The future education of nurses and healthcare assistants Professor Alan Glasper of the University of Southampton discusses the parameters of Lord Willis’s recommendations following his review of the future education and training of registered nurses and healthcare assistants (HCAs)
414
Background There has been a number of recent reports and inquiries that all cite recommendations for improving the education and training of registered nurses and care assistants. Of the 630 000 nurses who are currently registered with the NMC, 323 486 are working in NHS hospitals and community care settings. Similarly, of the 1.3 million HCAs, 271 890 are currently supporting doctors and nurses throughout the NHS. It is perhaps worth reflecting on the historical aspects of the journey of untrained HCAs in the health service, to appreciate more fully today’s current dilemma of how this large and essential component of the workforce should be managed. In 1938, before World War II, Earl Athlone chaired a committee that wanted to recognise the assistant nurse through the development of a role within the then General Nursing Council. The threat of impending war caused these reforms to be shelved but a separate role for assistant nurses did become a reality as part of the 1943 nurses’ act. The creation of the enrolled nurse did not, however, stem the need for more and more nursing assistants and by 1958 enrolled nurses were outnumbered by untrained staff to the ration of 2: 1 (Borsay and Hunter, 2012). In 1986, the United Kingdom Central Council for Nursing Midwifery and Health Visiting, the direct descendent of the General Nursing Council, published Project 2000. A New Preparation for Practice, which radically changed the face of nurse education. When Project 2000 was introduced, the 2-year training of state enrolled nurses, which had been introduced to support state registered nurses, was also abolished and over the ensuing years they were gradually were replaced by HCAs who are not accredited by a regulator, and in many cases not formally trained. Despite this, it is salutary to note that the nurses’ part of the register, sub-part 2 (enrolled nurses) has not actually been closed by the NMC! The current four fields of nursing practice mandated through the NMC’s 2010 Standards for Pre-Registration Nursing Education are
adult, children, learning disability and mental health.Within these fields of practice, there is a wide breadth of roles and settings across health and social care, such as hospital, domiciliary and community. Lord Willis published his independent review in March 2015: Raising the Bar. Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants. This report will generate much discussion over the coming months, not least within the NMC and the 79 approved educational institutions (AEIs) who provide nursing and midwifery education on behalf of the regulator (Health Education England (HEE), 2015). Lord Willis has made 34 recommendations for the future education and training of nurses and HCAs, which are grouped under eight themes.
1: Enhancing the voice of the patient and the public Willis has made recommendations related to how patient and public involvement can be harnessed to support learning. In this context, a number of universities such as Southampton and Robert Gordon in Aberdeen are already involving patients in the assessment of student nurses in practice. Additionally, the NMC seeks assurances that service users are involved in curricular activities and this is assessed through their annual quality assurance monitoring activities of universities that offer nursing.
2: Valuing the care assistant role Willis makes a number of recommendations about HCAs, but principally reiterates many of the Cavendish review proposals such as the full implementation of the Care Certificate, which should be a mandatory requirement for HCAs, and that they must have completed this before they can work unsupervised in healthcare settings. Willis also supports Cavendish’s endorsement that HEE implement the Higher Care Certificate and develops competency standards for HCAs (NHS bands 1–4) in both health and social care, and works with
© 2015 MA Healthcare Ltd
I
n 2014, Lord Willis was commissioned by Health Education England (HEE) in partnership with the Nursing and Midwifery Council (NMC) to act as an independent chair of a review, whose aim was to determine if the current education and training of care staff and registered nurses is fit for purpose. The review was precipitated after a range of reports pertaining to healthcare delivery, ranging from The Mid-Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013) through to the Cavendish Review (Cavendish, 2013). Lord Willis, Baron Willis of Knaresborough, is a Liberal Democrat member of the House of Lords and formerly the Member of Parliament for Harrogate and Knaresborough in Yorkshire, who chaired the House of Commons Science and Technology Committee. As a former head teacher, he has a deep interest in education and in widening access to higher education. This is not the first time that Lord Willis has reviewed the nursing profession, and in 2012 he was commissioned by the Royal College of Nursing (RCN) to investigate the education of pre-registration nurses (Glasper, 2012).This commission found no impediments in the current system of educating nurses that could be implicated in recent media reports of poor practice and a decline in standards of care. It is also important to stress that this commission did not reveal any evidence that degree-level registration was in any way linked to deterioration in the standards of patient care delivered by nurses. Crucially, Lord Willis’s report showed that graduate nurses have played and will continue to play a key role in enhancing care standards and in developing a nursing workforce fit for future working in a variety of roles across many healthcare settings. Willis also emphasised that better evaluation of research into nursing education programmes is necessary to ensure a programme that is fit for purpose and that recruitment campaigns to the profession need to embrace widening entry and diversity to encourage the widest, best possible range of applicants.
