Do branches make it hard to be holistic?

In his report of the Shape of Caring review, Lord Willis proposes a flexible model of nurse education based on two years of generic training followed by specialisation. Critics claim moving away from the branch system risks diminishing nursing expertise in certain areas. The issue will be debated at RCN Congress.

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Is the current system of nurse training fit for purpose? It is a question that has been posed many times, with the answers sometimes leading to significant change.

This time around the question has been asked by Lord Willis in his report of the Shape of Caring review, which was commissioned by Health Education England and published in March (see box).

Shape of Caring – key points

The report by Lord Willis on the future education and training of nurses and care assistants argues in favour of a flexible model of training and states:

We need to develop registered nurses who can deliver whole-person care in flexible environments, with patients who are often older and have multiple conditions.

There are concerns that the four fields do not lead to parity of esteem between mental health and physical health, or provide the experience required to promote care being transferred to the community.

Education should develop registered nurses who can provide person-centred care in a range of settings, based on patient needs and pathways.

The report recommends that the Nursing and Midwifery Council gather evidence, explore and consult on its proposed model, alongside alternatives, to examine whether the existing ‘four fields’ system is fit for the future.

Read the report at tinyurl.com/q8wrttv

Lord Willis’s recommendation of a flexible model based on two years of generic training, followed by a year of specialisation and another of preceptorships will be up for discussion at RCN Congress, taking place in Bournemouth later in June.

The debate will consider if the current four branches of nursing – adult, child, mental health and learning disability – lead to nurses working in isolation, or if they meet the needs of vulnerable patients.

Former chair of the RCN children and young people’s specialist care forum Rachel Hollis has been instrumental in getting the issue on the agenda.

‘The report calls the current training system into question,’ says Ms Hollis, who is lead nurse for children’s cancer at Leeds General Infirmary. ‘I hold a strong view that children’s nursing is one of the UK’s great strengths. Few other countries train children’s nurses as we do, with most doing generic training first.’

While she accepts that change may be necessary, she believes the idea that children’s nursing should be viewed as a specialty is fundamentally flawed. ‘Paediatrics is our generality – we all look after children and young people,’ she explains. ‘My particular specialism is cancer nursing.’

Using the Willis proposals as a starting point, Ms Hollis wants to see two years’ generic child-nurse training, followed in the third year by specialisation. This might include acute, community, mental health and other fields, but she would like the year to relate to the specific needs of children and young people.

‘We need a workforce whose primary concern is children and young people,’ says Ms Hollis, pointing to the UK’s poor record on child mortality, highlighted in a report by the Royal College of Paediatrics and Child Health. Based on 2013 figures, the report ranked the UK bottom of 20 western European countries for deaths of children under five.

‘At the moment our health service is focused on adult and older people’s care,’ says Ms Hollis. ‘A big proportion of the cases GPs see are children yet few have specialist training. And we’re still training fewer children’s nurses than we need. In Leeds, we have far more students applying for courses than there are places.’

City University London professor of collaborative mental health nursing Alan Simpson is wary of moves towards a generalist approach. ‘It threatens to diminish the attention given to mental health nursing in the curriculum, because the focus on adult nursing is overwhelming,’ he says. ‘But perhaps the most compelling reason is there just isn’t the evidence to say it works.’

He cites the example of Australia, which adopted university-based comprehensive education in the mid-1980s, with specialist training now offered only post-graduation. ‘They’ve regretted it ever since,’ says Professor Simpson. ‘There are great difficulties recruiting nurses into mental health and a continuing shortage as a result.’

Before its closure last year, the advisory body, Health Workforce Australia, predicted a significant shortfall of nurses in a decade’s time, with mental health being one of the areas at particular risk.

A motivation for Lord Willis’s proposed system is the perception that, under the branch structure, the physical health of patients with mental health problems can become marginalised. NHS England says many mental health patients are dying up to 20 years earlier than the general population.

