Setting new standards: the overhaul of nurse education

Speculation swirled for months about whether the NMC would make nurse education more generic – something critics claim would weaken specialist nursing. Now the regulator has revealed its controversial plans for the future.

Speculation swirled for months about whether the NMC would make nurse education more generic – something critics claim would weaken specialist nursing. Now the regulator has revealed its controversial plans for the future

Some nurses want a single course that would create a generalist nurse
at the point of registration.   Picture: iStock

The Nursing and Midwifery Council has begun its consultation on an education overhaul it describes as ‘radical’. The new standards are designed to ensure all nursing students complete their courses with a solid understanding of physical and mental health care. Some nurses are alarmed by what they see as a move towards a more generic nurse education system; others are disappointed the standards do not go far enough in that direction.   

The fierce debate about the direction of nurse education takes place as the NHS struggles to care for an ageing population with increasingly complex needs. At the same time, there are projections of a severe nurse shortage and falling numbers of applicants to nursing courses following the scrapping of the bursary in England.

The NMC’s proposals retain the four fields of adult, mental health, learning disability and children’s nursing, which are currently legally protected. The concise outcome-based standards, which have to be used by universities from September 2019, apply across all four disciplines of nursing and are divided into seven sections.

There are also lengthy lists of nursing procedures and communication and relationship management skills set out in two annexes. Some of these areas will be covered in more depth for particular branches of practice, the consultation document indicates. For example, under communication skills, mental health nursing students would have extra education on talking therapies, solution-focused therapies and cognitive behavioural therapies.

Working flexibly

The NMC says the standards meet the need for nurses to work ‘flexibly’, regardless of the field in which they work.

‘Registered nurses must be able to meet the fundamental care needs of people across their lifespan with a range of mental, physical, cognitive and behavioural health challenges,’ the consultation document says. ‘They must also be able to meet the more complex care needs of people in their chosen field of nursing practice.’

Some nurses want the NMC to introduce a single course for undergraduates that would create a generalist nurse at the point of registration. Supporters argue that this would give new graduates a better understanding of mental and physical health, helping them treat people more holistically.

But many others, particularly those in the three smaller specialties of mental health, learning disability and children’s nursing, are staunchly against a move to shared education, fearing their unique focus would be lost.

The RCN and the Council of Deans of Health, which represents nursing schools, say they understand the demand for nurses with skills to care for both the minds and bodies of patients. 

‘Registered nurses must be able to meet the fundamental care needs of people across their lifespan with a range of mental, physical, cognitive and behavioural health challenges’

NMC consultation document

‘We saw a realisation and an awareness that irrespective of their field, there is a fundamental need for students to be equipped with the right skills and knowledge for physical and mental health in whatever age group,’ says CODH executive director Katerina Kolyva.

But she adds: ‘I would like see less prescription in the new standards to allow universities to deliver programmes that can be more flexible between and across the fields.’

RCN deputy director of nursing Stephanie Aiken says the current system needs reform: ‘It is not about a generic nurse, it is a nurse with a wider understanding in the types of health issues that someone may present with, and therefore you need to prepare them to care holistically.

‘Current pre-registration nurse education is predominately focused on hospital-based care, and this needs to change to enable provision of care closer to home and greater emphasis on self-management of health. Nurses can lack confidence and competence to care for people with highly complex needs which span the fields of nursing practice.’

Generalist training

Many other countries use a single pre-registration course. A study of nursing education in 18 countries by the National Nursing Research Unit at King’s College London highlighted that 14 of the countries trained their nurses to be generalists at the point of registration, including the US, New Zealand and Australia.

Support for a more generic model of nurse education came in Lord Willis’s review Shape of Caring, published in March 2015, which called for all nursing students to share the first two years of their course before specialising in their final year.

It is the smaller specialties that are most concerned about the prospect of more generic education, fearing that adult nursing, by far the largest cohort of students, would dominate any core components of a course, to the detriment of their fields of practice and their patients.

Children’s nurses have been vociferous in their protests against a potentially generic course, including lodging a petition on the government’s website last year calling for the specialty to be saved.

University of Manchester senior lecturer Debbie Fallon, who is chair of Children and Young People's Nurse Academics UK, says the need for children’s nursing courses is demonstrated by the high rate of applicants and the chronic shortage of children’s nurses.

Genericism by stealth

The standards in the NMC’s consultation would need to be taught differently in the different fields of nursing, she says. ‘They may be able to couch it in the same terms for everyone, but it doesn’t mean that everyone will be learning the same thing,’ Dr Fallon says.

