fournal of Advanced Nursing, 1977, 2, 383-391
Some structural considerations in moduiar education for basic nursing students Janet Harrison S.R.N. B.A. Dip. Soc. Admin. Research Officer
Margaret E. Saunders S.R.N. R.N.T. B.A. Research Officer
Alan Sims B.A. M.Phil. Acting Director The General Nursing Council for England and Wales Research Unit, 32 Great Portland Street, London WiN sAD
Accepted for publication 26 November 1976
HARRISON JANET, SAUNDBRS MARGARET E . & SIMS ALAN {i^ji) Journal of Advanced Nursing 2,
383-391 Some structural considerations in modutar education for basic nursing students The report is concerned with some of the structural factors influencing modular schemes of nurse education. Based on interviews with students, teachers and ward staff, in addition to examination of ward staffing levels and structures, the report describes streaming of students, the possible effects of modular education on staffing and some changes introduced or proposed by four hospitals running such schemes. For the most part streaming was seen as being feasible but without any real advantages. Small drawbacks associated with streaming were, however, evident. The research suggested that many of the staffing difficulties associated with modular education were not created by the scheme of training but perhaps highlighted by it. Improvements which would both increase the effectiveness of the schemes and reduce some of these difficulties included movement towards more frequent intakes, a reduction in the length of classroom based element of the introductory course and abandonment of streaming and changes in the length/location of certain modules.
INTRODUCTION The modular system of nursing education is already documented elsewhere (Parnell 1975, Warcaba 1976) but it may be useful to reiterate briefly the aims of such schemes and the means and structure adopted to meet those aims. The 383
384
J- Harrison, M. E. Saunders and A. Sims
suggested structure (Department of Health and Social Security 1970) involved two major deviations from the normal pattern of nursing education in the UK. In order that theory and practice might be better integrated the programme was to be divided into 'modules'. A modular structure is aptly defined, albeit in another setting by Schinkel (1974) as 'A more or less voluminous and complex whole, consisting of a number of unambiguous, rounded-off, usually simply replaceable and interchangeable component parts'. These modules would comprise a week's specific preparation in the school of nursing, ten weeks in a related ward, or similar practical experience, and a further week consolidating the information gained through instruction and experience. Previous studies had shown that carefully selected students could be expected to succeed in the state final examinations after less than the statutory three year training (Pomeranz 1973, Scott Wright 1963) hence streaming was included as part of the innovation. A third structural change was the suggestion that students should have a broad introduction to nursing and its context. This introductory course was to involve eight weeks covering broad contextual material, in what might be described as 'man in society', and four weeks dealing with an introduction to basic nursing procedures. A further suggestion, aimed at improving integration, was for continuing practical instruction during the ward-based part of the module. In fact it was recommended that the schools should aim to provide at least ten hours of such instruction per week. Regrettably practical instruction can legitimately be defined very widely to include anything from a formal lecture/demonstration by a trained teacher to the student learning in a fairly unstructured situation by talking to patients or following the good (or bad) examples of more senior nurses. As definition must come before measurement (Pearson 1975) it was necessary to examine this recommendation in spirit rather than substance. A final recommendation was for a two week school-based management block coming towards the end of training. Throughout the programme students were to remain in the wards to which they were allocated for each module (i.e. they should not be moved to other wards to 'help out'). This was referred to as 'fixed allocation', again aimed at improving integration by providing the student with a relevant and stable setting for the practical experience. Finally all new students within the selected schools were to undertake modular training with a gradual phasing out of the existing schemes. SOME I M P O R T A N T
VARIATIONS
In practice the four hospitals, three general and one psychiatric, examined by the research team adopted structures and strategies which differed among themselves and from the initial recommendations. These differences included: I In one hospital the introduction of short modules (ten instead of twelve weeks to fit round the pattern of 'internal rotation' for night duty), truncation of the
Some structural considerations in modular education for basic nursing students introductory course to concentrate largely on the nursing procedures and having an intake of students every eight weeks. 2 In one hospital the introduction of a study day each week during the practical part of the module. 3 In two hospitals the splitting of sets (e.g. half the students being prepared for and going to a medical ward), whilst the other half had a surgical preparation and experience with the allocation being reversed for the next module. 4 In one hospital students were streamed in the first year and then followed different sequences of modules whilst in three the streaming decision was made in the first year but the streams were not educationally separated until towards the end of the second year. We mention these differences because all of them influence the overriding constraint of nurse education, that the system adopted should not adversely affect the staffing of the wards and departments, to the point where patient care suffers, nor render the teacher's job unmanageable. The effects of radical changes in educational structure are many and complex and we shall limit ourselves here to three main issues and outcomes: 1 The feasibility and desirability of streaming. 2 Possible effects on ward staffing levels and ways of measuring these effects. 3 Some actual and proposed structural changes.
