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New education standards will prepare students for the rigours of modern nursing

Reform of preregistration nurse education will not only affect students, but the profession as a whole. Lead adviser on the changes, Dame Jill Macleod Clark, explains her thinking

Reform of preregistration nurse education will not only affect students, but the profession as a whole. Lead adviser on the changes, Dame Jill Macleod Clark, explains her thinking


Dame Jill Macleod Clark. Picture: Chris Balcombe

When the Nursing and Midwifery Council asked Dame Jill Macleod Clark to lead the development of its new standards for nurses entering the profession, she was taken aback. ‘I absolutely didn’t expect to be approached – I supposed I would be seen as something of a challenger.’

The last time the NMC had revised its standards for pre-registration education, in 2010, Professor Macleod Clark had been unstinting in her disappointment. She was chair of the Council of Deans of Health at the time: ‘I was very vocal on behalf of the membership about the fact that the NMC h ad not radically reviewed the standards – they had made them longer, more complex and tortuous.

‘It said a lot about the NMC’s acceptance that change was needed that they approached someone who had been challenging in the past.’

Extensive consultation

Professor Macleod Clark has decades of achievement behind her in academic, research and leadership roles. She sees no point in retiring but is choosy about what she takes on and is only prepared to give her time to the things that matter.

She agreed to take on the lead adviser role, a huge job for which she visited and canvassed opinion from stakeholders including students and registrants at every level of practice across the UK because ‘it’s not much good complaining about things if you are not prepared to improve the situation. It was an opportunity – probably a once-in-a-lifetime opportunity – for the profession to recalibrate itself’.

Anyone who doubts the significance of the standards, should try discussing them with Professor Macleod Clark. I spent more than two hours with her at her home in Southampton, but ten minutes would be enough to make you believe. She is passionate about their importance not just to the future registered nurse (the first nurses to train under the new standards will graduate around 2022) but to every nurse practising today.

One of the key changes the updated standards usher in – replacing mentors with a system that separates support and supervision from assessment – should vastly expand the pool of nurses involved in the training of students. Indeed, she insists that preparing students for the rigours of the modern registered nurse role is every nurse’s business. She points out that to fulfil their responsibility to students, nurses will have to know the standards and demonstrate those that are relevant to their own area of practice.

The essence of nursing

The standards are designed to increase registered nurses’ contribution to public health and equip them to take a lead role in managing increasingly complex healthcare packages.

They focus on outcomes, not process, define the essence of nursing practice and provide the basis for career-long professional development.

It is exciting – but is it realistic? Professor Macleod Clark acknowledges that the standards are ambitious and that living up to them at a time of increasing demand and overstretched resources is a challenge. But she is clear that setting the bar lower for registered nurses – and leaving them with no hope of developing the skills and attributes they need to cope with the demands placed on them – is not an option.

The professor and her team have pinned down the minimum standards of proficiency that a newly registered nurse needs in order to practise safely and effectively. A great deal of work is underway at the NMC to fill in the detail of how the standards will be implemented. They are expected to be approved by the NMC on 28 March and introduced in 2019.

She says it is up to the profession now to get behind the standards, exercise its under-used political muscle, and insist on investment in the development of all registered nurses. She wants no one to be left behind. ‘There has to be an acknowledgement of the need to support the existing workforce. We have a professional responsibility to make sure the government coughs up and supports continuing professional development.’

If this puts nursing outside its comfort zone, then so be it. ‘We can’t stand still – and if you do things differently you have to work through what that means.’


Q&A

How flawed are the 2010 standards – what is it that you are trying to fix?

If you dig into the current standards there is some good content but it is wordy and repetitious and very much focused on process. For example, the document recognises the importance of leadership but it doesn’t identify what that means. The size and scale of the main document – more than 150 pages – make it extremely difficult to extract and focus on the essence of registered nursing, which includes playing a lead role in supporting people to remain independent and maximise their quality of life, particularly in terms of the fundamentals of care. That was one of many reasons for doing a radical review.

Has the focus on process in the current standards, and density of the document, had a negative impact on the quality of nursing graduates? 

It has had an impact. The variability in how they are interpreted and what is assessed at the end of nursing programmes can be huge because the outcomes are not clearly articulated. Variability doesn’t matter if everybody is fit for purpose but there have been a number of concerns raised by employers about the knowledge and skills of students graduating from the programmes.

Some of the most compelling evidence we heard was from current students and recently qualified practitioners, who were amazingly open and honest about what they had and hadn’t done. Some would say ‘I’ve never undertaken a catheterisation’ while others had that experience, and the same was true for other procedures such as the insertion of nasogastric tubes or cannulation.

The new standards require all students to have a basic competence across the four fields of nursing. What do you say to critics who fear this will weaken specialist nursing? 

I turn the question around to ask, ‘what is in the public interest?’ For example, it would be wrong to deny that a large proportion of people you encounter as a nurse will have both physical and mental health problems – and indeed they may also have cognitive challenges.

There was a knee-jerk response initially because people understandably felt their specialty was being undermined. That absolutely was not the intention and the four fields remain. Nobody doubts we need nurses with tremendous expertise in child health, mental health and learning disabilities. But the standards are about what you need as a baseline to function effectively as a registered nurse. You will then go on to develop much more expertise in your particular field.

There has always been an assumption that you hit the ground running as a new registrant, that you are fully formed. It cannot be – no other profession expects new professionals, on graduation, to be able to do everything.

Junior doctors are junior for a very long time…

There is a useful comparison with junior doctors. We have a problem because successive governments have systematically undermined the amount of money they put in to support post-qualification nursing training. Yet they haven’t really touched the money that goes into supporting the career development of doctors.

We have done the right thing in creating these standards, for the public and registrants, but you can’t expect registered nurses to continue developing expertise unless there is serious resource behind it. That has to change.

