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.
A 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.”
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I have no issue with hospital pharmacists and those working for a wage under a health authority. But what isn’t talked about is the major changes in pharmacies and their corporatization. They sell anything from quick weight loss programs, candy, groceries, beauty supplies, magazines clothing to dubious blood tests etc. They are driven by profit.
Nurses and doctors aren’t driven by profit by selling wares. They are paid by health authorities or via provincial medical plans. Their very ethics forbid commercialization. However, if speaking about privatized care such as cosmetic and anti-aging medicine, it is similar to pharmacies. In my experience it has become very American and has lost the confidence and trust of Canadian patients. Some paid private doctors offer incentives to staff to sell products. They try to offer this to nurses who refuse to take the money. In consequence, the doctors try to hire those who are not bound by these professional ethics as a workaround with sometimes harmful results. This is abhorrent in our Canadian system of excellent medical and nursing ethics.
Until the commercialization and corporatization of the pharmacy business is brought to light, I can not take seriously, the professions’ claim to be acting in the best interest of the public. If pharmacists didn’t own pharmacies which are in the business of groceries and anything they can hawk, I would see this differently. In this regard, don’t compare doctors and nurses, to pharmacists. I have seen pharmacies be sketchy providers of methadone programs, without providing naloxone. There have been cases of corruption in using tactics to win over the homeless so they would choose their pharmacy for methadone access as well as corruption in payments and records. There is a clear conflict of interest when pharmacists who own pharmacies are trying to profit from the public as customers. When was the last time you bought candy, groceries, cosmetics, magazines and a track suit from the doctor or nurse?
Pharmacists are pushing to expand scope into administering immunizations, prescribing medications and now chronic disease management under the guise of helping patients and alleviating healthcare system stress. They don’t do trauma informed care and there is a lack of privacy and consideration for the entire psychosocial element in a patient’s makeup. Patients don’t divulge their family issues, traumas etc to a pharmacist. These are key aspects to patient assessments which impact compliance and trust.
Pharmacy owners who are pharmacists are more accurately interested in increasing profits by offering these services to increase foot traffic through their megastores of drugs and merchandise. Soon they’ll be selling gas,
It’s time to recognize the differences in motive,
Lewis is incorrect in stating older diploma RNs and LPNs have the same education. LPNs take two years of college. Diploma RNs 20 yrs ago completed 3 yrs of education in 2 years in an accelerated program, The RNs did not take the traditional summer breaks like other programs and instead studied through for six semesters.Many programs were integrated with the hospitals from the first month into the program. There is a very distinct difference between the two tiers in critical thinking and with a focus on depth over breadth in RN programs. Comparing the textbooks between programs shows further evidence of this. The taught ability to critically analyze research studies and apply this knowledge in higher level administration and planning in RN training vs a very task focused, practical application focus in LPN training, is evident, I’ve seen the differences play out as a patient when I needed more pain meds from the LPN damaging my esophagus than obstruction pain. She didn’t check tubes for patency after insertion, left dirty syringes bedside, and failed to recognize signs of fluid overload. It wasn’t her fault as they were extremely short staffed and were pressured to practice beyond scope. A physician friend warned of an increase in patient mortality and lawsuits in the wake of creating a second tier of less educated nurses. And indeed it is exactly what happened in the States.
Cutting corners initially saves money but it costs lives and thus impacts families and future generations. Our quality of care has diminished to a point I know longer recognize due to politics and pressure to cut costs. I’m sick of the lab coat wearing actuaries crunching numbers and measuring care only in quantitative terms. People deserve more than measuring their worth in dollars and cents. Patient focused care is an absolute joke. It is a buzz phrase and is no more than that. We have lost patient trust fir good reason. They are wise to the BS and jargon. This is the fault of many intersections factors and I hope we go back to actually caring instead of business interfering with care.
With the shift to a team based approach and collaborative care, the subject of degree creep is an extremely interesting one and can be viewed from different angles. With the expanding scope of regulated health professionals, such as the pharmacist, advanced credentials make complete sense. Having worked in the pharmacy field from the mid 80’s, I have witnessed the impact of the evolving role of the pharmacist on the profession and on the role of the pharmacy technician. The pharmacist went from someone who mostly checked prescriptions and counseled patients on how to take their medication, to a highly trained expert in medication management and provider of health services. The complexity of medication management is critical to our health care system, especially with the aging population. The need for the expanded role of the pharmacist created a need for an expanded scope of practice for pharmacy technicians. The pharmacy technician program remains a two-year college diploma program, however, the program required integration of new elements that would develop critical thinking and foster confidence so that graduates could perform some of the tasks that were previously only performed by a pharmacist.