The feasibility and desirability of streaming Streaming in the modular scheme meant dividing a set into one group which followed an 'accelerated' programme and another which followed a 'normal' programme. Those on the accelerated stream registered after approximately 2^ years, those on the normal after three years. In effect the term 'streaming' was rather inappropriate. The course was not aiming at two different end products but at one—a registered nurse. Nor in the production of this common end were two different educational programmes actually used. The two groups tended to stay together receiving the same educational treatment until well into their second year. By and large the streaming decision in each of the hospitals was made on similar bases (i.e. a theoretical and practical assessment of each student at the end of the second module). In addition, tutors spoke of trying to identify students who could learn for themselves, e.g. those who might put in extra study, those who could use library facilities efficiently and those who were capable of abstracting information in the practical situation. The students had a varying amount of influence on the streaming decision. On the whole they were 'offered' a stream and could then put forward arguments as to why they would prefer the alternative. Approximately one-third of the students were placed on the accelerated programme in eacb hospital. Tutors emphasized that there was no 'slow' stream and, on the whole, students accepted the concept of streaming. In the questionnaire given to students at the end of their second year we asked them to indicate their agreement or disagreement with ten statements about
385
386
J. Harrison, M. E. Saunders and A. Sints
streaming. These statements were taken from the responses resulting from interviews with a small number of students in each hospital in which we asked for their views about streaming. The total figures for the three general hospitals are set out in Table i. TABLE I
Students' views on streaming
Streaming is a good idea The streaming decision is carried out too early Streaming itself is carried out too early Students do not have enough say in the streaming decision Streaming helps you to go at your own pace Students should be allowed to change streams at least once Streaming divides up friendships There is no illfeeling between fast and normal streams When the fast stream leaves the set the other students suffer academically Streaming is necessary in nurse training
Strongly agree
Agree
25
151
63
Undecided Disagree 60
Strongly No disagree response 13
II
56
147
26
83
4
7
16
74
35
176
12
10
33
126
41
104
12
7
16
181
32
75
II
8
20
132
50
94
13
14
25
III
27
131
20
9
34
150
41
75
14
9
6
23
57
185
52
0
7
51
80
138
41
6
Differences between normal and accelerated students. Accelerated students were more likely to think that streaming was a good idea (P < o*oi). The normal stream students were more critical of streaming. They were more likely to feel that the streaming decision was made too early (P < 0"00i) and that streaming itself was carried out too early (P < o-ooi). They were also more likely to feel they had too little say in the streaming decision (P < o-oi), that it broke up friendships (P < o-oi) and that it created illfeeling between streams (P < o-ooi). Differences between hospitals. Students from one hospital were much more likely to feel that the streaming decision was made too early (P < o-ooi) but, and there is no inconsistency here, they were more likely to feel that the timing of streaming itself was acceptable (P < 0-05). Students in the same hospital were again more likely to feel that they had too little say in the decision (P < 0"00i), that they should be able to change streams (P < o-oi), that it breaks up friendships (P < O'Oi) and that normal students can suffer academically when the streams divide (P < o*oi). From other questions asked we know that students were also influenced in other ways by streaming. The accelerated students tended to feel more prepared for being left in charge (P < 0-02) than did normal students. As might be predicted both groups of students felt better prepared for being left in charge on nights than
Some structural considerations in modular education for basic nursing students on days (P < o-ooi). Accelerated students were less likely to have felt like leaving during their training (P < o-oi) and in fact proportionally fewer had left by the end of the second year. Significantly more of these students also reported that they would choose nursing if they had to make the career decision again (P < 0-05). Presumably this difference would have been even larger had we been able to include those students who had already left. The accelerated group also felt better prepared for taking their final state examination (P < o-oi). In fact the examination results for these students were, at the time of writing, better (P < O'Oi). However, bearing in mind the selection criteria for the accelerated stream, some of these results are not surprising. For research purposes a truer test of the value of streaming, in respect of state finals, would have been possible if students had been allocated at random to fast and normal streams in equal numbers. In fact we already knew from the '2 + 1' experimental scheme of student nurse training that students who were given a training programme which integrated theory and practice had rather better pass rates at state finals after two years than those students with the traditional nonintegrated training had after three years (Pomeranz 1973). Some views and comments on the question of streaming were gathered via interviews with one set of students from each hospital and, together with tutors' views, provide supplementary information to that set out above. We asked all the students how happy they were about being in their particular stream. Interestingly, whatever their stream, students were, on the whole, happy about this allocation. The following verbatim comments illustrate the reasons most frequently given by students as to why they were glad to be on their particular streamAccelerated:
'I will be glad to get finals over with.' 'After finals I can concentrate on things which interest me.' 'I feel happy about taking my finals early as there are many things I wish to do and I feel the training is very adequate.' 'I shall be qualified more quickly and able to move to another hospital if I want to.' 'If I fail and have to take it again I won't be behind everyone else.' Normal:
'It is frightening to do finals before doing more basic medicine and surgery.' 'You need the experience before you take finals. It is more difficult to answer questions on someone you haven't nursed.' 'Most people could take the exam, but experience is important.' 'I need the time to study the theory.' 'If you are rushed through training so fast that you are worried about the exam, nursing itself can take second place.' The main feeling then, particularly of students on normal streams, but also by a number on the accelerated stream, was that the accelerated programme lacked basic surgical and medical experience but that it was nice to get finals behind them
387
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J . Harrison, M. E. Saunders and A. Sims
