Editorial

The liberal nursing curriculum and the enterprise university

Keith Cash
American University of Beirut, Beirut, Lebanon

PP: 105 - 108

Article Text

A conflict of values has come to pervade nurse education in the West. There is a disconnection between the virtues of a liberal education which are foundational in Western universities and the requirements of health service organisations for nurses who are technically competent. If the purpose of education is to impart wisdom then the curriculum is the delivery vehicle. The foundation of the nursing curriculum is a perennial problem. If the curriculum is to produce effective and ethical practitioners then it should map onto clinical practice. And, just like any other map, we don't want one that will lead us down non-existent streets, show us half the distance we should travel or guide us into swamps. The problem is that the health service organisations frequently have different destinations from the academy and the curriculum is the place where these differences become apparent.

The latest American Association of Colleges of Nursing (2008) guidelines for the undergraduate curriculum stress that it should be founded on the liberal arts. They state, although do not try to prove, that this is necessary to provide the sort of flexible and adaptable nursing workforce that will be increasingly needed in the future. However, the guidelines do not relate the assumptions they rely on to the current state of the universities. It is also not clear if the purpose of the guidelines is to justify nursing's position in the academy, or to resist the excesses of technocratic managerialism, the tendency for North American universities to be run as businesses rather than as centres of knowledge and discovery.

A strength of the guidelines is that they encourage us to reflect on what we believe should be the basis of nursing curricula in advanced economies. In the United Kingdom, this question becomes tricky because the health service Trusts that manage hospitals and other health care delivery services purchase nurse education from academic institutions. This creates two major pulls that affect curriculum design: the needs of the purchasers of nurse education, the NHS trusts, and the virtues of the academy, often expressed as the mission to provide a liberal, in the sense of broad, education. These two forces are seldom compatible. As purchaser, a NHS trust does not necessarily want to pay for students of nursing to develop a broad educational background. It is far more important to the NHS trusts that the students are ready to practice on graduation; that they can deal with patients efficiently and, hopefully, safely. This state of affairs is commonly found in the public sector, and the pressures against a broad education for nurses are no less pervasive when the purchaser of nurse education is a private company rather than an NHS trust. The profit motive in the private sector, which could perhaps support a liberal education for nurses on the grounds that an educated person is more likely to be a thoughtful and effective nurse, is more likely to prefer expediency over academic breadth.

Whether we should be concerned by any of this depends on what we think a university is. Most nurse education of nurses in the United Kingdom today takes place in universities. In a recent article Schwartz (2008) examined what separates the McDonalds Hamburger University from a 'proper' university. The MHU is an accredited institution in the USA and meets the standard criteria of a university: there is some research and teaching and course credits that can be transferred between institutions. There is even talk now of the university starting a PhD programme. Schwartz makes a convincing case that the MHU has all the surface features of a university but that something seems to be wrong with the idea that it is a 'proper' university. He suggests that the crucial factor that separates MHU from other universities is a difference in values. For him, the MHU exists to further the sectional interests of capital understood as the return on commercial enterprise and investment, but the universities exist to preserve the liberal democratic ideas essential to civil society and to a productive economy. Or, as Newman (1959) argued, it is more to do with developing the well-rounded individual than with the transfer of technical skills. As nursing is now increasingly taught in the academy presumably the curriculum should reflect this mission and be guided by it.

The challenge we have as nurses in the academy is how to operationalise a liberal arts based nursing curriculum in an environment that is becoming interested only in fitness for immediate practice. The enterprise university (Marginson & Considine 2000) is one where the traditional university values of collegiality are being eroded. As these authors say, 'We live in the age of business and it is plain to everyone that the moneychangers have long since mortgaged the temple' (p.2). As universities change, then the assumptions of Schwartz become more untenable unless the university sector is divided again into a vocational sector and a liberal education sector. As the financial pressures on universities increase then the pressure to reduce the liberal aspects of education will increase and the elite, who want the 'best' education, in the sense of the most prestigious education, will ensure the survival of heavily endowed liberal universities. As a result, the principle of 'legacy', or nepotism as it is more accurately called, will become more entrenched for those who can afford an elite education. At the other end of the spectrum, students taking nursing degrees in less prestigious universities will be increasingly constrained by curricula that privilege the work of the 'hands' over that of the mind.

So is there any sympathy among NHS trusts and private healthcare providers for a broad based nurse education that does justice to the liberal education assumptions of the ACC? Unfortunately, when nurse education in the UK was moved into the higher education, it did not take long for the purchasers of nurse education to rebel against what was seen as curriculum drift in the universities. The response of the purchasers was the policy document, 'Making a Difference' (Department of Health 1999) where key skills and relevance to practice were emphasised above all else. This imperative was imposed on the universities by government; the main source of funding for the trusts that controlled the funding of nursing programs. The problem had been that in the attempt to turn nursing into an academic discipline, nursing faculty, who generally were not practitioners, stressed the virtues of the academy, learning for learning's sake, rather than learning to meet the practice requirements of 'clinical', and for that read 'medical' settings. Although the impulse of academic nurses was to give students a broad based education that would encourage and sustain critical thinking from the perspectives of a variety of disciplinary approaches they unfortunately were, and still are, at the mercy of the funders and market forces that drive the curriculum.

