Rampersaud YR, Lewis S (2010) Nurse practitioner-led surgical spine consultation clinic. J Adv Nurs 66(12): 2671–6. doi: 10.1111/j.1365-2648.2010.05446.x Stacey G, Felton A, Joynson K (2010) Masters at work: a narrative inquiry into the experiences of mental health nurses qualifying with an undergraduate Masters degree. Nurse Educ Today 30(4): 333–7. doi: 10.1016/j.nedt.2009.09.002 Sturgeon D (2012) Higher education reform: conflict of interest or enhanced experience? Br J Nurs 21(1): 44–8. doi: 10.12968/bjon.2012.21.1.44 Watkins D (2011) The influence of Masters education on the professional lives of British and German nurses and the further professionalization of nursing. J Adv Nurs 67(12): 2605–14. doi: 10.1111/j.1365-2648.2011.05698.x Whyte DA, Lugton J, Fawcett TN (2000) Fit for purpose: the relevance of Masters preparation for the professional practice of nursing. A 10-year follow-up study of postgraduate nursing courses in the University of Edinburgh. J Adv Nurs 31(5): 1072–80 Williamson S,Twelvetree T,Thompson J, Beaver K (2012) An ethnographic study exploring the role of ward-based Advanced Nurse Practitioners in an acute medical setting. J Adv Nurs 68(7): 1579–88. doi: 10.1111/j.1365-2648.2012.05970.x
The British Journal of Nursing (BJN) Tissue Viability Supplement aims to promote evidence-based practice and the provision of high quality patient care. We welcome unsolicited articles including literature reviews, care studies and original research in all areas of tissue viability nursing. To contribute to the supplement or to enquire about how to become a peer reviewer in this area, contact us at [email protected] or 0207 501 6702.
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Quarterly supplement covering all aspects of tissue viability in nursing from prevention with compression techniques to wound care and management
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The value of graduates in the nursing workforce has been recognised in the move to all-graduate preparation of pre– registration nurses in England (Nursing and Midwifery Council, 2010). Increasingly, after registration continuing professional development programmes for nurses are being offered at Master’s level. However, there is limited evidence of the relationship between postgraduate study and improved patient outcomes. Evidence that does exist suggests that nurses who engage in postgraduate study are more likely to have improved critical thinking and decisionmaking skills, demonstrate leadership qualities to empower them to challenge poor practice, and have the skills needed for advanced clinical practice roles. This article explores these issues and makes recommendations for further work in this area. Key words: Students ■ Postgraduate ■ Decision making ■ Curriculum ■ Nurses
T
he value of higher education for nurses has been the subject of considerable debate over the last 30 years (Sturgeon, 2012). Issues of contention centre on the relationship between higher education and improved patient outcomes and quality of care. In recent years, nurse education and the nursing profession have been closely scrutinised by the media, government and the nursing profession itself, and a critique of nurse education, manifesting at times as anti-intellectualism, appears to have emerged. This includes the suggestion that education encourages nurses to disengage from caring in the ‘too posh to wash’ debate (Beer, 2013; Chapman and Martin, 2013). While these comments relate to undergraduate study, this critique has implications for the academic and professional development of all nurses, including programmes offered at postgraduate level. Moreover, there is increasing evidence that nurses who undertake degrees are more likely to have greater competence than non-graduates, and that learning experiences further develop these enhanced competencies (The King’s Fund, 2008). More importantly, a recently published cross-European study clearly demonstrated that an increased number of graduate nurses in the workplace Liz Clark, Principal Lecturer; Debbie Casey, Senior Lecturer; Sunita Morris, Senior Lecturer, Faculty of Health and Social Sciences, Leeds Beckett University, Leeds Accepted for publication: February 2015
328
resulted in a significant reduction in patient mortality (Aiken et al, 2014). This study supports similar work conducted in the USA (Blegan et al, 2013; Kutney-Lee et al, 2013) and, in the words of Professor Ieuan Ellis, former Chair of the Council of Deans of Health for the UK: ‘This research comprehensively rebuts the myth that degree-level education for nurses is a retrograde step.’ (Council of Deans of Health, 2014) The value of graduate nurses has been recognised in the move to pre-registration preparation in England being at first-degree level (Nursing and Midwifery Council, 2010). One corollary of this is that continuing professional development courses are increasingly being offered at postgraduate level.A clear relationship between postgraduate study by nurses and improved patient outcomes is to be expected. However, this appears to be an under-researched area as Gijbels et al (2010) note in their systematic review on the impact of post-registration nursing and midwifery education on practice. This article will explore some of the themes emerging from the literature on the potential value of Master’s-level study for registered nurses.