as quickly as possible. The general contentment with the streaming decision may well result from a measure of rationalization on the students' part. Comments made by students in both streams mirrored those frequently made by teachers and ward staff, particularly comments to the effect that three years was a minimum for gaining adequate practical experience. Despite the views set out in Table i some of the 'normal' length students interviewed, and many of the tutors, were conscious of a 'leadership gap' occurring when the streams separated. Some tutors felt that the accelerated students were more questioning and made for more participative sessions in the classroom. In fact there was evidence, with which we shall deal in a later paper, that the accelerated students were in fact better able to abstract relevant learning material from practical situations and preferred a greater range of teaching methods. Finally, all the students were greatly influenced in their views by the experiences to which they had been allocated. This was particularly the case for accelerated students, who felt that their allocation had to be carefully planned if they were to be confident when left in charge, having registered after 2^ years. Careful allocation in any case is vital. By and large scarce teaching resources were concentrated on more junior students so that seniors had increasingly to depend on the ward for their 'learning experiences'.
Some effects on staffing Clearly an unmodified modular scheme could have a marked impact on the pattern of staffing in hospital wards. A complete set of students, following the same sequence of experiences of fixed allocation to one ward for ten weeks, fixed holidays and a twelve week introductory block, were all seen as potentially damaging to the immediate provision of nursing on the ward. Secondary effects were also anticipated and in some cases did happen, e.g. parallel improvements in the pupil nurses' programme which made pupils less available to fill gaps in staffing resulting from the students' programme. Additionally, increased allocation of students to 'special' wards, to the community and to psychiatric hospitals or units (a trend independent of the modular scheme) influenced reactions of ward staff, as did a reduction in working hours for nurses which was implemented during the period of the research. In order to provide students with a similar sequence of experiences more wards were used for training, some in outlying districts, which again appeared to dilute the service provided by students. As we described briefly in the introduction, hospitals modified their schemes prior to their inception and during the first few years, but service staff still expressed concern over a real or perceived reduction in the students' service commitment. In order to examine this we collected data on actual staffing levels in 50% of wards used for training over a period of ten months. For each twenty-eight day period a random selection of eight 24-hour periods was made and the name, grade and actual hours worked were recorded for each ward and for each nurse, including nursing auxiliaries, working on that ward. The results of this study showed little evidence of lengthy 'peaks and troughs' in ward staffing levels. We identified wards receiving a steady flow of students and some receiving spasmodic alloca-
Some structural considerations in modular education for basic nursing students tions, but in both types of ward the number of learners was relatively constant as the numbers of students and pupils complemented each other. The following examples illustrate this: (i) For approximately half the time ward i had no students but for 79% of the time had between four and six learners (for some shift) during the 24-hour period. (2) Similarly ward 2 had between nil and four students (with considerable fluctuation) but for 66yQ of the time had between three and five learners. (3) Wards 3 and 4 both had a fairly steady flow of students and had seven to eleven learners for 70% and 77% of the time respectively. Whilst there is some variability in the number of students allocated to a ward over the period, 'troughs' are often met, rightly or wrongly, by increased numbers of pupils. Afternoon study periods cannot interfere too much with staffing as our figures for the level of staffing on the wards over a 24-hour period were typical (i.e. maximum numbers of staff between 12.00 and 17.00 hours). It is probable then that the peaks and troughs are briefer than we initially expected, e.g. morning shifts where the students have a full study day. Longer 'troughs' might also be hidden by increased mobility of pupils, but pupils have always been a flexible part of the work force. Again peaks and troughs may be emphasized by the movement of, say, four students from the ward to be replaced by four completely new students, with all the problems of reporting on those departing and integrating the newcomers into the ward team. A further problem for some ward staff was a perceived lack of senior students. This only partly resulted from the modular pattern. Some sisters, for example, had to get used to having only junior students. Even some of those receiving third year students felt that these students, having spent the best part of the second year outside of what might narrowly be described as general nursing, had to readjust to ward routines and to some extent this feeling was also expressed by students, particularly those on the accelerated stream. It would be wrong, however, to suggest that all the results on staffing were negative. Over a period many of the sisters began to value the predictability of the scheme in terms of the type and flow of students. Similarly splitting of sets, as described earlier, decreased the potential disruption. It would also be wrong to believe that teaching staff were immune from changes. Increasing the number of intakes per year can offset problems in the ward but clearly can easily result in there being a number of different sets in the school at the same time. It also depends on the ability of hospitals to recruit outside of normal school-leavingperiods. Whilst the schemes may well have increased the pressure on teachers this was largely offset by advantages. Teachers felt that the schemes were more open to improvement than the previous block system and that this encouraged a willingness to try out new ideas. Feedback to tutors was also valued. Students returned after eight or ten weeks on the ward and were better able to appraise the value of their preparatory week. The real enigma concerning the effect on staffing lies in costing nursing education. It is commonly held that student nurses constitute a net cost after the value of their service has been taken into consideration. However, streaming was
389
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f. Harrison, M. E. Saunders and A. Sims
seen as adding to costs since it reduced the number of senior students at any point in time, some having registered after 2-^ years, and these could not automatically be replaced by trained staff. In fact with more nurses wishing to remain in the service on registration, influenced by the economic climate, the more rapid production of trained staff is not always seen as a benefit. Perhaps students can only be said to be expensive when there is a ready supply of trained staff.