Did you consider a more radical approach to the branch system? There have been suggestions that a more holistic approach would be encouraged by reducing the number of branches. 

Removing the fields requires legislative change and I don’t know that the NMC had an appetite for that when the review of standards was initiated. My personal view is that there is a huge case for having a pre-registration programme that equips people intelligently to support and care for people with a range of health challenges at a basic level. I have always liked the North American and Australian systems of doing a basic undergraduate programme and then focusing on your chosen field or fields.

I don’t think reconstructing the branches is the answer. But over time the pattern of healthcare demand and people’s need for nursing support and care should inform changes to fields of nursing practice.


Every nurse – rather than a limited field of mentors – will be involved in supporting students’ education. Picture: John Houlihan

You said you would tie yourself to the railings of the NMC building if the word ‘mentor’ appeared in the new standards. Why do you feel so strongly that mentoring has to go?

The current mentorship system is costly and time-consuming and it’s not sustainable in terms of meeting the needs of large numbers of students equitably. Undoubtedly, there are many superb mentors but largely their job is impossible. For me it is also about semantics. I’m concerned when terminology is used slackly. The term mentor is not used appropriately. A mentor is somebody with whom you have a long-term relationship, who supports you on a journey and who does not assess you.

I was asked to lead a radical review of the standards. You can’t modernise the standards without modernising the system of supporting, supervising and assessing students.

It could be argued that you have rebranded mentors rather than replaced the system with something radically new.

The big difference is that instead of the responsibility for supporting, supervising and assessing students being vested in a limited number of mentors, the expectation is that every registered nurse will be responsible for supporting, supervising and potentially assessing students who are placed in their area of practice. It should become an embedded professional responsibility. This is often implicit in other professions, that you support junior colleagues, you help them to learn.

People who are excellent mentors can play a very important role in being the architects and leaders of the new system of practice learning, supervision and assessment.

Many overworked nurses don’t have the time to mentor students. Isn’t there a risk that the new standards will increase the already intense pressure on the existing workforce?

I don’t buy that argument. Under the existing system one person can be asked to mentor nine students; compare that to nine people being asked to support the learning of nine students. The new system will disperse the demands on registered nurses and mean students are not left on practice placements without adequate support.

The draft standards relax the cap on the hours a student can spend in simulated learning, but reducing the focus on practice placements is controversial.

Maintaining an arbitrary cap makes no sense whatsoever. The evidence for the success of learning in virtual and simulated environments is compelling. And we are moving to outcome-led standards – it shouldn’t matter how you meet the outcome. If you have fewer but higher-quality hours of learning experience in practice that has to be better than more hours of possibly mediocre experience.

The proposal that students could be supervised by non‑nursing professionals also attracted a lot of opposition. Is this a sign that, despite all the rhetoric about multi‑professional teamwork, people are still stuck in silos?

Yes. And many people can’t see it the other way – imagine how much value there would be in a doctor learning from a nurse?

There has been a lot of discussion about how much is expected of newly qualified nurses under the new standards. Not just relatively advanced clinical skills but sophisticated behaviours and leadership ability. Are you asking too much?

They are ambitious but that is what we heard from the public that they will need from registered nurses in the future. The standards expect you to understand what you need to be able to know and do at the point of registration; you might still need help initially.

Is a three-year course long enough for students to reach these standards?

The best-case scenario would be that the standards prompt us to revisit the need for a foundation year. But I think theoretically it is achievable in three years because it is much more focused. It will be much harder to have woolly content in courses because students will have to meet these outcomes.

How much depends on the government creating conditions which will make it easier to deliver these standards? I’m thinking particularly of the existing workforce who were trained under the old system.

The government has a huge responsibility to support existing nurses and help them to come up to speed where they need to. In my opinion, the government is expecting everything [from nurses] for nothing. The failure to invest in the continuing professional development of the registered nursing workforce will come back to bite them. If it doesn’t change, there will be a continued brain drain, to some extent also determined by pay, which has been miserably neglected.

As a profession we are unsuccessful in punching at our weight, never mind above our weight. We just don’t seem to have the confidence. You will notice that the new standards mention the need to understand policy and politics.

How far away are we from ensuring nurses have the confidence to make every contact count with patients and exert a wider influence on health policy? 

We will only get to that level by expecting people to be proficient on these outcomes. For example, there is a whole section on promoting health and preventing ill health, with 12 outcomes you have to meet. As a student you can pick this up and say, ‘that’s what I’m supposed to be able to know and do when I graduate’.

And registered nurses will have to look at the standards because they will be supporting students. Our extensive engagement with the profession during the project confirms that most of the existing registered workforce will welcome these standards with open arms.

The new standards – key points

  • New registrants required to have a basic competence in all four fields of nursing
  • Replacement of mentors with a system separating support and supervision from assessment. Many more registrants involved in supporting students
  • Outcome-focused standards of proficiency are grouped under seven headings: be an accountable professional; promote health; assess needs and plan care; provide and evaluate care; lead nursing care and work in teams; improve safety and quality of care; coordinate care

CV – Dame Jill Macleod Clark

Dame Jill Macleod Clark has a background in clinical and academic nursing and is regarded as a key figure in the development of research capacity in nursing and the embedding of undergraduate nursing education in universities.

  • Emeritus professor of nursing at the University of Southampton where she is former head of the health faculty. Her research interests include evidence-based nursing interventions and health promotion
  • Trained at University College Hospital in London and has worked in the acute and community sectors. She completed a doctorate on nurse-patient communication at Kings College London
  • A former chair of the UK Council of Deans of Health, she continues to contribute to nursing and healthcare policy nationally and globally

Listen to Dame Jill Macleod Clark on the Nursing Standard podcast

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