Practice makes perfect?

January 21, 2000

This week's announcement of better pay for experienced nurses complements the efforts to improve training. Claire Sanders reports

Nurses studying in English universities could soon have their courses reviewed under a contract being drawn up by the Quality Assurance Agency and the National Health Service.

As the flu epidemic has once again brought the shortage of nurses to the public's attention, the contract (and any future arrangements elsewhere in the United Kingdom) is just one part of a complex jigsaw designed to bring more and better trained nurses into the NHS.

The Royal College of Nursing puts the shortage of nurses in England at 15,000. The figures for Scotland and Wales are 1,000 and 500 respectively. But over the past year, in particular, there have been various initiatives to train more nurses, to bring back qualified nurses into the NHS and to stop experienced nurses leaving.

The RCN argues that nursing needs to be far more attractive and affordable if the shortage - exacerbated by the Conservative policy of cutting training places - is to be made good. (The graph on the opposite page shows the drop in entries to nursing courses.)

Eleven years ago, nurse education moved from hospitals into universities with the introduction of Project 2000. Now 70 universities and colleges educate around 56,000 nurses and midwives to both degree and diploma standard.

Only about one in ten nursing students

studies for a degree (although the figure varies across the country), but both courses lead to a qualification as a registered nurse.

This time last year university nursing courses were under fire. The then health secretary Frank Dobson said: "We must ... reform the system of nurse education and training which the previous government introduced in the 1980s. It has achieved some of its objectives, but its emphasis on the academic element has put off some potential recruits."

He drew attention to persistent concerns about the lack of practical skills among

newly registered nurses. "Many nurses, when they qualify, think that they lack the practical skills necessary on a ward. The transfer

of responsibility to the education sector

from the health service has broken down the old links between individual hospitals and nurses in training, to the disadvantage of both."

But since this low point, things have improved for nurses and their educators. In the same month, Mr Dobson promised to create an extra 6,000 nurse or midwife training places over the next three years.

He also announced a Pounds 5 million initiative aimed at getting former nurses back into practice. In July the government published Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. It was billed as "the most comprehensive strategy ever produced for improving the status, training, pay and job opportunities for Britain's 500,000 nurses, midwives and health visitors". Nurses were not only offered better pay but also improved and more flexible working conditions and training.

Making a Difference was not as tough on universities as Mr Dobson had been. But the paper does say: "Evidence suggests that in recent years, students completing training have not been equipped at the point of qualification with the full range of clinical skills they need ... A stronger practical orientation to pre-registration education and training is needed."

The government proposed more flexible courses that would have built on experience and had a number of stopping-off points. It proposed that this "new model of nurse education" should begin in September 2000, on at least 16 sites. (See box on opposite page for case study.)

By August, the attempts to improve a nurse's lot seemed to be paying off. Mr Dobson was able to announce that nearly 30,000 applicants had applied for nursing and midwifery courses compared with 16,000 at the same stage last year.

End-of-year figures released by the Universities and Colleges Admissions Service last week showed that the number of students taking places on degree courses for nursing and midwifery for the academic year 1999-2000 rose by 24 per cent. Acceptances for diploma courses were also up by 18 per cent - from 12,567 to 14,834.

The United Kingdom Central Council for Nursing, Midwifery and Education is the statutory regulatory body for nursing, midwifery and health visiting. It maintains a register of qualified nurses, midwives and health visitors and sets standards for their education, practice and conduct. In April 1998, the UKCC asked Sir Len Peach to chair its Commission for Education, and last September he produced his report, Fitness for Practice.

As the Peach report notes: "It has been agreed ... that the UKCC needed to provide an authoritative stance on pre-registration education and to do so urgently."

The report makes 33 recommendations in all and says they should be implemented in the next two to three years. It endorses the finding that nurses lacked practical skills on registration and recommended the following:

* More and better clinical practice

* Greater flexibility of courses

* Improvements in partnership between education and the health services. (See box on opposite page for details.)

Eve Jagusiewicz, policy officer at the Committee of Vice-Chancellors and Principals, says: "We broadly welcomed the report. It had involved wide consulations and most of the key stakeholders agreed with it."