Some further changes As can be seen some of the potentially deleterious effects of the modular scheme were anticipated and modifications were made from the outset. Changes were also made during the first four years of the schemes and suggested changes were made when the schemes came up for renewal—all 'experimental' schemes have to be reapproved by the GNC after five years. The following changes were made or suggested by at least one of the hospitals. The abandonment of streaming. Whilst the evidence strongly suggests that in educational terms streaming can be made to work, and students and teachers in these terms were in favour of the idea, the case has been made for removing it from the revised schemes. Forecasting the numbers of students registering at any point in time becomes more difficult unless students are allocated to a stream early and then forced to remain in that stream. A more flexible system of streaming would have been incompatible with forecasting. Additionally new EEC regulations may result in three years being the accepted minimum time for training for the register. Modular length. There is no evidence that all modules need to be the same length and it has been suggested that length can be flexible if it is felt that the aims of a module can be met in less or more than the normal modular length. The introductory module. It is probable that this twelve week course will be greatly shortened with more time being spent in the wards and on preparation for practical procedures. It was difficult to justify this part of the course which was seen very much as a luxury. Number of intakes. Of the three hospitals currently having two intakes per year, two of them are proposing an increase in the number of intakes. This will even out the flow of students and seems particularly feasible where teaching staff can be divided into teams. Management course. Towards the end of training, students had undertaken a two week school based management course. A management module, following the pattern of other modules, is seen as potentially more beneficial. Where practicable students will be able to choose to which type of ward they return for the ten week part of the module. Not only might this improve the integration of the management experience but might also assist ward staffing by the allocation of senior students to wards which presently receive predominantly juniors.
Some structural considerations in modular education for basic nursing students CONCLUSION Perhaps by its very nature research tends to identify more negative than positive results. People are better able to identify problems than advantages, possibly because problems are immediate whilst advantages may be potential or longterm. Similarly an advantage may be the nonoccurrence of a problem and hence goes unnoticed. Thus, whilst we have tended to concentrate on things which might go wrong with a modular scheme, we must stress that the majority of students, teachers and service staff supported the decision to continue with the schemes, albeit with the modifications described. The research evidence similarly would support the continuation of the schemes. As with any other scheme it should be tailored to fit the hospital, including the school. It should be remembered that 'integration' was the main aim of these schemes, the modular structure was the means and, in trying to improve integration, no part of this structure should be held sacrosanct. Finally, as with any other system, discussion with staff at all levels, prior to its introduction and during its formative years, would appear essential.
References DEPARTMENT OF HEALTH & SOCIAL SECURITY (1970) Report of the Nurse Tutor Working Party. PARNELL J.E. (1975) Modular systems and allocation. In A Guidefor Teachers ofNursing. Ed. Raybould E. Blackwell Scientific Publications, Oxford. PEARSON J. (1975) Learning Opportunities in Hospital Wards. Unpublished paper, Conference on Nursing, University of Liverpool. POMERANZ R . (1973) The Lady Apprentices. Occasional papers on social administration. No. 51. G. Bell & Sons, London. ScHiNKBL A. (1974) Certificate in Informatics. Education yearbook 1973-74, 117-125. British Computer Society, London. Scorr WRIGHT M . (1963) Experimental Nurse Training at Glasgoii' Royal Infirmary. H.M.S.O., Edinburgh. WARCABA B . (1976) An experimental scheme in nurse education. JoHrna/ of Advanced Nursing i, 243-252.