Advanced nursing practice In response to a range of political and professional drivers (Box 1), the value of developing advanced nursing roles in areas previously part of the doctor’s role, has been recognised (Dalton, 2013). Although there is no professionally recognised definition of the advanced nursing role, the Royal College of Nursing (RCN) definition is generally used to describe the role, with attributes such as a nurse who practices with a higher level of autonomy, and who can assess and manage patients with undifferentiated and undiagnosed problems, using highly-developed nursing knowledge and skills, including physical examination (RCN, 2012). These nurses often will have undertaken Master’slevel educational preparation. There is some evidence demonstrating the relationship between the higher level educational preparation of advanced nurse practitioners and improved patient outcomes. Examples include: ■■ Paediatric-nurse-practitioner-managed cardiology clinics are associated with high-quality patient care while earning high levels of patient satisfaction (Evangelista et al, 2012) ■■ The nurse-practitioner-run surgical spine consultations offer accurate and earlier assessment, facilitating a more timely diagnosis and management (Sarro et al, 2010) ■■ The diagnostic accuracy of nurse practitioners in breast care compares favourably with that of a consultant
© 2015 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2015, Vol 24, No 6
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.216.030.116 on May 16, 2015. For personal use only. No other uses without permission. . All rights reserved.
■ Economic ■ Junior
doctors’ hours/ European Working Time Directive obligations organisation of health service delivery ■ Consumer demand and approval for nursing role development ■ Better educated workforce ■ Enabling legislation—amendments to Medicines Act 1968 ■ Patients have increasingly complex healthcare needs ■ Changing
Box 2. Failings at the Mid Staffordshire NHS Foundation Trust ■ Confused
view of responsibilities focus on systems not outcomes ■ Those who received care were not listened to ■ Staff disengaged from the process of management ■ Insufficient attention to professional standards ■ Lack of support for staff ■ A weak professional voice in management decisions ■ A failure to meet the challenge of caring for the elderly and the vulnerable ■ A
surgeon (Osborn et al, 2010). Williamson et al (2012), in their study of advanced nurse practitioners in a ward setting, recognised that nurses drew on their considerable expertise, networks and insider knowledge of health care to develop a pivotal role facilitating nursing practice. This includes enhancing communication and practice, acting as a role model and facilitating the patient’s journey (Williamson et al, 2012). This suggests that postgraduate education may have a role beyond defined specialist or advanced practice skills. These wider characteristics are transferable to a broader nursing context, in particular for those who have responsibility for leading clinical practice and ensuring compassionate, competent care.
Postgraduate study and empowerment of nurses The Francis Report (Francis, 2013) on the failings at the Mid Staffordshire NHS Foundation Trust (Box 2) clearly outlined the consequences of a lack of clinical leadership. Francis suggested this was a significant factor at board and middle-management level, and crucially, for those leading wards (Francis, 2013). The evidence seems to suggest that effective leadership skills are more likely to be seen in nurses who have undertaken postgraduate study. Drennan (2012) evaluated leadership and management abilities of Master’s-level nurses and found that there were some gains in these when assessed objectively compared to their skills on commencing the programme, as a result of their higher degree. This mirrored previous work by Whyte et al (2000) and Ashworth et al (2001) and suggests that investing in clinical leadership education at postgraduate level for nurses may be appropriate in terms of developing the advanced capabilities required in today’s challenging healthcare environment. These capabilities are likely to include complex problem solving, change management and relationship development. This concurs with the outcomes of postgraduate studies as detailed by the Quality Assurance Agency for Higher Education (QAA), 2008). Its descriptors state that the
330