The report was followed by guidance from the NHS executive on how to implement both Making a Difference and Fitness for Practice. It set a timetable for the introduction of more part-time courses, the development of "stepping on and off" points, higher quality and longer placements and a stronger role for the NHS in selecting students.

In November, the CVCP and the NHS executive held a conference to announce their new partnership statement.

The statement outlined a number of principles designed to underpin relationships between higher education and the NHS. They covered issues ranging from recruiting and selecting students, providing high-quality clinical placements, to quality assurance. The application of the principles will be monitored.

At the same conference the new health secretary, Alan Milburn, announced the contract to be signed by the Quality Assurance Agency and the NHS executive. The bulk of nursing education is already funded by the NHS, but the remainder is being transferred from the Higher Education Funding Council for England to the NHS. In Making a Difference the government makes it clear that it wanted the Department of Health to take the lead in assuring the quality of education in nursing - but working in partnership with the QAA and the professional bodies.

In November, Mr Milburn said: "I also want to implement an education quality assurance system with more bite: a streamlined system to assess fitness for purpose, fitness for practice and fitness for award."

He said that the contract with the QAA should ensure that "NHS-funded education is subject to the same rigorous quality assurance system as other university provision while satisfying the requirements of the regulatory bodies and the NHS employers" (see box below for details).

The CVCP capped a busy year for nurse educators in December, with the publication of Good Practice in the Recruitment and Retention of Nurses in Higher Education Institutions. All the examples of good practice involved "positive partnerships" between NHS trusts and higher education.

This year the hectic pace of reform continues. The government is committed to a review of NHS-funded student support arrangements - but has no details of this as yet. (See box on the left for details of current student funding arrangments.)

But will all this be enough to bring more nurses back to the NHS and to ensure those that are there are well-educated and want to stay? The RCN says no.

"These measures are not in any way enough to have a long-term impact on shortages," says a spokesman.

There still needs to be more flexibility at work, a greater respect for nurses as professionals and, above all, better pay. Nurses at the bottom end of the pay scale may be better off as a result of the pay awards announced last year, and experienced nurses will benefit from the pay award announced this week.

"But this award will only help to keep these nurses in the NHS if the real-terms increases are continued year on year and if it is combined with the extra cash needed to prevent the current NHS crisis from happening again," says the RCN.


An early draft shows how the Quality Assurance Agency new model subject review will be adapted for NHS education and training.

For the first time the QAA will be expected to look at fitness for award, fitness for practice and fitness for purpose.

In the past, the UKCC has been primarily concerned with fitness for practice (can the student register as a practitioner?). Prospective employers have been primarily concerned with fitness for purpose (can the newly qualified nurse function competently in clinical practice?) and the universities with fitness for award (has the student attained the appropriate level, breadth and depth of learning to be awarded a diploma or a degree?).

The contract will build on existing QAA collaboration and experience of joint reviews with the nursing professional bodies that are themselves undergoing reorganisation. The draft says that the new model subject review will provide stakeholders with the following:

"Common and so comparable specification of the intended outcomes of the NHS-funded programmes"

"General assurance that the education and training for health care professions meets the same overall

standards as other programmes in the HE sector"

"A more specific assurance that the pre-registration programmes in particular meet benchmark standards that have been developed and agreed by all the key stakeholders A collective database about the

quality differences among higher education providers

An independent ongoing evaluation of the effectiveness of the interactions between NHS education consortia and HE providers aimed at securing provision that meets service needs.

Subject review will deliver definitive judgements about:

Programme outcome standards

The quality

of learning


The quality and effectiveness of links between the provider, the contracting consortium/consortia, and its/their member organisations

Institutional management of standards and quality.

The training of subject reviewers will be extended to include how partnerships work between universities, colleges and the NHS and how those partnerships can affect quality. Reviewers will also need to understand that judgements about programme outcome standards will relate to fitness for purpose and practice as well as for award and to know how to evaluate the clinical learning experience in NHS-funded programmes. FUNDING

Students on nursing and midwifery diploma-level courses receive a non-means tested bursary. This is a flat-rate maintenance grant with no contribution required from the student or their family.

Degree-level students receive their support in the form of a means-tested bursary, supplemented by a reduced-rate repayble student loan.