391
Some structural considerations in moduiar education for basic nursing students Janet Harrison S.R.N. B.A. Dip. Soc. Admin. Research Officer
Margaret E. Saunders S.R.N. R.N.T. B.A. Research Officer
Alan Sims B.A. M.Phil. Acting Director The General Nursing Council for England and Wales Research Unit, 32 Great Portland Street, London WiN sAD
Accepted for publication 26 November 1976
HARRISON JANET, SAUNDBRS MARGARET E . & SIMS ALAN {i^ji) Journal of Advanced Nursing 2,
383-391 Some structural considerations in modutar education for basic nursing students The report is concerned with some of the structural factors influencing modular schemes of nurse education. Based on interviews with students, teachers and ward staff, in addition to examination of ward staffing levels and structures, the report describes streaming of students, the possible effects of modular education on staffing and some changes introduced or proposed by four hospitals running such schemes. For the most part streaming was seen as being feasible but without any real advantages. Small drawbacks associated with streaming were, however, evident. The research suggested that many of the staffing difficulties associated with modular education were not created by the scheme of training but perhaps highlighted by it. Improvements which would both increase the effectiveness of the schemes and reduce some of these difficulties included movement towards more frequent intakes, a reduction in the length of classroom based element of the introductory course and abandonment of streaming and changes in the length/location of certain modules.
INTRODUCTION The modular system of nursing education is already documented elsewhere (Parnell 1975, Warcaba 1976) but it may be useful to reiterate briefly the aims of such schemes and the means and structure adopted to meet those aims. The 383
384
J- Harrison, M. E. Saunders and A. Sims
suggested structure (Department of Health and Social Security 1970) involved two major deviations from the normal pattern of nursing education in the UK. In order that theory and practice might be better integrated the programme was to be divided into 'modules'. A modular structure is aptly defined, albeit in another setting by Schinkel (1974) as 'A more or less voluminous and complex whole, consisting of a number of unambiguous, rounded-off, usually simply replaceable and interchangeable component parts'. These modules would comprise a week's specific preparation in the school of nursing, ten weeks in a related ward, or similar practical experience, and a further week consolidating the information gained through instruction and experience. Previous studies had shown that carefully selected students could be expected to succeed in the state final examinations after less than the statutory three year training (Pomeranz 1973, Scott Wright 1963) hence streaming was included as part of the innovation. A third structural change was the suggestion that students should have a broad introduction to nursing and its context. This introductory course was to involve eight weeks covering broad contextual material, in what might be described as 'man in society', and four weeks dealing with an introduction to basic nursing procedures. A further suggestion, aimed at improving integration, was for continuing practical instruction during the ward-based part of the module. In fact it was recommended that the schools should aim to provide at least ten hours of such instruction per week. Regrettably practical instruction can legitimately be defined very widely to include anything from a formal lecture/demonstration by a trained teacher to the student learning in a fairly unstructured situation by talking to patients or following the good (or bad) examples of more senior nurses. As definition must come before measurement (Pearson 1975) it was necessary to examine this recommendation in spirit rather than substance. A final recommendation was for a two week school-based management block coming towards the end of training. Throughout the programme students were to remain in the wards to which they were allocated for each module (i.e. they should not be moved to other wards to 'help out'). This was referred to as 'fixed allocation', again aimed at improving integration by providing the student with a relevant and stable setting for the practical experience. Finally all new students within the selected schools were to undertake modular training with a gradual phasing out of the existing schemes. SOME I M P O R T A N T
VARIATIONS
In practice the four hospitals, three general and one psychiatric, examined by the research team adopted structures and strategies which differed among themselves and from the initial recommendations. These differences included: I In one hospital the introduction of short modules (ten instead of twelve weeks to fit round the pattern of 'internal rotation' for night duty), truncation of the
Some structural considerations in modular education for basic nursing students introductory course to concentrate largely on the nursing procedures and having an intake of students every eight weeks. 2 In one hospital the introduction of a study day each week during the practical part of the module. 3 In two hospitals the splitting of sets (e.g. half the students being prepared for and going to a medical ward), whilst the other half had a surgical preparation and experience with the allocation being reversed for the next module. 4 In one hospital students were streamed in the first year and then followed different sequences of modules whilst in three the streaming decision was made in the first year but the streams were not educationally separated until towards the end of the second year. We mention these differences because all of them influence the overriding constraint of nurse education, that the system adopted should not adversely affect the staffing of the wards and departments, to the point where patient care suffers, nor render the teacher's job unmanageable. The effects of radical changes in educational structure are many and complex and we shall limit ourselves here to three main issues and outcomes: 1 The feasibility and desirability of streaming. 2 Possible effects on ward staffing levels and ways of measuring these effects. 3 Some actual and proposed structural changes.
