Tag: pre-registration education

Counting the hours

If ‘ten thousand hours is the magic number of greatness‘, then after how many hours of study and practice should a student of nursing be able to register? According to the EU, in the case of nurses with responsibility for general care the answer is four thousand six hundred. Of these total hours, the theoretical component must amount to a minimum of one-third of the overall length of programmes of preparation and the clinical component at least one-half. Here in the UK, in usual times (i.e., not whilst emergency, and then recovery, standards during the pandemic have been in place) this 4,600 hours is split down the middle with 50% spent in practice and 50% devoted to theory.

Now that the UK has left the EU, the Nursing and Midwifery Council (NMC) is sounding out the views of stakeholders on its current education programme standards. As the NMC puts it, the research they are commissioning as part of this work aims to:

[…] provide us with up-to-date evidence about parts of our pre-registration programme standards, looking at standards in other countries and for other professions within the UK.

It covers the areas of the standards that reflect aspects of EU law, including:

  • the length of programmes and the number/ratio of theory and practice hours
  • the definition of practice learning for adult nursing and the lack of reference to simulation
  • general education required for admission
  • recognition of prior learning
  • entry to shortened midwifery programmes
  • content and clinical experience requirements for nursing and midwifery programmes, with specific mention of minimum numbers in midwifery such as 40 births.

By way of comparison, via Lorna Moxham I learn that, in Australia’s generalist nursing education system, students complete only 800 hours in clinical practice:

Meanwhile, students of physiotherapy in the UK must complete a minimum of 1,000 hours in practice as part of their pre-registration preparation, as must students of occupational therapy. Looking at the diagnostic radiography programme run in Cardiff University, where I work, I see a figure of 1,460 hours in practice for students before registration, and for students of social work I see a minimum number of 200 days. As another point of comparison, I am also aware of how the 4,600 hours of theory and practice expected of pre-registration undergaraduate nurses in Ireland is spread over four years, and not the usual three that we have here in the UK.

I have no idea how these differing figures for the minimum number of hours necessary for health and social care professional registration came to be arrived at, or how decisions have been made on the balance between placement learning and university-based learning. As Steven Pryjmachuk has also pointed out, not all hours are necessarily equal:

The ‘number of hours’ question is not one we’ve particularly considered here in the UK in recent reviews of nursing education, this being tied up at EU level: but what we most definitely have done is to have reviewed (and re-reviewed), pretty much everything else about how we educate nurses. I’m grateful to Jo Stucke for sharing this paper written by Karen Ousey, which sets out some key moments in the history of preparing nurses, included in which is the understatement that ‘nurse education is not static’. In universities and in practice areas up and down the country, students of nursing are now either engaged in programmes of preparation linked to the NMC’s 2018 standards of proficiency, or are completing their studies linked to NMC standards of pre-registration education produced in 2010 and to standards of competence for registered nurses produced in 2014. By my count not one new registered nurse will have graduated, by April 2021, from a programme linked to the 2018 standards. Already, though (signalled by the NMC’s newly launched programme to review those parts of the UK’s standards linked to EU law), moves are afoot to  reflect on, and review again, our approach to the initial preparation of nurses. As it happens, I think there is a discussion to be had on the issue of hours: but, more generally, I believe there is a strong case for introducing more stability into nursing education, and for placing much greater emphasis on the evaluation of what we currently do before making wholesale changes.

Educating nurses

The Nursing and Midwifery Council is consulting on its programme of change for education. Information can be found here, and there’s a lot of it. Mental Health Nurse Academics UK (MHNAUK) will be submitting a response, with Anne Felton from Nottingham University (who leads MHNAUK’s Education Standing Group) coordinating this work.

On July 11th, with mental health nurse academic colleagues in the School of Healthcare Sciences in Cardiff I spent part of our annual summer away day formulating a team response to the NMC’s proposals. Once we’re happy with the content we’ll be forwarding it to Anne, and simultaneously submitting directly to the NMC.

