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Pre-registration education

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The Willis Report, an independent review commissioned by the Royal College of Nursing, (RCN), published in October 2012, reaffirmed that all pre-registration nursing education in England would become degree-level by September 2013. By 2020 a relevant degree will be a requirement for all nurses in leadership and specialist practice roles.1

Until now around 85 per cent of pre-registration training in England has been provided as higher education diplomas.1

Standards

In 2008 the Nursing and Midwifery Council (NMC) decided that the minimum academic level for nursing should be a bachelors degree. UK government health ministers endorsed the decision and after a period of consultation, in 2010 the NMC issued new Standards for pre-registration nursing education.

The standard for pre-registration training consists of two separate sets for nurses and midwives. Only programmes approved by the NMC will lead to registration as a nurse or midwife.

The criteria state that all pre-registration programmes must be no less than three years of study, at least half of all training must take place in clinical settings (which must include hospital and community environments), programme providers must ensure that students are of 'good health and good character' (regarding honesty, trustworthiness, conduct, behaviour and attitude) when they are first admitted to the programme, at progression points and on course completion.2

The nursing programme curriculum must incorporate five groups of essential skills: care, compassion and communication, organisational aspects of care, infection prevention and control, nutrition and fluid management and medicines management.

The essential skills that midwifery programmes must cover are: communication, initial consultation between the midwife and woman, normal labour and birth, initiation and continuation of breastfeeding and medicinal products management.

The changes were made to pre-registration nursing education to ensure that education continues to evolve in line with the health needs of the population according to the NMC. The changes acknowledge the skills required to address future health priorities such as reducing smoking, obesity, unplanned pregnancies and alcohol abuse. They meet the challenges posed by an ageing population and caring for people with long-term conditions, the NMC says.

Tim Curry, the assistant head of nursing at the RCN agrees with the view that as the population continues to live longer and with more complex long-term conditions that nursing education must continue to expand and evolve to reflect these changes.

'Nursing is a complex task and the future health needs of the population are increasingly complex. Whilst many aspects of nursing are rooted in 'practice', they all require critical thinking, detailed pharmaceutical and anatomical knowledge and a wide appreciation of related disciplines such as sociology and psychology,' he says.

'This is about nursing coming into it's own as a profession and being able to articulate its unique contribution to person-centred care,' he added.

Mr Curry also highlights evidence that supports graduate level nursing over decades and in different countries. American studies have found that graduate nurses stay in the profession on average four years longer than non-graduates. Other research in the US has also noted that graduate nurses acted more independently, took more responsibility for their professional judgement and additionally took on advocacy roles. They were better than non-graduate nurses at making nursing diagnoses and evaluating the effects of nursing interventions.

Student perspective

Jessica Curtis, Hertfordshire University, enhanced diploma in children's nursing

My experience of being a student nurse was very positive and empowering. I was very lucky to have very supportive mentors in my placements that pushed and inspired me to excel. It is thanks to one of them that I am in my current nursing post doing general medicine with extremely sick children.

My placements varied from general medicine, children's emergency medicine to oncology in the community. During my first year of training I gained an insight into all four branches of nursing (adult, children, learning disability and mental health). I feel this was a very important part of my training as it allowed me to learn more about the other branches.

I believe that nursing education is done well. We get a varied learning experience through lectures, clinical practice and skills sessions. It allows student nurses to put what they learn in the classroom into practice in the real world. I remember learning injection techniques and then first doing them in practice. It is important to encourage students to reflect upon practice to allow them to enhance their training. I was lucky enough that my university was very keen on reflection and I have continued this reflective practice into my career.

My diploma is the same qualification as a degree, there is no difference in the training. This isn't an option for students anymore. I will be attending university in the next couple of years to gain my last credits for the full degree.

UK Context

Higher Education Institutions across the UK have been offering degrees at undergraduate level for years but the recommendations in the Willis Commission's report means universities will now be phasing out the higher education diplomas.

Universities in Scotland have offered degrees in nursing for the past few years. Six universities fulfil the Scottish government's contract for nursing education and five other non-commissioned universities deliver pre-registration programmes.1

The programmes at the University of Stirling, Scotland, have been BSc's since 2011, so all of their alumni are now graduates, Sandra Menzies, the director of undergraduate programmes at the University of Stirling explains.

'The Francis Report informed some of the teaching changes such as ensuring students are taught resilience in all situations, and how to confidently spot concerns, and how to be supported throughout the process. Time is being invested to ensure all these things are being done.' The programme was revised when it became a BSc, she says, so that each module is thematically led, with key skills revisited over the course of the three years.