outcome for all Master’s-level graduates is that they will have the qualities needed for employment in circumstances: ‘Requiring sound judgement, personal responsibility and initiative, in complex and unpredictable professional environments.’ (QAA, 2008: 20) This QAA outcome around judgement and responsibility for actions links closely to the notion of professional accountability. This is a particularly important concept as it may be that recognition of individual personal accountability for practice standards is the most important factor in protecting the public from poor practice. The relationship between these Master’s-level outcomes and empowerment to raise concerns about standards of practice needs further examination. Certainly, these outcomes appear to have a particular currency today given the concern about care standards. Dixon et al (2012) stated that front line professionals: ‘Are first-hand witnesses when things go wrong and often have ideas about how the quality of care could be improved. It is vital that they are able to speak up and empowered to act to prevent failings in care.’ (Dixon et al, 2012: 2) The failings at Mid Staffordshire NHS Foundation Trust clearly illustrate a lack of empowerment to escalate concerns about care standards by nurses and other health workers. The role of occupational socialisation in perpetuating poor care standards is worth considering. This is when nurses may compromise the quality of care as a result of peer pressure. Personal and professional values are lost if nurses conform to the cultural norms of the workplace that are detrimental to patient care, or do not promote best practice. This has been acknowledged in research looking into the work conflicts of newly qualified nurses, where ‘covert rules’ of the ward were identified, such as ‘fit in and don’t rock the boat’ (Maben et al, 2006). This inability to challenge and acknowledge personal and professional responsibility for raising concerns about standards of practice may stem from a lack of professional confidence. Indeed, Gallagher (2010) has suggested that whistleblowers embody the characteristics of professional wisdom, courage and integrity. These characteristics seem particularly important in the current healthcare environment with the pressures and challenges facing professionals today, in particular the potential tensions between value-based practice as espoused by professional ethical codes, and the increasing focus on value for money and achieving targets. The role of postgraduate education in supporting the development of increased confidence and self-esteem among nurses is clearly highlighted in Cotterill–Walker’s literature review on postgraduate education and its effect on patient care (Cotterill-Walker, 2012). This included an increase in confidence to question care decisions after undertaking postgraduate study. A study by Ellis and Nolan (2005) suggested that Master’s-level programmes can also have a positive impact on nurses’ attitudes, and aid the development
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Box 1. Drivers for advanced practice roles
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Critical thinking and decision making in practice The notion of critical thinking is defined by Drennan (2010) as encompassing: ■■ Problem solving ■■ Decision making ■■ Inference ■■ Evaluative thinking ■■ Reasoning. Drennan’s (2010) study demonstrated higher critical thinking scores on completion of a postgraduate nursing programme. While the gains in critical thinking were ‘relatively modest’, they should be considered as a potential positive outcome of Master’s-level education and practice. An early piece of work by Girot (1995) acknowledged that there was a growing recognition of the strong relationship between decision-making skills and the ability to think critically. Certainly, critical thinking appears to be an essential requirement for nurses to engage in safe, competent and autonomous practice. In the authors’ opinions it could also be argued that the ability to apply critical thinking to clinical decision making is what distinguishes health professionals from non-professional support workers. Cotterill-Walker’s literature review found a correlation between Master’s-level graduates and improved critical analysis of care, clinical judgment and improved diagnostic reasoning and problem solving (Cotterill-Walker, 2012). Perhaps more significantly, a systematic review by Gijbels et al (2010) found evidence that this translated to benefits for patients and carers, including a reduction in symptoms, length of stay, and patient satisfaction with nurses’ knowledge, skills and personal qualities. This suggests there are benefits of critical thinkers as practitioners and is supported by research exploring the experience of mental health nurses qualifying with a Master’s degree (Stacey et al, 2010). Stacey et al (2010) found that the criticality and decision-making skills gained from postgraduate study were maintained and accepted by others when the former students became staff nurses. However, there is a need for further research in this area. Indeed Cotterill-Walker’s (2012) literature review identified only three studies that focused on clinical practice outcomes,
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and all of these had significant limitations. These included, for example, small sample sizes and were related to a specialised clinical area only. The lack of robust evidence is not an indication that outcomes are not improved, but indicative of an under-scrutinised area.
