Healthy Debate (July, 6): Does more education for health professionals equal better patient care?

In recent years, nurses, physiotherapists, audiologists, speech therapists, and pharmacists have all increased their entry-to-practice requirements, with registered nurses needing at least a bachelor degree, and physio and other therapists obligated to obtain a master’s degree to be considered for licensing.

By 2020, all pharmacy schools in Canada will move to a doctorate degree, adding a year to their training and bringing the total time in school to at least eight years. In the meantime, physician assistants are feeling the pressure to move, as their American counterparts have begun to do, from a master’s to a doctorate as the first step to practice.

These ever-advancing requirements to enter into practice are known as “degree creep.” But does the drive for more time in the classroom actually improve patient care?

Aligning education with practice

Professionals who’ve seen their entry-to-practice requirements change say it’s less about having advanced credentials and more a response to increasing complexity in patients, a need for more clinical confidence, more capacity to conduct research and, in some cases, the desire to see more autonomy in patient care.

Introducing advanced degrees can offer a chance to augment existing training programs and reflect greater responsibilities within the role. They can also offer a path for mid-career professionals to move into administrative or leadership positions.

“We see this as a great retention strategy for the younger generation and the novice nurses see this as a way up the career ladder,” says Josette Roussel, a senior nurse advisor in the Policy, Advocacy and Strategy division at the Canadian Nurses Association.

“You have more choices in your career. We see a lot of nurses with diplomas going back to school, even those with many years experience. From a retention perspective, it gives them more choices.”

But degree creep is rarely popular with those already in the profession, or their employers.

“At the beginning, there were mixed feelings,” says Phil Emberley, Director of Practice Advancement and Research at the Canadian Pharmacist Association. “When it was first being discussed nine or 10 years ago, some people thought this was just being done to keep up with what was happening south of the border, so there was a natural resistance at that point.”

To some, a call for higher degrees can be interpreted as a criticism of their skills. For employers, more education often translates into higher salaries, says health policy consultant Steven Lewis, who was a member of the now-defunct Coordinating Committee on Entrance to Practice Credentials, which consisted mainly of assistant deputy ministers of health with responsibility for health workforce planning. It was formed in the 1990s, when advanced degrees for several allied health professions were being considered.

“We entertained a number of proposals to enhance credentials. Not one made a compelling, evidence-supported case that distinguished between what exists and what the potential change would bring, in terms of impact on quality,” Lewis says. “Notably, I know of not a single example where employers have promoted credential enhancement and in several cases they actively opposed it.”

Ripple effects

Kate O’Connor, Director of Practice and Policy at the Canadian Physiotherapy Association, says once the service was delisted and more physiotherapists began working outside hospitals, it was thought a master’s program would help newly-minted physiotherapists operating without the same opportunities for mentorship to sharpen their clinical reasoning.

However, she says many of the “potential challenges” identified at the time advanced entry-to-practice was being considered have proven to be true, including issues with access to care, demand for physiotherapy outpacing supply and no corresponding increase in insurance reimbursement.

“What’s happening in the workforce is that services that would previously be done by a therapist are now being done by assistants,” she says.

Whether assistants are qualified to do the work formerly done by therapists is an issue that hasn’t been well-studied, says Ivy Lynn Bourgeault, who holds the Canadian Institutes of Health Research Chair in Gender, Work and Health Human Resources and is lead coordinator of the pan-Canadian Health Human Resources Network.

The proliferation of assistant positions is often a response to costs. Human resources already account for about 70 percent of healthcare spending, and while higher degrees usually come with calls for higher salaries, hospital budgets remain largely the same.

These kind of turf wars are common, Lewis says.

“Almost every profession is working at less than optimal scope of practice,” he says. “If RNs with degrees become increasingly expensive, then suddenly there’s greater interest in (registered practical nurses). They now have as much training as RNs did 20 years ago. It’s just a different ratio of personnel.”

Emberley says the change affects more than just graduates entering the profession.

Practicing pharmacists will face pressure to help meet a component of the curriculum that is meant to give trainees more clinical experience. “As a profession we really need to ramp that up, because it was something that was under-anticipated when we began this journey,” he says.

Existing pharmacists may also feel compelled to go back for their PharmD designation to give them a competitive advantage in an increasingly tight labour market. Emberley says some pharmacists are already asking what comes next.

Limited evidence

And what does this actually do for patient care? The literature is scarce.

Responses to a 2001 survey conducted by the U.S. Nursing Credentialing Research Coalition show many nurses with advanced certification felt their additional training led to fewer adverse events in patient care, higher patient satisfaction ratings, more effective communication and collaboration, fewer disciplinary events, and fewer work-related injuries.

2016 survey of 754 American employers of physiotherapists with advanced degrees found that just over half felt “there are differences in clinical outcomes between certified specialists and other physical therapists.” But a 1994 US study of physiotherapy students had mixed findings: while more master’s students anticipated “greater involvement in research and teaching and felt better prepared to practice across a broad spectrum of clinical practice,” baccalaureate programs appeared to attract a greater percentage of minority students.

There are virtually no comparative analyses looking at impacts on patient care after an advanced entry-to-practice has been introduced, and few studies assessing the cost benefit of advanced degrees.

“We proposed doing a study to find out exactly what the implications would be, but people deliberately don’t want to know,” Lewis says. “I don’t find the research persuasive. Part of it is what the theory of improvement is about – how much can be associated with individual credentials anyway?”

“There’s no oversight body whereby a profession has to make a case that the reason to move to a higher level for entry to practice is because it will improve patient outcomes. I’ve never seen that. There’s no oversight body to present that to, so there’s no scrutiny of those decisions,” Bourgeault says.

“We need to take a step back, look at patients and families first and really challenge what changes are going to be made for patient and families,” says Howard Waldner, an adjunct professor in the faculty of medicine at the University of British Columbia and past president and CEO at the Vancouver Island Health Authority.

“What is the difference in services or the quality of services in event of these changes? Maybe that should be the determining factor, along with affordability for the system.”

Career-long learning

Roussel says there’s no push to bump up nursing entry-to-practice credentials to a master’s. Instead, she says there’s more discussion on how to integrate a practical doctorate in Canada, and how to enhance the PhD-level degrees that already exist.

Physiotherapy has similarly backed away – for now – from the idea of a doctorate as an entry-to-practice.

Sunita Mathur, a physiotherapist and assistant professor in the Department of Physical Therapy at the University of Toronto, wrote a 2011 editorial in Physiotherapy Canada asking whether it was time to consider a more advanced degree. The answer was a firm no.

“We didn’t want it to just be ‘creeping credentialism.’ We didn’t want to say, they’re going to basically get the same education but we’ll call it a doctorate and increase it by a few months,” Mathur says.

“What we’re doing instead is working on curriculum renewal to change how we teach, how we deliver information to help students be creative and critical thinkers,” Mathur says. “We’re keeping the same structure, but working on the curriculum to help learners prepare for the environment.”

O’Connor says the view needs to be wider than just the start of one’s career.

“Entry to practice is just the beginning,” she says. “We need to have a map for the whole career pathway.”

Author: Karen Palmer, Christopher Doig & Jill Konkin

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Health Canadacihr logo1This initiative has been generously funded by grants from Health Canada and the Canadian Institutes of Health Research. The views expressed here do not necessarily reflect those of the funders.