The feasibility and desirability of streaming Streaming in the modular scheme meant dividing a set into one group which followed an 'accelerated' programme and another which followed a 'normal' programme. Those on the accelerated stream registered after approximately 2^ years, those on the normal after three years. In effect the term 'streaming' was rather inappropriate. The course was not aiming at two different end products but at one—a registered nurse. Nor in the production of this common end were two different educational programmes actually used. The two groups tended to stay together receiving the same educational treatment until well into their second year. By and large the streaming decision in each of the hospitals was made on similar bases (i.e. a theoretical and practical assessment of each student at the end of the second module). In addition, tutors spoke of trying to identify students who could learn for themselves, e.g. those who might put in extra study, those who could use library facilities efficiently and those who were capable of abstracting information in the practical situation. The students had a varying amount of influence on the streaming decision. On the whole they were 'offered' a stream and could then put forward arguments as to why they would prefer the alternative. Approximately one-third of the students were placed on the accelerated programme in eacb hospital. Tutors emphasized that there was no 'slow' stream and, on the whole, students accepted the concept of streaming. In the questionnaire given to students at the end of their second year we asked them to indicate their agreement or disagreement with ten statements about
385
386
J. Harrison, M. E. Saunders and A. Sints
streaming. These statements were taken from the responses resulting from interviews with a small number of students in each hospital in which we asked for their views about streaming. The total figures for the three general hospitals are set out in Table i. TABLE I
Students' views on streaming
Streaming is a good idea The streaming decision is carried out too early Streaming itself is carried out too early Students do not have enough say in the streaming decision Streaming helps you to go at your own pace Students should be allowed to change streams at least once Streaming divides up friendships There is no illfeeling between fast and normal streams When the fast stream leaves the set the other students suffer academically Streaming is necessary in nurse training
Strongly agree
Agree
25
151
63
Undecided Disagree 60
Strongly No disagree response 13
II
56
147
26
83
4
7
16
74
35
176
12
10
33
126
41
104
12
7
16
181
32
75
II
8
20
132
50
94
13
14
25
III
27
131
20
9
34
150
41
75
14
9
6
23
57
185
52
0
7
51
80
138
41
6
Differences between normal and accelerated students. Accelerated students were more likely to think that streaming was a good idea (P < o*oi). The normal stream students were more critical of streaming. They were more likely to feel that the streaming decision was made too early (P < 0"00i) and that streaming itself was carried out too early (P < o-ooi). They were also more likely to feel they had too little say in the streaming decision (P < o-oi), that it broke up friendships (P < o-oi) and that it created illfeeling between streams (P < o-ooi). Differences between hospitals. Students from one hospital were much more likely to feel that the streaming decision was made too early (P < o-ooi) but, and there is no inconsistency here, they were more likely to feel that the timing of streaming itself was acceptable (P < 0-05). Students in the same hospital were again more likely to feel that they had too little say in the decision (P < 0"00i), that they should be able to change streams (P < o-oi), that it breaks up friendships (P < O'Oi) and that normal students can suffer academically when the streams divide (P < o*oi). From other questions asked we know that students were also influenced in other ways by streaming. The accelerated students tended to feel more prepared for being left in charge (P < 0-02) than did normal students. As might be predicted both groups of students felt better prepared for being left in charge on nights than
Some structural considerations in modular education for basic nursing students on days (P < o-ooi). Accelerated students were less likely to have felt like leaving during their training (P < o-oi) and in fact proportionally fewer had left by the end of the second year. Significantly more of these students also reported that they would choose nursing if they had to make the career decision again (P < 0-05). Presumably this difference would have been even larger had we been able to include those students who had already left. The accelerated group also felt better prepared for taking their final state examination (P < o-oi). In fact the examination results for these students were, at the time of writing, better (P < O'Oi). However, bearing in mind the selection criteria for the accelerated stream, some of these results are not surprising. For research purposes a truer test of the value of streaming, in respect of state finals, would have been possible if students had been allocated at random to fast and normal streams in equal numbers. In fact we already knew from the '2 + 1' experimental scheme of student nurse training that students who were given a training programme which integrated theory and practice had rather better pass rates at state finals after two years than those students with the traditional nonintegrated training had after three years (Pomeranz 1973). Some views and comments on the question of streaming were gathered via interviews with one set of students from each hospital and, together with tutors' views, provide supplementary information to that set out above. We asked all the students how happy they were about being in their particular stream. Interestingly, whatever their stream, students were, on the whole, happy about this allocation. The following verbatim comments illustrate the reasons most frequently given by students as to why they were glad to be on their particular streamAccelerated:
'I will be glad to get finals over with.' 'After finals I can concentrate on things which interest me.' 'I feel happy about taking my finals early as there are many things I wish to do and I feel the training is very adequate.' 'I shall be qualified more quickly and able to move to another hospital if I want to.' 'If I fail and have to take it again I won't be behind everyone else.' Normal:
'It is frightening to do finals before doing more basic medicine and surgery.' 'You need the experience before you take finals. It is more difficult to answer questions on someone you haven't nursed.' 'Most people could take the exam, but experience is important.' 'I need the time to study the theory.' 'If you are rushed through training so fast that you are worried about the exam, nursing itself can take second place.' The main feeling then, particularly of students on normal streams, but also by a number on the accelerated stream, was that the accelerated programme lacked basic surgical and medical experience but that it was nice to get finals behind them
387