Expert nursing practice In addition to possessing fundamental knowledge of patients’ healthcare needs and the skills and abilities required for entry-level nursing practice, today’s nurses are called upon to take part in and lead organisational initiatives aimed at improving the quality, safety, and efficiency of care delivery (NHS England, 2013). Nurses are also increasingly at the forefront of care coordination and prevention as a result of more care being delivered in the home, the community, and remotely (NHS England, 2013). In order to support changing roles and increased responsibilities, a Master’s qualification has been viewed as a tool for legitimacy of nursing as a professional occupation, strengthening the clinical credibility and confidence in a nurse (Gerrish et al, 2003). This is important to acknowledge as the nursing role has moved away from that of the stereotypical handmaiden to the doctor towards a more autonomous, accountable practitioner (Dalton, 2013). For example, Gerrish et al (2003) suggested that: ‘Clinical capability attributed to the nurse [as a result of a Master’s qualification] … has been interpreted as leading to an increase in the authority commanded by the expert professional.’ (Gerrish et al, 2003: 103) Morrison and Symes (2011) undertook a literature review on expert practice in nursing which revealed some common characteristics across the breadth of nursing specialties and work settings, including knowing the patient, intuitive knowledge, reflective practice, risk taking and skilled knowhow. These skills clearly require education and training that develops an in-depth knowledge base beyond the professional body requirements at the point of registration. Expert nurses must be able to demonstrate insight and originality in the application of this knowledge, which in turn should have a positive influence on patient outcomes. Watkins (2011) looked at the influence of Master’s education on nurses and reported changes in their way of thinking and, in particular, how information was analysed and synthesised. Watkins (2011) found improved cognitive functioning and, importantly, enhanced evidence-based practice skills. The potential for Master’s-educated nurses to contribute to developing and leading expert nursing practice therefore needs to be considered. Advanced academic knowledge and application of theory related to clinical practice is usually a requirement of any Master’s nursing programme; indeed, most programmes require the student to undertake a small research project. It is desirable that the focus of this is practice or service development in line with the QAA outcomes of postgraduate study which include the requirement for research to be aligned with the professional field (QAA, 2008). However, this may not always the case and educational institutions and sponsoring organisations
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of, for example, assertiveness skills. While there appears to be a lack of empirical work demonstrating an association between whistleblowers, empowerment and educational background, it is difficult not to draw conclusions that if the skill set of Master’s-level nurses includes increased confidence and awareness of professional and personal accountability, then these practitioners would be more likely to challenge unacceptable care and to accept responsibility for escalating concerns. Another under-researched area appears to be the nature of what is studied on Masters programmes. Some Master’slevel programmes for nurses may focus on research skills or generic personal and professional development rather than the acquisition of advanced clinical skills or practice roles. It is unclear if this makes a difference to improved patient outcomes such as identifying poor practice and advocating for patients and service users.
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PROFESSIONAL ISSUES need to promote and support this focus on nursing practice and service development. The authors believe that the contribution of nurses undertaking Master’s degrees to the quality of care delivered by health organisations is currently under-acknowledged and under-used. Difficulties in the logistics of identifying these nurses may be one factor impacting on this. The lack of any frameworks for regulating and recording practice beyond registration may be an issue, and it makes it imperative that employers actively identify and target how they will use expert nurses to enhance service delivery and support the achievement of organisational objectives. There is an argument that expertise can be achieved through experience alone. Certainly the seminal work of Benner (1984), based on the Dreyfus model of skills acquisition, suggests that practitioners move through five cognitive stages to become an expert nurse. The novice relies on abstract principles and the application of rules to guide his or her practice. The expert performer, however, no longer relies on analytical principle to connect his or her understanding of the situation to an appropriate action. Having engaged in a range of practice experiences, pattern recognition enables the nurse to demonstrate an intuitive grasp of situations and make an accurate and quick assessment of the problem, appearing to bypass lengthy reasoning processes (Benner, 1984). Benner suggests that this results from experience. It seems likely that this intuitive assessment of clinical situations is based on a deep, tacit understanding of their area of practice that starts with an underpinning knowledge base. However, the authors suggest that this comes from a synthesis of both experience and ‘taught’ knowledge, and the integration of both practice and classroom learning is the basis for expertise. This ability to recognise context, without conscious consideration of a wide range of alternative diagnoses and solutions, is allied to the skills of the critical thinker, and potentially links to the outcomes of postgraduate study.
