1 Pre-registration nurse education: A brief history A Eaton, 2012 Context Nurse education and the quality of its product has recently been the subject of public and professional comment. The Royal College of Nursing (RCN) has seen this subject debated at its annual Congress under headings such as too posh to wash. There have been comments made publically by patients and carers about the lack of care and compassion of registered nurses. Enquiries and publications have questioned the calibre of current registered nurses and asked how they have been educated. Nurse education itself is not a static phenomenon. Since the 1980s it has been mainstreamed from hospital schools of nursing to higher education institutions (HEIs). This has been accompanied by a significant growth in associated activities such as research, publication, and the appointment of deans of nursing posts. Despite this professionalisation, concern remains regarding the fitness for purpose of nursing graduates. Scope and objectives Given the above context the RCN Commission on Nurse Education will consider the following question: What are the defining features of excellent education and practice preparation and supervision for those working towards registration that will provide a nursing workforce fit for future health and social care services in the UK? Nursing and nurse education a brief history 1930s The RCN gains its Royal Charter. 1940s The state enrolled nurse is formally recognised with two years of training instead of three. The NHS is launched, offering comprehensive health care for all, free at the point of delivery, but paid for through taxation. 1950s Male nurses join the main nursing register in 1951.
2 1960s Edinburgh initiates the first degree in nursing. 1970s Manchester University appoints the first professor of nursing. The Briggs committee is established due to pressure from the RCN, to consider issues around the quality and nature of nurse training and the place of nursing within the NHS. It recommends a number of changes to professional education and the regulatory structure. 1980s United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) becomes the profession s new regulatory body in National Boards are set up in each country to monitor the quality of nursing and midwifery education courses, and to maintain the training records of students on these courses. 1990s Reforms to nurse education, commonly termed Project 2000 are implemented, with the academic level of training established at a minimum of higher education diploma Health care reforms are set out in the NHS Plan. Agenda for Change sets out a new structure of pay for nurses and other NHS staff. In 2005, nurse numbers hit 397,500 an all-time high. Nursing students are given supernumerary status throughout their three years of education; this means they are no longer part of the workforce numbers UKCC ceases to exist and its functions are taken over by the Nursing and Midwifery Council (NMC). The English National Board is abolished and its Quality Assurance role is taken over by the NMC. The national boards in the other three UK countries are also abolished but new bodies are created in each country to take over their functions, eg NHS Education for Scotland (NES) Further changes to the standards of pre-registration nursing education programmes by the NMC mean that all programmes will be at under graduate level with all successful candidates exiting with a first degree in nursing and the eligibility to enter the NMC register. Various high-publicity issues hit the press mainly based around the public s perceived perceptions of the role of the nurse. They suggest, amongst other things, that registered nurses are too busy completing paperwork to undertake nursing care such as meeting the hygiene and nutritional needs of patients.
3 The role of the NMC The core function of the NMC, as a regulator, is to establish and improve standards of nursing and midwifery care in order to serve and protect the public. Its key functions are to: register all nurses and midwives and ensure that they are properly qualified and competent to work in the UK set the standards of training and conduct that nurses and midwives need to deliver high-quality health care consistently throughout their careers set the standards for pre-registration nursing education ensure that nurses and midwives keep their skills and knowledge up to date and uphold the standards of the professional code ensure that midwives are safe to practice by setting rules for their practice and supervision use fair processes to investigate allegations made against nurses and midwives who may not have followed the code. Regulation To practise lawfully as a registered nurse in the UK, the practitioner must hold a current and valid registration with the NMC. The title registered nurse can only be granted to those holding such registration; this protected title is laid down in the Nurses, Midwives and Health Visitors Act The register In August 2005 the NMC register was split into three parts: nurses, midwives and specialist public health nurses. Prior to this there were 15 sub parts of the register. Current figures suggest there are more than 660,000 registrants with the NMC (NMC, 2012). Registered staff First level nurses make up the bulk of registered nurses in the UK. Second level nurses Second level, still referred to as EN (enrolled nurse) or SEN (state enrolled nurse), nurse training is no longer provided. However, they are still legally allowed to practise in the UK as a nurse and also, by law, may refer to themselves as a registered nurse. ENs trained for two years in England and Wales, but for 20 months in Scotland. Non-registered staff Non-registered staff often work in support of registered professionals, including allied health professionals, though the vast majority work with registered nurses. They have a variety of titles depending upon their employers and roles but are commonly called health care assistants (HCAs) and health care support workers (HCSWs). They often deliver direct patient care, performing tasks such as: personal care including hygiene needs; physiological measurements such as blood pressure and temperature; and invasive tasks such as cannulation and catheterisation. All functions undertaken by these staff must have been appropriately delegated by the