In Northern Ireland, three universities, Queen's University Belfast, the University of Ulster and the Open University all offer degree-level programmes. They introduced the new curriculums in line with the NMC standards in 2012.

Queen's University in Belfast has been offering degrees for around 10 years alongside higher education diplomas. When the faculty began offering degree-only courses, they dropped the diplomas and have focused solely on providing the degrees.

In Wales, all pre-registration nursing programmes have been at undergraduate level since 2004.

Some universities in England have offered BSc's for a number of years and with these new recommendations they all are.

The new programme at the University of Nottingham began in 2012 and all of the current students will leave with a degree. The curriculum was completely rewritten in May 2012 to adhere to the standards put forward by the NMC. said: 'We took it as an opportunity to be more innovative and to fit the curriculum with the needs of the current workforce. We changed the style of teaching and went for single entry in October.'

'The concept of degree-level undergraduate education is not a new concept, the new concept is the broader application of degree-level education,' says Carol Hall, the director of pre-registration nursing courses, at The University of Nottingham.

Steve Walton

'There is no reason why it can't be a degree-only subject as it is important students have grounding in the theory.'

Applicants

According to figures from UCAS the number of applicants applying to nursing courses at higher education institutions in the UK has risen from 60,307 in 2006, to 212,572 in 2012.3 These numbers indicate the rising demand for quality education with more stringent entry levels which will ensure a constantly improving workforce in the future. However views have been expressed that degree-level courses might deter applicants that would otherwise have been accepted.

Ms Hall says that their application rate has remained healthy and that they are often oversubscribed. 'Applications are more healthy in midwifery and children's nursing, possibly because there are fewer places available, and also because of extensive media coverage due to shows such as One Born Every Minute and Call the Midwife.

'I think the change to degree-level education is good, if you look at the skills and requirements needed for a nurse in a clinical environment in terms of problem solving then they are the skills required of a graduate,' she added.

Dr Marian Traynor, the director of education at Queen's University Belfast agrees.They ensure that the university actively plays a part in recruiting prospective students. 'We work with schools and career teachers to promote nursing which means that we are oversubscribed every year. We have not noticed any changes in the number of applicants since the diploma was dropped.' she says.

'I don't believe that changing entry into nursing to purely degree level will discourage people from applying as all of the entrance criteria will be outlined on UCAS, and many of our applicants have gone to night classes to build up their skills and applications.'

Student perspective

Steve Walton, advanced diploma in mental health nursing from Northumbria University.

I worked as a mental health support worker for around 13 years before deciding it was time to qualify as a mental health nurse. I qualified as a mental health nurse in March of this year.

During my time at University I was well supported and I was very lucky as I had generally very good placements, which I know isn't always the case. I also had lots of good mentors and actively sought out the information I needed.

There is no reason why the changes to degree-level entry should not happen but I worry that people like myself who do not have A- Levels would not be able to get on to degree courses. However, it is important that students have a good grounding in the theory of nursing. It is also important that they have the human, caring side, and people who have those skills may no longer have the opportunity to fill the roles.I have been given positive feedback since I started working and I worry that I may not have been accepted to a degree programme.

The future

A spokesperson from the NMC said that the changes are not about undermining the skills of the current workforce. 'They bring about a wealth of experience to nursing and the delivery of healthcare, and will continue to do so. They are the role models and mentors for future nurses and have a vital role to play in ensuring the successful implementation of the new standards and the culture of nursing.

'All registered nurses will have achieved further knowledge and skills through their own continuing professional development.

We expect that an all graduate programme outcome will mean nurses are better prepared earlier on in their careers to be more assertive , more questioning and take greater responsibility. This will help nursing as a profession to continue to deliver high-quality care in ever changing environments,' they said.

It is also important to ensure that graduate nurses continue to recieve support once they qualify and enter the workplace, says Mr Curry.

The RCN is currently working on a series of resources for newly-registered nurses to ensure that they continue to recieve support in their first six months in the workplace.

The first set of students to be educated under the 2010 NMC standards will graduate next year. Following this the standards will be evaluated for their effectiveness.

Mr Curry says that perspective of nursing needs to change to continue to ensure that the education system turns out high-quality nurses. 'Politically people have to stop talking nursing down, it remains a diverse, challenging and positive career, that is valued by the public. We need nurses that can make critical decisions and the change to degree-level education will continue to ensure that will happen.'

References

1. Report of the The Willis Commission. October 2012. http://bit.ly/TTjyFL - 2012. Accessed 30 September 2013

2. NMC Standards for education. 2010. http://bit.ly/Z5Ax6h. Accessed 4 October 2013

3. UCAS annual reference tables. http://bit.ly/H3pW85. Accessed 4 October 2013

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