Individually and collectively, other mental health nurses will be formulating responses too. For now, the NMC confirms that the four nursing fields (mental health, adult, child and learning disability) will remain. For an explanation of the importance of preserving mental health nursing as a pre-registration speciality, follow this link for MHNAUK’s relevant position paper. But, as MHNAUK Chair Steven Pryjmachuk pointed out last month in this piece (£) for the Nursing Times, the list of nursing procedures contained in the NMC’s draft standards of proficiency is heavily skewed towards the adult field. This is the Cardiff University mental health team’s concern too, and we’ll be saying so (with specific examples) in our response. Another place for this (and any other) view to be given is at this forthcoming WeMHNurses chat:

Meanwhile, last week ended with two days of professional doctorate teaching. With Nicola Evans I lead a module which addresses working in, and examining, complex systems of health and social care. We’ve run this module before, and as always the student group was a lively and engaged one. Amongst the things we discussed together are the connections running within and between systems of different scale, and the sometimes unforeseen consequences of introducing change. These are matters about which both Nic and I have written (see here, here, here and here). 

To link the two parts of this post together: the NMC is a big player, and for better or worse its programme of education reform will trigger significant disruption. A systems thinking perspective encourages us to consider the possible impact of the NMC’s proposals alongside other sources of change. These include the introduction of fees for student nurses in England, the arrival of nursing associates and reductions in the size of the UK’s registered nurse workforce. As cumulative shifts take place I’m hoping mental health nursing as a distinct profession emerges intact, with its current and future practitioners able to fulfil their places in a system which continues to very much need them. 

The shape of nursing?

Congratulations to Steven Pryjmachuk on his pre-Christmas election as Vice Chair, and Chair-elect, for Mental Health Nurse Academics UK. Steven works with Joy Duxbury throughout 2015 and 2016, and becomes Chair for the two years following.

During the December 2014 MHNAUK election, for which I acted as returning officer, news seeped out that Health Education England’s Shape of Caring review (led by Lord Willis) was weighing up the future of UK nursing’s four fields (mental health, adult, child, learning disability). Michael Coffey, in his last month as MHNAUK Chair, led this response sent to the Health Service Journal:

Michael Coffey
Chair of MHNAUK

11th December 2014

Dear Sir

Shaun Lintern writes in the Health Service Journal (11th December 2015) that Lord Willis, chair of the Shape of Caring review envisages changes to nurse education that would see the loss of the current branches of nursing. One of those fields is mental health nursing. Those who practise in this area provide skilled compassionate care to some of the most marginalised and stigmatised people in society. We write on behalf of Mental Health Nurse Academics UK a group consisting of representatives of 65 Higher Education Institutions providing education and research in mental health nursing. As people long experienced in this field we are disappointed though not surprised to read your article presenting these views on the future of nurse education. We are disappointed because the evidence for the changes that Lord Willis claims are needed is largely non-existent. We are not surprised because we have been here before and can see that despite claims to the contrary, there is no evidence that this future for nurse education will deliver what it promises.

Nurses account for the highest number of professionals providing mental health care; the median average number of nurses per 100,000 of the population working in mental health is 5.8, more than all other professionals combined (WHO, 2011), making mental health nurses pivotal to the delivery of the WHO action plan. None of this is likely with a generic curriculum.

To be clear “the greater element of generalism” (which presumably means adult nursing) has been tried previously in the UK and found wanting. Internationally generalism has failed to deliver better care for people with mental health problems. The effect will be to dilute mental health nursing when there is increasing evidence that specialist knowledge, values and skills are required in the care of people with a range of long-term conditions and dementia. We remain unclear from your article what precisely is being proposed though our favoured suggestion would be for nurses to spend two years rigorously learning how to interact with people in compassionate ways that promote dignity and respect (core mental health nursing skills if you will) before launching themselves into the cold clinical world of high technology nursing.

The evidence from abroad and from evaluations here in the UK of the previous version of generalist frontloaded training (Project 2000; Robinson and Griffith 2007) show clearly that mental health nursing as a specialism suffered from a minimal focus on mental health in curricula and a depletion of mental health skills across the workforce. The strengthening of the mental health ‘field specific’ elements within the 2010 NMC standards reflected positive differences in areas such as language, the co–production of care and inter–professional practice. Any move to generic, or general (adult?) nurse ‘training’ as a start point for all will inevitably lead to a different set of values underpinning mental health nursing practice over time.