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Conclusion The recurring themes in the literature suggest that there are some positive gains for nurses who successfully complete Master’s degrees that in turn may lead to improved care delivery and/or improved patient outcomes. There may be a relationship between Master’s-level study by registered nurses and critical thinking and leadership skills that is likely to positively influence nursing practice. However there is a need: ■■ To develop measurable and observable criteria against which Master’s level educational outcomes can be evaluated within nursing practice ■■ To ensure the content and curriculum of Master’s programmes meet the requirements of stakeholders through robust and specific educational commissioning processes ■■ For higher educational institutions to further engage with stakeholders to develop appropriate Master’s programmes ■■ To articulate the benefits of employing Master’s nurses and the contribution they could make to improving organisational performance The Shape of Caring review of pre- and post-registration education for nurses and midwives in England that is being
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KEY POINTS n There
is some evidence on the relationship between postgraduate study and improved patient outcomes but further research is required
n Evidence
exists suggesting that critical thinking development, empowerment to challenge poor practice and improved decision making are outcomes of Master’s-level study for nurses
n Further
work is needed to develop measurable criteria that demonstrate the value of postgraduate study on clinical outcomes
led by Lord Willis (Health Education England, 2014) is considering some of these recommendations. The evidence suggests that there is a relationship between postgraduate study for nurses and improved patient outcomes. Exploring the potential of increasing the number of nurses with Master’s qualifications is pivotal to developing future nursing practice, and this may have significant benefits for patients, BJN employers and the wider community. Conflict of interest: none Aiken LH, Sloane DM, Bruyneel L et al (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 383(9931): 1824–30. doi: 10.1016/S0140-6736(13)62631-8 Ashworth PD, Gerrish K, McManus M (2001) Whither nursing? Discourses underlying the attribution of master’s level performance in nursing. J Adv Nurs 34(5): 621–8 Beer G (ed) (2013) Too Posh to Wash? Reflections on the Future of Nursing. 2020health (online) 28 January. http://tinyurl.com/pphektk (accessed 23 February 2015) Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park Blegen MA, Goode CJ, Park SH,Vaughn T, Spetz J (2013) Baccalaureate education in nursing and patient outcomes. J Nurs Adm 43(2): 89–94. doi: 10.1097/NNA.0b013e31827f2028 Chapman J, Martin D (2013) Nurses told ‘you’re not too posh to wash a patient’: Minister orders student nurses back to basics to improve compassion in NHS. Mail online (26 March). http://tinyurl.com/mbnxn34 (accessed 23 January 2015) Cotterill-Walker SM (2012) Where is the evidence that master’s level nursing education makes a difference to patient care? A literature review. Nurse Educ Today 32(1): 57–64. doi: 10.1016/j.nedt.2011.02.001 Council of Deans of Health (2014) New study shows degree level nursing education cuts unnecessary hospital deaths. http://tinyurl.com/pmycr5q (accessed 23 February 2015) Dalton MA (2013) Perceptions of the advanced nurse practitioner role in a hospital setting. Br J Nurs 22(1): 48–53. doi: 10.12968/bjon.2013.22.1.48 Dixon A, Foot C, Harrison T (2012) Preparing for the Francis report: how to assure quality in the NHS. The King’s Fund. http://tinyurl.com/n77f58l (accessed 23 February 2015) Drennan J (2010) Critical thinking as an outcome of a Master’s degree in Nursing programme. J Adv Nurs 66(2): 422–31. doi: 10.1111/j.1365-2648.2009.05170.x Drennan J (2012) Masters in nursing degrees: an evaluation of management and leadership outcomes using a retrospective pre-test design. J Nurs Manag 20(1): 102–12. doi: 10.1111/j.1365-2834.2011.01346.x Ellis L, Nolan M (2005) Illuminating continuing professional education: unpacking the black box. Int J Nurs Stud 42(1): 97–106. doi: 10.1016/j.ijnurstu.2004.05.006 Evangelista J-AK, Connor JA, Pintz C et al (2012) Paediatric nurse practitioner managed cardiology clinics: patient satisfaction and appointment access. J Adv Nurs 68(10): 2165–74. doi: 10.1111/j.1365-2648.2011.05901.x Francis R (2013) The Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry. http://tinyurl.com/anb9zme (accessed 23 February 2015) Gallagher A (2010) Whistleblowing: what influences nurses’ decisions on whether to report poor practice? Nurs Times 106(4): 22–5 Gerrish K, McManus M, Ashworth P (2003) Creating what sort of professional? Master’s level nurse education as a professionalising strategy. Nurs Inq 10(2): 103–12 Gijbels H, O’Connell R, Dalton-O’Connor C, O’Donovan M (2010) A systematic review evaluating the impact of post-registration nursing and midwifery education on practice. Nurse Educ Pract 10(2): 64–9. doi: 10.1016/j.nepr.2009.03.011 Girot EA (1995) Preparing the practitioner for advanced academic study: the development of critical thinking. J Adv Nurs 21(2): 387–94 Health Education England (2014) The Shape of Caring Review. http://tinyurl.com/ mojlp4f (accessed 23 February 2015) The Kings Fund (2008) Moving to an all-degree nursing profession at registration: How might the nursing workforce and quality of care be affected? Policy + Issue 14. http:// tinyurl.com/lvx8foj (accessed 23 February 2015) Kutney-Lee A, Sloane DM, Aiken LH (2013) An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Aff (Millwood) 32(3): 579–86. doi: 10.1377/hlthaff.2012.0504 Maben J, Latter S, Clark JM (2006) The theory-practice gap: impact of professional-
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bureaucratic work conflict on newly-qualified nurses. J Adv Nurs 55(4): 465–77. doi: 10.1111/j.1365-2648.2006.03939.x Morrison SM, Symes L (2011) An integrative review of expert nursing practice. J Nurs Scholarsh 43(2): 163–70. doi: 10.1111/j.1547-5069.2011.01398.x NHS England (2013) Transforming urgent and emergency care services in England. Urgent and emergency care review—End of Phase 1 report. http://tinyurl.com/prx9qtg (accessed 23 February 2015) Nursing and Midwifery Council (2010) Standards for Pre-registration nursing education. http:// tinyurl.com/6f443py (accessed 23 February 2015) Osborn GD, Jones M, Gower-Thomas K, Vaughan-Williams E (2010) Breast disease diagnostic ability of nurse practitioners and surgeons. J Adv Nurs 66(7): 1452–8. doi: 10.1111/j.1365-2648.2010.05291.x The Quality Assurance Agency for Higher Education (2008) The framework for higher education qualifications in England, Wales and Northern Ireland. http://tinyurl.com/n2n5taa (accessed 23 February 2015) Royal College of Nursing (2012) Advanced nurse practitioners. An RCN guide to the advanced nursing practice, advanced nurse practitioners and programme accreditation. http://tinyurl.
com/24xsm3 (accessed 23 February 2015) Sarro A, Rampersaud YR, Lewis S (2010) Nurse practitioner-led surgical spine consultation clinic. J Adv Nurs 66(12): 2671–6. doi: 10.1111/j.1365-2648.2010.05446.x Stacey G, Felton A, Joynson K (2010) Masters at work: a narrative inquiry into the experiences of mental health nurses qualifying with an undergraduate Masters degree. Nurse Educ Today 30(4): 333–7. doi: 10.1016/j.nedt.2009.09.002 Sturgeon D (2012) Higher education reform: conflict of interest or enhanced experience? Br J Nurs 21(1): 44–8. doi: 10.12968/bjon.2012.21.1.44 Watkins D (2011) The influence of Masters education on the professional lives of British and German nurses and the further professionalization of nursing. J Adv Nurs 67(12): 2605–14. doi: 10.1111/j.1365-2648.2011.05698.x Whyte DA, Lugton J, Fawcett TN (2000) Fit for purpose: the relevance of Masters preparation for the professional practice of nursing. A 10-year follow-up study of postgraduate nursing courses in the University of Edinburgh. J Adv Nurs 31(5): 1072–80 Williamson S,Twelvetree T,Thompson J, Beaver K (2012) An ethnographic study exploring the role of ward-based Advanced Nurse Practitioners in an acute medical setting. J Adv Nurs 68(7): 1579–88. doi: 10.1111/j.1365-2648.2012.05970.x
The British Journal of Nursing (BJN) Tissue Viability Supplement aims to promote evidence-based practice and the provision of high quality patient care. We welcome unsolicited articles including literature reviews, care studies and original research in all areas of tissue viability nursing. To contribute to the supplement or to enquire about how to become a peer reviewer in this area, contact us at [email protected] or 0207 501 6702.
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Quarterly supplement covering all aspects of tissue viability in nursing from prevention with compression techniques to wound care and management
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