In addition, the NHS meets students' liability for a tuition fee contribution, normally Pounds 1,025 a year.

Additional allowances are payable to older students, single parents, and those with dependants, and students are also paid the travel costs they incur while on clinical placements.

The basic rates of support payable annually to a student living away from home outside London are:

Degree course: Means-tested bursary Pounds 1,855

Repayable student loan Pounds 1,780 (maximum); Pounds 1,295 in final year

Diploma course: Non-means-tested bursary Pounds 4,686.


Anglia Polytechnic University and the North and South Essex Consortia have been chosen by the Department of Health to pilot one of the 16 new model nursing courses.

One of the reasons APU was chosen was because it has introduced a method of teaching called inquiry-based learning (IBL), which allows students to discuss what are called "problem situations" in groups and then divide into smaller groups to research particular aspects. Although the pilot projects will not begin until October this year, IBL is already used at the university and nursing students seem very enthusiastic.

Tracy Corney is in the final year of her BSc nursing degree. She has found IBL, with its stress on practical experience, very helpful. "The last situation we discussed was of a patient brought into accident and emergency, unconscious and suffering from a cardiac arrest," she says. "The whole class discussed the case - from the nature of the injuries to how to break bad news."

Sharon Toora, in the second year of her nursing degree, says that to begin with she found IBL difficult. "I suppose I preferred being spoon-fed," she says.

"But IBL forces you to take responsibility for your own learning. I get a real buzz out of it now. Especially when I know I have researched something well, I enjoy making a presentation back to the group."

Jenny Green, in the third year of her midwifery degree, says this is particularly good for midwives.

"A lot of our work is about educating people and presenting information to them, so IBL is ideal."

She says that the internet has transformed the research side of IBL.

"It is so much easier now to go off and gather information. We can all share our references knowing that other people in the group can access the information easily."

All three have enjoyed good clinical placements - the key component of any new model course.

Ms Green says: "My mentoring has been very good. My clinical tutor is excellent, I have access to her whenever

I need it. I can ring her at home if necessary. I have worked with a number of midwives and benefited from their different perspectives."

Ms Toora agrees, although she says it can be difficult if your mentor is a sister. "They have so much paperwork to do and so many management responsibilities that it is hard for them to mentor you as you deal with patients."

All three say IBL has helped them cope with working on the wards."My first day on the ward was still nerve-racking," says Ms Corney. "But I feel quite confident now."

Ms Green's first experience of attending a birth was at a water birth.

"It was a very positive experience," she says. "Not every one since has been - but that first time was wonderful."

All three nurses are very positive about their experiences so far. But Ms Toora argues that nurses are still not respected enough by the general public. All three have also had to do agency work to survive financially.

"It can be really tough worrying about the workload and the money," says Ms Toora.


Key recommendations of the Peach report Fitness for Practice (some have already been acted upon).

To address concerns about practical skills:

Movement to a competency-based approach to

education. This meant that standards required for

registration should be constructed in terms of competencies (agreed outcomes for courses covering knowledge, understanding, skills, values and abilities).

Last week the UKCC published a set of competencies to be used by universities and the NHS when devising the curriculum

The introduction of practice skills and clinical placements early in the Common Foundation Programme (the first part of any degree or diploma), which should be reduced from 18 months to one year

A period of at least three months supervised clinical practice towards the end of the course

Longer student placements with agreed outcomes

A review of the four branches of nursing (adult, mental health, learning disabilities and children's nursing)

To address concerns about the relationship between universities and the health service:

The involvement of health service providers in the recruitment and selection of students

Purchasers of education, university departments and service providers to resolve together the ownership of, and responsibility for practice-based


The development of exchanges and secondments between HE institutions and the health services, joint appointments, a more clearly defined role for lecturer-practitioners and more of them.

To address concerns about a lack of flexibility:

Greater flexibility in entry to nursing programmes to attract more recruits with a wider range of skills and abilities - widening the entry gate at all


The Accreditation of Prior (Experiental) Learning to be used so that students with relevant experience, such as health-care assistants, can have programmes

tailored to suit their needs

An expansion of graduate preparation for nursing and midwifery

Students who decide to leave at the end of the

new Common Foundation Programme should gain academic and practice credit for that year.

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