The expectation that the training of mental health nursing skills will be picked up and delivered in the workplace is without foundation despite the numerous examples to do this. The result will be that in an era of claims of parity of esteem people who use services will effectively be deprived of specialist trained nurses. Moreover, there is no evidence that current models of training are not fit for purpose or that a focus on generalist nursing skills will adequately address the needs of people with complex and enduring mental health difficulties.

The longer term effect of this approach is clear to see from countries who have moved down this road ahead of us, depleted services provided by unskilled workers, extra costs for employers in re-training and educating a workforce not fit for practice, difficulty in securing sufficient qualified staff to provide evidence based mental health care and longer term the stripping away of a set of skills in higher education that are unlikely to be replaced.

We don’t know what advice Lord Willis has taken to come to his view. Our worry though is that already the language being used here is designed to undermine professional skills that have been long in the making. For example, the unhelpful rhetoric embodied in the use of the term “silo” downplays specialist skills for the purposes of promoting something far less specific like “flexibility”. It is a largely hollow rhetoric and is never heard in relation to cardiologists, neurosurgeons or diabetes nurses. It seems that the pressure for change then is not one premised on the needs of people using healthcare services nor one based on the evidence of what works but driven by other factors that choose to position specialist nursing skills (and by corollary those who need these skills) as having little value.

We also note that any modification to the NMC’s standards for pre-registration nursing education and to the four fields driven by the Shape of Caring review will be felt across all parts of the UK. As an HEE-sponsored Review we are concerned that voices from parts of the UK other than England will not have opportunities to be heard.

We readily acknowledge that the full report is not yet due but wish to advance the notion of such a review democratically reflecting the voices of nurses and the people who use their services. In this regard we have been disappointed at the absence of any real attempt by the review to engage with our group specifically and have questions about the level of engagement with mental health service users more generally.

Yours Sincerely

Dr Michael Coffey
Chair of Mental Health Nurse Academics UK
Swansea University

Professor Joy Duxbury
Chair-elect of Mental Health Nurse Academics UK
University of Central Lancashire

Professor Len Bowers
Institute of Psychiatry
Kings College London

Professor Patrick Callaghan
Nottingham University

Professor Alan Simpson
City University London

Professor John Playle
University of Huddersfield

Professor Steven Pryjmachuk
University of Manchester

Professor Hugh McKenna
University of Ulster

Professor Doug Macinnes
University of Canterbury

Professor Karina Lovell
University of Manchester

Professor Geoff Dickens
Abertay University

Dr Ben Hannigan
Cardiff University

Dr Liz Hughes
University of York

Dr John Baker
University of Manchester

Dr Mick McKeown and Dr Karen Wright
University of Central Lancashire

Dr Robin Ion and Emma Lamont
Abertay University

Dr Sue McAndrew
University of Salford

Dr Andy Mercer
Bournemouth University

Dr Naomi Sharples
University of Chester

Dr Majorie Lloyd
Bangor University

Around this time there was some debate, via email, amongst MHNAUK members centring on the kind of nurses people felt were needed for the future and how they might best be prepared for practice. Important differences in view were freely expressed. Not all who are associated with MNHAUK are in favour of the retention of mental health nursing as a pre-registration field, for example, though my reading of the flow of pre-Christmas exchanges is that most are. Joy Duxbury and Steven Pryjmachuk, I suspect, will be returning to some of this debate during their tenures.

December catch-up

Competing priorities have kept me away from this site in recent weeks. There’s been work to do on COCAPP, which is close to the finish line, and doctoral students’ drafts to read and comment on (before imminent thesis submission, in one case). I’ve also been reading a thesis ahead of a PhD examination I’m involved in at the end of the coming week. So if this catch-up post feels a little bitty, then that’s because it is: there’s been lots happening that I want to comment on.