Consistent approach

Lord Willis called for parity between physical and mental health nursing, with a more consistent, holistic approach. But according to Professor Simpson, the Australian system has not led to improvements in the physical health of mental health patients. ‘I say this not from a position of complacency. We do need to up our game,’ he adds.

However, he does see the need for those following the adult nursing branch to undergo a strong component of mental health training. ‘I’d like to see some of the skills, attitudes and values of mental health nursing reflected across the curriculum,’ he adds.

It is a view partially echoed in the Shape of Caring report, in which Lord Willis states: ‘Considering that a quarter of the population will experience some form of mental health issue during their lives, adult registered nurse training does not focus enough on mental health issues, other than dementia.’

But should students be asked to choose their branch at the outset, before they have any real understanding of nursing? Professor Simpson says: ‘People usually have a clear idea of the sort of nursing they want to do. They don’t just turn up saying, “I want to be a nurse, but I’m not sure what kind”.

‘When people apply here to become a mental health nurse, it’s because that is exactly what they want to be. Different kinds of nursing attracts different people.’

Kate Hendy of Avon and Wiltshire Mental Health Partnership NHS Trust qualified as a state registered nurse in 1979. She undertook her mental health nursing qualification four years later and has worked in that field ever since, mostly in the community.

She says: ‘I benefited by doing general training first and I think there should be some generic training, especially as our approach to patients needs to be holistic.’

I’d like to see the skills and values of mental health nursing reflected across the curriculum

She would like core training to include topics such as listening skills, personal care and aseptic technique.

However, Ms Hendy is against any watering down of the mental health branch. ‘We need greater emphasis on continuing training that is directly related to the job you’re doing, in your specialism,’ she maintains.

Consultant nurse and clinical director Gwen Moulster rejects the suggestion that learning disability nurses work in silos. ‘I don’t believe it for a minute,’ says Ms Moulster, who works for South Staffordshire and Shropshire Healthcare NHS Foundation Trust. ‘We work with such a diversity of people, circumstances and settings and have the ability to be flexible.’

For her, the issue is whether nurses in other branches know enough about learning disability. ‘Most people with learning disabilities are dealt with by generic health services and they can often be seriously ill before they’re referred to us. We need to find a way of increasing the knowledge of other nurses about learning disabilities.’

The same point is made in a Council of Deans of Health report, Learning Disabilities: Meeting Education Needs of Nursing Students. It states that many staff working in general health and social care settings have limited knowledge of people with learning disabilities.

Ms Moulster argues that learning disability nurses already have broad health expertise as a cornerstone of their training programme. ‘What might work is to use what we do at the start of our training as the basis for every nurse,’ she says. This includes good communication skills, problem solving, partnership working, public health and person-centred care.

‘But don’t get rid of learning disability nursing,’ Ms Moulster urges. ‘There are fewer courses already, I worry it will disappear.’

Foundations for training

At present students are asked to choose in which of the four branches of nursing they wish to train before they apply for a programme. A small number of universities offer the flexibility of choosing the branch after the student has started the course.

Some universities are approved to run dual branch pre-registration courses leading to registration in both branches – for example, adult and mental health or adult and children’s nursing.

The last time a common foundation was established was as part of Project 2000, which was introduced in the 1990s. Nursing students studied an 18-month core programme before choosing one of four specialist programmes in adult, child, mental health or learning disability, for a further 18 months. The comprehensive component was later revised down to a year to allow greater emphasis on branch specific education.

Fellow learning disability nurse consultant Michael Brown agrees that the problems are with the adult nursing programme, rather than the other branches.

‘It’s not fit for purpose,’ says Professor Brown, who chairs the RCN learning disability forum.

‘The demographics are changing and nurses are looking after more people with long-term conditions. We need to re-orientate services and training – but the last thing we need is a rewrite of the SRN programme by a different name.

‘If we want to change things, that should never be at the expense of the people we are there to protect’.

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