4 registered professional. Within the NHS it can be seen that staff nurses start their careers on AfC pay band five whereas HCAs may be paid at AfC band two or three. The NMC Code of Conduct (May 2008) for registered nurses includes the following statement: Delegate effectively 29 You must establish that anyone you delegate to is able to carry out your instructions. 30 You must confirm that the outcome of any delegated task meets required standards. 31 You must make sure that everyone you are responsible for is supervised and supported. Throughout 2011 there has been a growing number of assistant practitioner roles established, sometimes paid on AfC band four, who may undertake more complex care but are still allocated work by the respective registered professional. Pre-registration nurse education Nurse education has seen significant changes throughout the 20 th and early 21 st centuries. Further changes are to be implemented from September 2012 when all new programmes must lead to degree level qualification as well as registration with the NMC. These changes have included the academic level at which pre-registration nurses study, the content of the NMC standards for pre-registration nursing, and the curriculum then delivered by the institutions approved for such delivery. In the last decade of the 20 th century, nurse education changed from a programme delivered via approved schools of nursing at certificate level, to higher education diploma level or above programmes delivered through HEIs, with variations appearing across the four UK countries. Prior to 1990, nurse education followed an apprentice type model with knowledge delivery and the delivery of nursing practise being undertaken within schools of nursing and their related hospitals. In order to become a registered nurse, students must complete a programme recognised by the NMC. Currently this involves completing a diploma or degree level programme, available form a range of universities in a chosen branch area, ie adult nursing, children s nursing, learning disabilities nursing or mental health nursing. Successful completion of this programme of study will lead to both an academic award and professional registration as a first level nurse. All pre-registration courses must be three years long and comprise 4,600 hours in length, split between 50 per cent theory and 50 per cent clinical (including community and hospital) placements.
5 There are differences between the four UK countries, but the NMC remains the regulatory body and all programmes must meet the NMC standards for preregistration nursing education. All universities must adhere to the NMC standards but all are allowed autonomy on the structure of their programmes and as such there are no national curricula for preregistration nursing programmes. Country differences Although all pre-registration nursing courses enable the candidate to register with the NMC upon successful completion, there are differences in the academic level of such programmes. England Until September 2013 England has a mixed economy of academic level for preregistration programmes, which are offered by around 80 universities. The majority (approximately 85 per cent) of learners have studied at diploma in HE level, with the rest studying at first degree level or above. From September 2013 all programmes will be at undergraduate level leading to an award of a first degree upon successful completion. Wales In Wales, pre-registration programmes leading to midwifery registration at undergraduate level began in Since 2004 all pre-registration programmes leading to registration as a nurse have been at undergraduate level. There are five HEIs offering pre-registration programmes in Wales. Ten years ago the Welsh Government established its All Wales Fitness for Practice (FFP) initiative. Originally there were nine core all-wales elements and now the five HEIs work in partnership to develop a common set of evaluation and assessment tools and procedures. While the specific course content is still unique to each school, the policy means less duplication in materials, standardised data collection, analysis and reporting mechanisms, and the potential for nationwide evaluations. For the NMC validation of the new pre-registration programmes to be delivered from September 2012, the NMC is working with the all-wales system, and has agreed that one school will have responsibility for approving the all-wales elements that will then be used by every school. A high-level group overseeing the initiative includes representatives from each HEI, who work together to ensure that the common standards and tools are revised and implemented collectively. The initiative offers proposed benefits for the universities including reductions in time, effort and costs associated with designing, and producing and translating course materials. Admission forms, student portfolio documents, educational clinical audit tools, assessment of clinical practice forms and course evaluation forms are shared rather than developed individually by each institution. The proposed benefits for students are that there is more consistency in their learning experiences. The course framework is similar at each school, and performance in clinical placements is assessed using the same criteria.