First up is the RiSC study, which I’ve mentioned here plenty of times before. In the last ten or so days the NIHR has published a first look summary of our aims, methods and findings. This is a precursor to the publication of our whole report, which is now post-peer review. Sometime in the new year we’ll be reconvening as a research team to plan our next project.

In October I made the short trip to the University of South Wales to hear Professor Linda Aiken from the University of Pennsylvania deliver this year’s RCN Winifred Raphael Lecture. Professor Aiken spoke on Quality nursing care: what makes a difference?, drawing on findings from the RN4Cast study and more. As promised, the RCN Research Society has now uploaded its video of the event for the world to see. It’s well worth watching.

News on the Mental Health Nurse Academics UK front includes an election, which we are now midway through, for the group’s next Vice Chair and Chair Elect. I’m overseeing this process (as I’ve done twice before), and will be in a position to announce the successful nominee on December 15th. One of the things that MHNAUK does is to work with the RCN to run the annual NPNR conference, and I’m very pleased to have had the chance to join the NPNR scientific and organising committee for a three year stint. More to follow on that front in the future, including details of next year’s event as they emerge.

Elsewhere I read that the Shape of Caring review, chaired by Lord Willis, is looking at the UK practice of preparing new nurses, at the point of registration, for work in one of four fields (mental health, adult, child and learning disability). This is something to keep a close eye on, with reports from last month’s Chief Nursing Officer Summit in England suggesting that the fields may be on their way out. For a useful, balanced, review in this area I refer the reader to the 2008 King’s College London Policy+ paper Educating students for mental health nursing practice: has the UK got it right? and, for a longer read, to Approaches to specialist training at pre-registration level: an international comparison.

Review fever

Just what we need: another review of nurse education. Yesterday the Nursing Times carried this item reporting a joint Health Education England and Nursing and Midwifery Council plan to investigate standards. The NT says:

Health Education England and the Nursing and Midwifery Council will launch the review in May to specifically investigate the standard of education provided to around 60,000 nursing and midwifery students each year.

The Shape of Caring Review, which will be led by Lord Willis of Knaresborough, will also consider the standard of post-registration training for the NHS nurses once they have qualified. The review is due to produce a final report by early next year.

It follows concerns over the standard of nurse training raised by the Francis report into care failings at Mid Staffordshire Foundation Trust.

As part of its work, the review will examine the controversial pre-nursing experience pilots that have seen around 160 students work as healthcare assistants for a year before starting courses, and which were a key plank of the government’s initial response to the Francis report.

This is the same Lord Willis who chaired the RCN’s review of nursing education which reported in 2012, and about which I wrote a piece on this site here. As I wrote then, there was some scepticism on the timing given that universities and their partners in the NHS were in the throes of reshaping their pre-registration curricula following the publication in 2010 of new NMC standards for pre-registration education. This latest review is going to start before more than a handful of new, post-2010, nurses have registered and certainly before we know anything of the impact of these new regulatory standards on practice. This is exactly a point the NT goes on to make:

But Professor Ieuan Ellis, chair of the Council of Deans of Health, said he was concerned the review would duplicate work already underway by “multiple different projects and working groups”.

“This group needs to reflect on the reviews that have already happened, some quite recently – otherwise there will be a lot of duplication going on,” he added.

Jackie Kelly, head of nursing at the University of Hertfordshire, pointed out that the NMC had already imposed new standards for pre-registration courses in 2010, and stressed 50% of nursing students time was spent in a clinical setting away from the classroom.

She said: “We have already gone a long way and I wouldn’t want the review to move in a direction of travel before we have seen the output from the new standards agreed in 2010.”

Quite so.

Identity and education

One of the things I discussed with Swansea University’s Approved Mental Health Professional (AMHP) students today was how the emergence of a system of community mental health care opened up important new sites for the advancement of professional jurisdictional claims. For more on this idea of jurisdiction (which comes from the sociology of work) check out these earlier posts and embedded links to full-text articles here, here, here and here. It implies that in a dynamic division of labour professions engage in a constant jostling to cement and advance their positions, against the claims of others. The appearance of the AMHP role, fulfilled not just by social workers (as was the case with the old ASW role) but also by nurses, occupational therapists and psychologists, shows how the relationships between professions and tasks can change over time.