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as quickly as possible. The general contentment with the streaming decision may well result from a measure of rationalization on the students' part. Comments made by students in both streams mirrored those frequently made by teachers and ward staff, particularly comments to the effect that three years was a minimum for gaining adequate practical experience. Despite the views set out in Table i some of the 'normal' length students interviewed, and many of the tutors, were conscious of a 'leadership gap' occurring when the streams separated. Some tutors felt that the accelerated students were more questioning and made for more participative sessions in the classroom. In fact there was evidence, with which we shall deal in a later paper, that the accelerated students were in fact better able to abstract relevant learning material from practical situations and preferred a greater range of teaching methods. Finally, all the students were greatly influenced in their views by the experiences to which they had been allocated. This was particularly the case for accelerated students, who felt that their allocation had to be carefully planned if they were to be confident when left in charge, having registered after 2^ years. Careful allocation in any case is vital. By and large scarce teaching resources were concentrated on more junior students so that seniors had increasingly to depend on the ward for their 'learning experiences'.
Some effects on staffing Clearly an unmodified modular scheme could have a marked impact on the pattern of staffing in hospital wards. A complete set of students, following the same sequence of experiences of fixed allocation to one ward for ten weeks, fixed holidays and a twelve week introductory block, were all seen as potentially damaging to the immediate provision of nursing on the ward. Secondary effects were also anticipated and in some cases did happen, e.g. parallel improvements in the pupil nurses' programme which made pupils less available to fill gaps in staffing resulting from the students' programme. Additionally, increased allocation of students to 'special' wards, to the community and to psychiatric hospitals or units (a trend independent of the modular scheme) influenced reactions of ward staff, as did a reduction in working hours for nurses which was implemented during the period of the research. In order to provide students with a similar sequence of experiences more wards were used for training, some in outlying districts, which again appeared to dilute the service provided by students. As we described briefly in the introduction, hospitals modified their schemes prior to their inception and during the first few years, but service staff still expressed concern over a real or perceived reduction in the students' service commitment. In order to examine this we collected data on actual staffing levels in 50% of wards used for training over a period of ten months. For each twenty-eight day period a random selection of eight 24-hour periods was made and the name, grade and actual hours worked were recorded for each ward and for each nurse, including nursing auxiliaries, working on that ward. The results of this study showed little evidence of lengthy 'peaks and troughs' in ward staffing levels. We identified wards receiving a steady flow of students and some receiving spasmodic alloca-
Some structural considerations in modular education for basic nursing students tions, but in both types of ward the number of learners was relatively constant as the numbers of students and pupils complemented each other. The following examples illustrate this: (i) For approximately half the time ward i had no students but for 79% of the time had between four and six learners (for some shift) during the 24-hour period. (2) Similarly ward 2 had between nil and four students (with considerable fluctuation) but for 66yQ of the time had between three and five learners. (3) Wards 3 and 4 both had a fairly steady flow of students and had seven to eleven learners for 70% and 77% of the time respectively. Whilst there is some variability in the number of students allocated to a ward over the period, 'troughs' are often met, rightly or wrongly, by increased numbers of pupils. Afternoon study periods cannot interfere too much with staffing as our figures for the level of staffing on the wards over a 24-hour period were typical (i.e. maximum numbers of staff between 12.00 and 17.00 hours). It is probable then that the peaks and troughs are briefer than we initially expected, e.g. morning shifts where the students have a full study day. Longer 'troughs' might also be hidden by increased mobility of pupils, but pupils have always been a flexible part of the work force. Again peaks and troughs may be emphasized by the movement of, say, four students from the ward to be replaced by four completely new students, with all the problems of reporting on those departing and integrating the newcomers into the ward team. A further problem for some ward staff was a perceived lack of senior students. This only partly resulted from the modular pattern. Some sisters, for example, had to get used to having only junior students. Even some of those receiving third year students felt that these students, having spent the best part of the second year outside of what might narrowly be described as general nursing, had to readjust to ward routines and to some extent this feeling was also expressed by students, particularly those on the accelerated stream. It would be wrong, however, to suggest that all the results on staffing were negative. Over a period many of the sisters began to value the predictability of the scheme in terms of the type and flow of students. Similarly splitting of sets, as described earlier, decreased the potential disruption. It would also be wrong to believe that teaching staff were immune from changes. Increasing the number of intakes per year can offset problems in the ward but clearly can easily result in there being a number of different sets in the school at the same time. It also depends on the ability of hospitals to recruit outside of normal school-leavingperiods. Whilst the schemes may well have increased the pressure on teachers this was largely offset by advantages. Teachers felt that the schemes were more open to improvement than the previous block system and that this encouraged a willingness to try out new ideas. Feedback to tutors was also valued. Students returned after eight or ten weeks on the ward and were better able to appraise the value of their preparatory week. The real enigma concerning the effect on staffing lies in costing nursing education. It is commonly held that student nurses constitute a net cost after the value of their service has been taken into consideration. However, streaming was
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seen as adding to costs since it reduced the number of senior students at any point in time, some having registered after 2-^ years, and these could not automatically be replaced by trained staff. In fact with more nurses wishing to remain in the service on registration, influenced by the economic climate, the more rapid production of trained staff is not always seen as a benefit. Perhaps students can only be said to be expensive when there is a ready supply of trained staff.