6 The proposed benefits for health care providers are that each student, regardless of the school attended, uses the same tools for assessing clinical learning and practice outcomes, making it easier for them and their clinical mentors. Scotland For a number of years the universities in Scotland delivering both nursing and midwifery programmes have offered both diploma and degree programmes, making them well placed to meet the new NMC education standards and requirements. There are six Scottish universities (Edinburgh Napier University, Glasgow Caledonian University, Stirling University, Robert Gordon University, University of Dundee and the University of the West of Scotland) fulfil the Scottish Government contract for nursing education. Students who attend these institutions are offered a non-means tested bursary. The contract is managed by NHS Education for Scotland and to date there has been a contentious annual process for determining commissioned student numbers which is led by Scottish Government. In addition there are five other non-commissioned universities who also deliver preregistration nursing programmes in Scotland which include Edinburgh University, Glasgow University, Abertay University, Queen Margaret University and the Open University (primarily to remote and rural areas). There are 14 territorial health boards in Scotland which are the practice learning providers. With the shift in the balance of care, and the health and social care integration agenda, the range of learning providers is also expanding to include the independent and third sectors. Due to these drivers, the quality health care agenda, and the significant health funding dedicated to pre-registration and post-registration education programmes offered by all these HEIs, the Chief Nursing Officer in Scotland is currently in the process of undertaking a nursing and midwifery education review. Northern Ireland Northern Ireland offers degree level programmes in three universities, including the Open University. The University of Ulster has always offered degree-only programmes. Queen s University Belfast began with the traditional three year Project 2000 programme with the option to top up to degree level. As participants increasingly chose the degree option, the programme was revalidated to a threeyear degree programme with the facility to exit with a diploma if necessary. Both Queen s and University of Ulster are implementing a new revised curriculum, based on NMC standards for pre-registration nursing education 2010, in September These programmes will be degree only. At present there is a group of stakeholders meeting to review the process for entry and selection for the nursing degree courses in Northern Ireland. Structure and process Applications to pre-registration programmes vary according to which country the individual wants to study in. In England, applications are made through the Universities and Colleges Admissions Service (UCAS).
7 The NMC lays down basic entry requirements but allows each university to set down their own entry requirements for pre-registration nursing programmes. These vary considerably, from no set entry requirements for the Open University through to three high grades at A-level at other universities. Some universities will consider applicants with NVQ in health at level three, or its new (September 2011) replacement Qualifications and Credit Framework (QCF) diploma level 3 in Health, and others will not accept these qualifications for entry to pre-registration programmes. Selection processes also vary. Some HEIs carry out joint interviews with academic and hospital staff, even including service users (patients) before places are offered, while at some there is no interview process at all and offers are made on examination results alone. HEIs have considerable autonomy in their entry and selection processes which leads to the question of whether there should be some investigation into current practice in relation to entry criteria and selection process, which could then be matched against attrition and success rates. Europe Since the late 1970s there have been harmonised minimum standards for nurse education across Europe as part of the EU s regulatory framework for mutual recognition of professional qualifications. Their prime purpose was to assist free movement of professionals. These standards cover nurses in general care and include a minimum length of education of 4,600 hours or three years, with at least half of this being clinical and at least a third theoretical. All pre-registration adult branch programmes in the UK have to meet these requirements. The legislation also includes a list of subjects which must be covered in the nursing curriculum and entry into nurse education is dependent on completion of at least ten years general education. Given the significant differences between countries in Europe in the training of specialist nurses, these standards have never been harmonised. So those nurses in the UK completing the other branch programmes (mental health, learning disability, children) do not have automatic recognition of their qualifications in Europe. The EU legislation does not specify whether nurse education should be within higher education (although this is the trend), nor the level of the qualification (diploma, degree, masters). But the World Health Organization (WHO) Europe has recommended since the year 2000 that the academic level of professional qualification for nurses and midwives should be a university degree. The current EU standards are being reviewed and the European Commission proposed legislative changes at the end of 2011 which would open the way for the minimum education requirements to include competencies and for 12 years general education or equivalent to be the minimum to enter nurse education. The proposals would allow a tightening of language controls for nurses seeking to practice in
8 another EU country. Continuing professional development for nurses would not, however, be made mandatory across the EU. Investment and commissioning planning NB The following processes apply to England and are given as an illustration of funding and commissioning processes. There are differences across the 4 UK countries. Strategic health authorities (SHAs) are accountable to the Department of Health (DH) for the use of the Multi-Professional Education and Training (MPET) levy. SHAs plan how they are going to invest MPET funds and commission education from a variety of education providers. The guidance has been designed to help SHAs maximise the benefits from the investment and commissioning planning processes. The integrated workforce planning and education commissioning system The majority of workforce planning is locally owned and led. Organisations which provide NHS services, such as foundation trusts and care trusts, plan for the workforce they need to deliver high-quality services. At a local level, workforce plans will be driven by local needs and care pathways. Organisations which commission NHS and social care services, such as primary care trusts (PCTs) and local authorities, act on behalf of the health and care system to identify the workforce implications and risks of the commissioning decisions they make. Locally, health innovation and education clusters (HIECs) are being established to help facilitate high-quality training that is more responsive to local service needs. HIECs will bring together the NHS, universities, industry and other organisations, and will work in partnership with commissioners to align training and education with the local vision for improved services. They will be supported by and, in turn, support informed local workforce planning. At a regional level, SHAs have a key role in strategic workforce leadership. They develop, in partnership with commissioners and providers, an area strategic workforce development plan to support the regional clinical vision. They are accountable for investing in education and training to meet the local workforce needs of the NHS system and for securing high-quality training and best value for money. At a national level, the Centre for Workforce Intelligence will source, synthesise, critique and disseminate the best available analysis, evidence and intelligence to support the whole system in effective workforce planning. Medical Education England (MEE) and the other national professional advisory boards for nursing midwifery and allied health professions provide co-ordinated clinical input into workforce planning, education and training. These national boards link with the regional professional advisory services which will provide similar support to SHAs. The role of Department of Health (DH) at national level is to support change. It will do this by creating the right conditions and incentives, setting standards and advocating improvements with a strong national voice.