‘These standards will not turn our curriculum into a more generic programme. We can fight our corner as we are a big team.  But if you are a small team with smaller numbers you tend to be sucked into a more generic model. I am not sure if there is a long-term agenda of genericism by stealth.’

University of Manchester mental health nursing education Professor Steven Pryjmachuk says the draft standards lack parity between mental health and physical health.

He welcomes the move to give all nurses more mental health education, but says the standards still focus too heavily on adult, hospital-based nursing tasks. He also points out that the NMC consultation documentation almost entirely features pictures of nurses in uniform, which does not reflect mental health or learning disability nurses.

‘Of course we need specialisation. Our problem is premature specialisation’

Dame June Clark

‘With the fields being retained, the explicit threat of genericism has gone for now, though there are anxieties about genericism through the back door, in that there is an overemphasis on the long list of physical, technical skills in the annexes,’ says Professor Pryjmachuk.

‘You might wonder where in an already crowded curriculum we are going to find the time to focus on specialist mental health skills.’

While many students and nurses support the NMC’s aim to ensure more nurses acquire good skills in mental and physical health assessment, how all this can fit into already busy courses is less clear.

London South Bank University third-year mental health student Mark Weetman welcomes more physical and mental health knowledge for all nurses to improve holistic care. He would have liked greater exposure to physical healthcare education. But he worries the new standards are too generic.

Unique skills

‘The standards include a lot of skills that are not broken down into specialist areas and don’t appear to take into account the different skills that are unique to particular areas of nursing,’ he says. Mr Weetman points to concerns that the workforce will become ‘diluted and capable of doing many things but not have the sufficient depth of knowledge to work effectively in one area’.

Many universities already have modules that are shared across courses for different fields of nursing. Birmingham City University adult nursing department head Kevin Crimmons says half the modules taken by each of the fields of practice each year are shared across all four specialties. He expects this kind of approach to be more formalised in the NMC’s new standards.

The desire to shift more care away from hospitals and into the community, advocated in the Five Year Forward View and many other policies, is one of the drivers behind more generic education, he says. Creating nurses with the knowledge and skills for the variety of work needed in the community and primary care will require changes.

‘As an adult nurse, I think exposure to the other fields of nursing enriches and leads to more capable nurses,’ he says.

'Selfish' specialists

Swansea University professor emeritus in nursing Dame June Clark firmly supports the idea of a single curriculum to produce a generalist nurse, with postgraduate specialist courses supported by appropriate funding. Research suggests that many adult nurses don’t understand dementia and many mental health nurses miss or do not know how to treat physical problems well, Dame June says. 

‘Of course we need specialisation. Our problem is premature specialisation,’ she says. ‘There is some limited research that generalists focus on the needs of patients whereas specialists focus on protecting their specialism.

‘Nurses who support premature specialisation cannot claim to be patient-centred – their primary aim is the selfish aim to protect their specialty.’

Dame June is pleased with the direction the standards are moving in but believes they don’t go far enough. ‘The standards are a big step towards the generalist nurse. But I’m sad that they couldn’t go the whole hog and get rid of the branches,’ she says.

The NMC’s consultation runs until September 12. For more information click here

Australia: mental health nursing 'diluted' by generic education

All nursing students in Australia have taken a generic course since direct-entry specialist courses were phased out about 20 years ago. They can choose to specialise at postgraduate level, although specialist training is not always a prerequisite to work in a particular area.

Mental health academics have said the change has had a serious impact on the quality of nurses available to care for mental health patients.

A number of inquiries have suggested that mental health nursing is under-represented in undergraduate programmes, with serious consequences for creating a sustainable mental health nursing workforce.

Learning disability is also under-represented, according to a study published last year that found more than half (52%) of Australian nursing schools had no intellectual disability content on their nurse training courses. Only one out of 31 nursing schools involved a person with intellectual disability in developing or delivering content. 

Eimear Muir-Cochrane, chair of mental health nursing at Flinders University in Adelaide, says that, increasingly, nurses with no mental health qualifications are being recruited to work in mental health settings.

‘It has diluted the potency of what being a mental health nurse is,’ Professor Muir-Cochrane says. ‘Not having direct entry to mental health means that anyone who wants to be a mental health nurse has to become a registered nurse first then take a postgraduate qualification.

‘However, they don’t have to have that qualification because it isn’t a national registration mandatory requirement. Someone with a bachelor of nursing with a small amount of theory but no clinical experience can be employed directly into mental health settings, and that is extremely problematic. In the past that didn’t happen.’

Erin Dean is a freelance health writer

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