Some further changes As can be seen some of the potentially deleterious effects of the modular scheme were anticipated and modifications were made from the outset. Changes were also made during the first four years of the schemes and suggested changes were made when the schemes came up for renewal—all 'experimental' schemes have to be reapproved by the GNC after five years. The following changes were made or suggested by at least one of the hospitals. The abandonment of streaming. Whilst the evidence strongly suggests that in educational terms streaming can be made to work, and students and teachers in these terms were in favour of the idea, the case has been made for removing it from the revised schemes. Forecasting the numbers of students registering at any point in time becomes more difficult unless students are allocated to a stream early and then forced to remain in that stream. A more flexible system of streaming would have been incompatible with forecasting. Additionally new EEC regulations may result in three years being the accepted minimum time for training for the register. Modular length. There is no evidence that all modules need to be the same length and it has been suggested that length can be flexible if it is felt that the aims of a module can be met in less or more than the normal modular length. The introductory module. It is probable that this twelve week course will be greatly shortened with more time being spent in the wards and on preparation for practical procedures. It was difficult to justify this part of the course which was seen very much as a luxury. Number of intakes. Of the three hospitals currently having two intakes per year, two of them are proposing an increase in the number of intakes. This will even out the flow of students and seems particularly feasible where teaching staff can be divided into teams. Management course. Towards the end of training, students had undertaken a two week school based management course. A management module, following the pattern of other modules, is seen as potentially more beneficial. Where practicable students will be able to choose to which type of ward they return for the ten week part of the module. Not only might this improve the integration of the management experience but might also assist ward staffing by the allocation of senior students to wards which presently receive predominantly juniors.
Some structural considerations in modular education for basic nursing students CONCLUSION Perhaps by its very nature research tends to identify more negative than positive results. People are better able to identify problems than advantages, possibly because problems are immediate whilst advantages may be potential or longterm. Similarly an advantage may be the nonoccurrence of a problem and hence goes unnoticed. Thus, whilst we have tended to concentrate on things which might go wrong with a modular scheme, we must stress that the majority of students, teachers and service staff supported the decision to continue with the schemes, albeit with the modifications described. The research evidence similarly would support the continuation of the schemes. As with any other scheme it should be tailored to fit the hospital, including the school. It should be remembered that 'integration' was the main aim of these schemes, the modular structure was the means and, in trying to improve integration, no part of this structure should be held sacrosanct. Finally, as with any other system, discussion with staff at all levels, prior to its introduction and during its formative years, would appear essential.
References DEPARTMENT OF HEALTH & SOCIAL SECURITY (1970) Report of the Nurse Tutor Working Party. PARNELL J.E. (1975) Modular systems and allocation. In A Guidefor Teachers ofNursing. Ed. Raybould E. Blackwell Scientific Publications, Oxford. PEARSON J. (1975) Learning Opportunities in Hospital Wards. Unpublished paper, Conference on Nursing, University of Liverpool. POMERANZ R . (1973) The Lady Apprentices. Occasional papers on social administration. No. 51. G. Bell & Sons, London. ScHiNKBL A. (1974) Certificate in Informatics. Education yearbook 1973-74, 117-125. British Computer Society, London. Scorr WRIGHT M . (1963) Experimental Nurse Training at Glasgoii' Royal Infirmary. H.M.S.O., Edinburgh. WARCABA B . (1976) An experimental scheme in nurse education. JoHrna/ of Advanced Nursing i, 243-252.
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