9 The Health and Social Care Bill Summary of the bill The bill proposes to create an independent NHS board, promote patient choice, and to reduce NHS administration costs. Key areas: establish an independent NHS board to allocate resources and provide commissioning guidance increase GP powers to commission services on behalf of their patients strengthen the role of the Care Quality Commission (CQC) develop and monitor the body that currently regulates NHS Foundation trusts, into an economic regulator to oversee aspects of access and competition in the NHS cut the number of health bodies to meet the Government s commitment to cut NHS administration costs by a third, including abolishing primary care trusts and strategic health authorities. There are currently 10 SHAs in England but this will change in line with the proposed NHS reforms when SHAs will be replaced by GP consortia. It is too early to say how this will affect commissioning and funding. Overview of current concerns Over the past few years numerous incidents have been reported by the press raising concerns over the care given to patients in a variety of settings and in different parts of the UK. Complaints of this nature are not new and criticisms have been levied against nurses and nurse education over a considerable period of time. The peak of activity links to the movement of pre-registration nurse education from hospital-based schools of nursing to universities and the introduction of higher level academic qualifications (Project 2000). As the academic level of pre-registration programmes will soon sit across the UK at a minimum of first degree, can we expect renewed complaints and criticisms about the way the nursing workforce enters the profession? Probably the most serious situation has been to investigate the shocking systematic failures of hospital care in Mid-Staffordshire that left patients routinely neglected, humiliated and in pain as the trust focused on cutting costs and hitting government targets. (Sarah Bosely, The Guardian 24 February 2010). The Francis inquiry was commissioned in September 2009 after a damning investigation by the Healthcare Commission. It found that between 400 and 1,200 more people died at the Mid Staffordshire Hospital NHS Foundation Trust than at other hospital trusts between 2005 and 2008.
10 Francis found that for many patients the most basic elements of care were neglected. The Mid Staffordshire NHS Foundation Trust Inquiry an independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust, January March 2009, chaired by Richard Francis QC, found that: patients were left in sheets soiled with urine and faeces for considerable periods of time there was striking evidence of the incidence of falls suffered by patients the attitude of nursing staff left much to be desired relatives took to taking sheets home to wash there was insufficient care for patients dignity families were forced to remove used bandages and dressings from public areas and clean toilets themselves. It must be noted that many staff raised their own concerns about the standards with Francis reporting the tragedy was that they were ignored. The government accepted the report and all of the recommendations in full. Areas of investigation and complaint included: 1. Continence, and bladder and bowel care 2. Safety 3. Personal and oral hygiene 4. Nutrition and hydration 5. Pressure area care 6. Cleanliness and infection control 7. Privacy and dignity 8. Record keeping 9. Diagnosis and treatment 10. Communication 11. Discharge management Whilst registered nurses, pre-registration nursing students and health care assistants will deliver the vast majority of care in these areas, it must not be assumed that they are the only part of the wider inclusive care team where any degree of responsibility for these failures lie. Other less publicised or headline hitting complaints can be seen virtually every day in the tabloid press. The Daily Mail reported on 31 January 2001 Exposed: how patients are dying needlessly from bedsores. The article states that more than 27,000 people died with bedsores or infected wounds in 2010 (Office of National Statistics data). Bed sores can be prevented simply by changing the patients position on a regular and frequent basis. Peter Walsh from the charity Action Against Medical Accidents suggests In this day and age, no one should acquire a pressure sore in hospital it demonstrates a lack of basic care. But is nursing care all bad? What is not reported in the tabloid press are the good news stories of nursing staff delivering excellent care in often difficult situations,
11 made even harder by staff shortages, financial constraints and the need for management to meet Government targets. References RCN (December 2010) Terms of Reference Education Commission NMC (May 2008) The Code, Standards of conduct, performance and ethics for nurses and midwives. Department of Health (2010) Education commissioning for quality framework dguidance/dh_ Worth, Jennifer (2008) Call the midwife: a true story of the East End in the 1950s. p 217, Phoenix Publishers Mid Staffordshire NHS Foundation Trust Inquiry. Independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 March Chaired by Richard Francis QC. 24 February 2010 HMSO