The current growth of managerialism and technocratic nursing means that an alternative set of values is being offered and these are not the explicit values of the academy. But at the same time the academy is being transformed into the enterprise university, and these values are more consonant with those of the NHS trusts and private health care providers than those of nursing itself.

To the extent that this is true, the transfer of nurse education to the higher education sector in the UK has resulted in not a continuing exploration of the discipline and profession of nursing within the context of a particular set of liberal values that were based on Christian notions of sacrifice and compassion, but increasingly on the doctrine of producing graduates with the narrow technical skills associated with the provision of efficient rather than effective healthcare. What was essentially a moral mission associated with nursing that, coupled with gender, led to the contradictory image of the nurse as angel or whore, or more recently angel or 'knowledge worker' has given way to the idea of the nurse as an efficient technician valued less for her (most nurses are women) character and moral purpose and more for her ability to meet whatever technical demands are made of her in diverse health care settings.

Consequently, it has become almost impossible to properly debate the nature of nursing in UK universities. The emphasis on technique over values has displaced consideration of how values affect nursing practice. Long gone are the times when the sacrifice of the nurse (long hours, hierarchical working conditions, explicit adherence to liberal values) was seen as admirable, while the contact with bodies and their emissions was stigmatising. Moreover, in countries influenced by Western nurse education where the ethic of sacrifice has never been mainstream, nursing never has, and arguably never will be an occupation of choice for the majority of women and men (the Middle East typifies this) and nurses are still seen as more whore than angel. Unfortunately such matters cannot be addressed in the academy unless nursing curricula permit the kind of critical scrutiny of assumptions about nursing that are best achieved within a liberal education. Therefore, we have reached a stage in nurse education in which the requirement of a liberal education is more in tune with the intellectual inquiry that was once the hallmark of the university rather than with the narrow obsession with preparing practice-ready graduates.

The adherents of professionalisation could argue that there is no need to worry about any of this because complex Western medicine needs co-ordination, and as long as this is the case, there is a natural role for nursing, and this will force universities to maintain a liberal education component in the nursing curriculum. The small privately owned hospital is a dominant provider of this sort of medicine internationally and the owner is generally a medical doctor. Once a hospital exceeds a small number of beds then the organisation cannot be effectively managed by the owner. With the growth in the size of hospitals comes the growth of the need for co- ordination. Where there is tight control of entry into the medical profession, and medical doctors are in short supply, nursing flourishes. Where there is an oversupply of medical graduates, nursing languishes. For example, in Lebanon where I teach there are approximately 17000 physicians to 7000 nurses. Many things that a UK, Australian or New Zealand nurse might regard as the natural domain of nursing are undertaken here by medicine. The reason is quite simple, if a medically qualified person does something that a nurse could or should do, the patient can be billed. If the nurse were to do the same thing, perhaps in the same way, the cost is included in the general daily bed cost. This does not mean that the population gets the best care, just that care which is more profitable for those health professions with the influence to charge a premium for their services.

The tensions between these competing forces are powerful and contradictory. So where are there other places that we can look for a foundation for the curriculum? Nursing theory, or rather nursing models should be a source of guidance. After all, a considerable amount of effort has been expended on developing and codifying it. It is taught in many universities (it seems to be de rigueur in the American academy), there are numerous textbooks and some theorists have reached almost guru status. However, the problem with nursing theory is that it has confounded values and science, the mission of nursing with technical details, or has slipped in non-consensual spiritually based models with a patina of scientific jargon. What is not found is a coherent set of values that enable an intelligent discourse with other members of the academy. The hermetic world of nursing theory represents what Witz (1990) calls 'dual closure'. As nursing was excluded from the male world of medicine, so it drew up a protective screen of practices that were not accessible to outsiders. Nursing theory, with its strange language does not enable one to engage in the wider world. Elsewhere I have (taking the term from the critics of academic economics), autistic theorising (Cash 2004). This is self-referential and has little contact with the reality of clinical nursing. Nursing theory is therefore not the guide that we require.

The curriculum is then a social document that contains all the tensions of nursing in the world, the demands of the technocrat, the boundary with medicine and the other health professions, but rarely with the teaching that enables the consumer of the curriculum, the student, to locate these tensions and live with them. The only foundations that we can turn to are the foundational values of service, compassion and humility. We should not select students solely on the basis of grade but also character. For nursing to flourish and be more than a job requires a situation where medical doctors are scarce, where the health system is dominated by western medical models, where there are large hospitals. The profession might argue that a liberal education produces good nurses and have extensive discussion and debates about the content of such a curriculum. But the pressures and the logic of the market for medicine mean that nursing will worth doing in the interstices of the health care system, dealing with those who medicine finds 'unfashionable' (read 'unprofitable'), the working class mentally ill, the chronically ill and the poor individuals and communities. But, of course, this is a value laden position, one that is open to criticism from those, including the nursing theorists who see the professionalisation of nursing as an end in itself, where the demonstration that nursing has a theory will raise its status and ensure its place in the pantheon of professionals. Anyone who has taught a class of students who are in nursing because it is a job knows that this contributes, as Sennet (1998) puts it, to the 'corrosion of character'. These values do not mesh well with the modern world of the academy or the health care sector but perhaps nursing can try to reinvigorate these sectors by setting the example.

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