It is additionally the case that occupational groups are not homogeneous, but are internally segmented. This means that within a single profession differentiated elements can find themselves battling it out to control work and its underpinning knowledge, or to determine what counts as a necessary preparation for new entrants. And nursing, it appears to me, has plenty of form when it comes to internal divisions and disputes of this type.

With all this in mind, two papers caught my eye before heading off to teach this morning. Both are authored by Professor Brenda Happell. In her editorial in the current issue of the International Journal of Mental Health Nursing, titled Let the buyer beware! Loss of professional identity in mental health nursing, Brenda says (amongst other things):

Most of the time, I feel eternally grateful for my decision to pursue a career in mental health nursing […] At other times, I despair and wonder about the future of our profession, and the care of people experiencing mental health challenges.

I’ll quote some more, as the full text of the editorial is behind a subscription paywall. Writing about the Australian context in particular (this being a part of the world where nurses are trained as generalists rather than, as here in the UK, for a specific field of practice), Brenda adds:

Some of my concern can be traced back to the professional identity of mental health nursing. Identity is such an important part of being professional, and how we consider and present ourselves both individually and collectively.

[…]

Mental health nursing is becoming integrated into other content, in the absence of any evidence to suggest this is an effective means of education and plenty of anecdotal evidence to suggest it isn’t. Nurses without any specialist qualifications,
and often without experience in mental health, are increasingly teaching the content, medical-surgical wards are being considered suitable places to gain clinical experience in mental health, and nurses who work in mental health for more than 5 minutes are referred to as mental health nurses, despite not having the appropriate qualifications.

That’s a dismal picture indeed. Through a ‘jurisdictions’ prism it might be thought of as a case of one segment within a highly differentiated profession claiming possession of sufficient knowledge to capture the work previously done by another, and to reframe what counts as adequate educational preparation.

Brenda and colleagues’ second paper has just appeared in early online form in Perspectives in Psychiatric Care. Majors in Mental Health Nursing: Issues of Sustainability and Commitment reports findings from an interview study involving representatives of Australian universities which had committed to (or actually implemented) mental health ‘majors’ within their comprehensive undergraduate nursing curricula, but which then discontinued them. Noting the lack of sustainability of embedded mental health nursing options within larger courses of generalist pre-registration education, Brenda and her team conclude:

[…] these experiences suggest that the current comprehensive nursing education programs are not well suited to promoting mental health nursing education as a positive future career destination. While such apparent attitudes prevail, the workforce problems in mental health nursing are likely to persist and indeed worsen.

A dismal conclusion again, linked once more in Brenda’s analysis to a shift away from a pre-qualification route to specialist mental health nursing practice.

Arguments for comprehensive, generalist, nurse education and thus for greater homogeneity in the workforce are frequently made here in the UK. When the Nursing and Midwifery Council opened a consultation on proposed new standards for pre-registration nursing in 2007 it specifically asked people to give a view on whether the branches (Mental Health, Adult, Children and Learning Disabilities) should remain. Mental Health Nurse Academics UK (drawing in part on Sarah Robinson and Peter Griffiths’ National Nursing Research Unit international comparison of approaches to specialist training at pre-registration level) submitted this in its 2008 response:

Experiences from other countries that have gone down the generalist pre-qualifying nursing education route show that this leads to a lack of skilled MHN workforce, difficulties in recruiting to post-registration MHN training and a reduction in the quality of care and service provision for those with MH problems […] In attempting to achieve some unitary, generalist view of nursing to fit with other countries, many of whom are envious of our branch specific pre-registration model, we run the very real and significant risk of simply repeating the errors of others for no gain.

We’ve had changes in formal interprofessional divisions of work (which takes me back to this morning’s AMHP students, notwithstanding that all in this class happened to be social workers). But we’ve hung on to branches (or ‘fields’, to use the current nomenclature) in UK nursing, and continue to prepare nurses to exclusively do mental health work from pre-registration level onwards. Six years on, Brenda Happell’s cautionary tales from Australia remind us of what might have been had decisions been made differently.