Scientific progression along with technological advancement requires the skills of a highly skilled healthcare worker. College programs are 2 or 3 years in length during which students engage in a comprehensive outcome based education that prepares them for entry to practice. It is important to use this time to ensure students are able to demonstrate the appropriate skills, attitudes and behaviors of a health care professional. As a college educator working with allied health programs, I think it is important to consider the following aspects when we look at advancing credentials: What will the impact of adding more time to programs be to clinical placements? Our placement partners are already stretched to the max so will adding more time put more strain on our placement partners. Shouldn’t the main focus be on constantly improving current pedagogy? By expanding the length of certain programs, (diploma to advanced diploma, diploma to degree) programs need to consider the true meaning of competence and the way we assess competence. Will advancing credentials better prepare students to tackle problems, collaborate within teams to make patient centered decisions? How do we ensure our students are competent and how do we assess competence? I think paramedicine should advance credentials to better prepare student to cope with the demands of the job; however, overall I think allied health education does a good job ensuring that curriculum is grounded in humanistic philosophy that teaches students to practice critical reflection, values team-based approach and fosters the behaviors and attitudes that support ongoing professional development and life long learning.
While this discussion focused on credential creep and entry to practice educational credentials, just as O’Connor has stated I would like to hear about what the vision should be for continuing practice requirements. Educators have professionals for a short period of a professionals career. Professional associations, regulators and employers have the professionals for much longer. What about the strategy to have robust work oriented systems in place via regulatory and employers that makes sure that the personnel trained are continuously critically thinking for the benefit of improving the quality of patient care and the health systems. Lets develop a culture in which all health professionals from entry to practice and throughout their career are and (allowed to) think critically and work in quality systems for the benefit of patients. I am not sure that focusing the debate on higher credentials for entry to practice degrees alone achieves this vision. Perhaps a healthy debate should also include what should be the continuing practice requirements that build upon entry to practice requirements.
Is “Quality of care” directly related with level and quality of medical education? The complicated relation between personal ability, motivation, quality of educational school, conditions of entry into real care etc. etc. is an issue of study for as long as medical education exists. Putting it in the way this blog is stating, is a rather tiny perspective on the matter. Why not just turn the question around: “What should medical education do and how would they need to do that”, to ensure that medical education improves health care practices!
I am not sure what evidence the above authors and Lewis actually explored, but I have read numerous peer-reviewed studies that suggest that patients receiving care from a nurse with baccalaureate education are more likely to live beyond 30 days after surgery than those who received care from diploma nursing graduates. It might be interesting for the authors to explore the issue of such abilities as critical thinking, communication and collaboration and their association with increased patient safety and better health outcomes.
I suspect that many readers may be making the assumption that I am a nurse. However, that is not the case; I am a dental hygienists interested in understanding how we could achieve better oral health outcomes for Canadians.
I do understand that many of the examples of ‘credential creep’ in the article were related to professions seeking to go from master’s to doctorate education and I do not have the knowledge to comment on that shift. However, I would encourage people to closely explore the importance of enhanced critical thinking abilities gained through baccalaureate education and the impact of those abilities on patient safety and better health outcomes.
Personally, I appreciate receiving care from professionals with a wide range of educational backgrounds, but I would be comforted by the presence of a baccalaureate educated nurse if I was hospitalized. My husband had surgery recently and that was our focus. We listened to the input of all providers but we sought the input of baccalaureate nurses to guide our decision making. Of course we also sought the guidance of the surgeon but surgeons are not often on the wards. That is the reality and it is quite reasonable from an economic perspective.
However, before you start judging changes in education to be examples of unjustified credential creep, you many need to reflect on the educational background of the professionals who are going to assist you when the doctors are not necessarily there. I know who I would like to be present on the wards.
Does increasing, enhancing our knowledge have to equal earning another degree or making a higher salary? As a “patient and caregiver”, necessity was the “Stimulation & Motivation” for me to learn, as much as I could, when I could, however, I could to help myself and be of assistance to my loved ones. There was/is no “degree” I aspire/aspired to or “salary” increase I could/can expect. Learning is a life-long opportunity, if we choose it. This “Necessity Learning” has benefitted me beyond what I imagined in that: the more I learned, the better I was/am able to care for my health and assist those close to me. I’ve become better at asking questions, acquiring answers, making plans, following-up, monitoring and adjusting for health changes and making decisions that align with my values. And oh, yes, less stress and better life quality.
I can only speak in regards to the profession of pharmacy, both as a pharmacist who went to the U.S. myself to obtain Doctor of Pharmacy education back in 1983, and as a current pharmacy owner who very recently hired a newly minted Pharm D graduate from U of T.
What the advanced education does is make the professional ready to handle complex patient cases earlier and makes them more confident to use their knowledge in the real world of patient care. To quote from above: “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.” That is it in a nutshell. The title itself is not needed, nor is it really used in practice, but the education and the confidence is. My newly hired grad was ready to confidently go from the start.
Many pharmacists practice today who have gained the same knowledge and confidence through experience and desire, and they are just as qualified. I imagine that many of them wish they had been able to have that confidence right from the start of their careers.
Keep the good practical education that students are receiving now. The titles and degree designations are not as important.
are we pricing ourselves out of the opportunity to provide good primary care for an affordable amount by requiring advanced degrees and then the salaries that go along with that?
Many services that patients need do not require advanced degrees for each practitioner, as we require advanced degrees we encourage autonomy of practice that can interfere with offering a nimble team based environment