British Journal of Nursing, 2015, Vol 24, No 7
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY employers to ensure that the NHS workforce is adequately trained to meet those standards. Crucially, Willis believes that it is for NHS England to consolidate and agree the myriad job titles that pervade the HCA community to meet the aspirations of HEE’s Talent for Care strategy for developing the health and social care support workforce (HEE, 2014).
he believes that the current standards for nurse mentors embedded within Standards to support learning and assessment in practice settings (SLAiP) ‘require amendment, predicated on the reality that 50% of nurse training occurs in the workplace’ (NMC, 2008).
3: Widening access for care assistants who wish to enter nursing
Willis is adamant that professional partners, such as the universities and employers, should work collaboratively to promote the need for the implementation of a year-long preceptorship programme for newly qualified registered nurses, which will meet requirements for revalidation with the NMC. He recommends that HEE consult and explore the membership and fellowship mode and subsequently, in partnership with universities, develop clinical membership and fellowship standards whereby members would follow an award-bearing postgraduate pathway/programme. Importantly, he believes that funding arrangements for postqualifying learning for registered nurses should be made more transparent.
Willis is championing the notion of widening access to higher education, which would allow existing and future HCAs to embrace a career that will enable them to access a degree course in nursing. He wants universities to use the existing NMC mandate which allows for APL to be applied for up to 50% of an undergraduate nursing degree course to help HCAs aspiring to professional nursing. Furthermore, he envisages that HEE could support more pioneering work-based learning routes to higher education nursing for HCAs that would continue to allow them to work in paid employment while studying.
4: Developing a flexible model
© 2015 MA Healthcare Ltd
Willis is proposing some radical shifts in the current training of nurses, but not, as was feared by many, the abandonment of the current four fields of practice model. Interestingly, Willis, in asking if the current four-field model is fit for the future, actually raises the possibility of additional fields of practice, such as community nursing. This is reflective of changing health patterns and the increase in the numbers of patients with longterm conditions, which in turn is indicative of the need to develop a workforce that is more community- and public-health focused. Although Willis falls short of suggesting the introduction of a totally generic nursepreparation programme, he does concede that more generic elements should be inculcated within all of the current fields’ of practice educational curriculum structures. Hence, on the one hand, he supports the need for some groups of nurses to have specific skills—for example, to care for sick children or those with mental health problems—and on the other, the need for more generic nurse preparation, which is more in line with the European perspective.
5: Assuring a high-quality learning environment for pre-registration nurses Willis recognises that tomorrow’s nurses will need an enhanced toolkit of skills to support the delivery of future patient care. To achieve this,
British Journal of Nursing, 2015, Vol 24, No 7
6: Assuring high-quality, ongoing learning for registered nurses
7: Assuring sustainable research and innovation Following in the wake of the excellent 2014 Research Excellence Framework (REF) results for nursing, it is no surprise that Lord Willis believes that HEE should develop greater links with the Academic Health Science Networks (AHSNs) to ensure that the workforce is able to adopt and use the latest research to inform and provide better patient care. His emphasis on the efficacy of nursing research and its link with improvements in patient care is an explicit acknowledgement of the coming of age of the nursing profession as a research-led community. In this context, Willis believes that there should be greater development of postgraduate doctoral centres to augment clinical research in
practice and, crucially, to increase the numbers of academics engaged in practice.
8: Assuring high-quality funding and commissioning In his final theme, Willis considers the professional collaboration of the various members of the healthcare team and urges HEE to further explore multiprofessional skill mix in its education and training plans for the workforce. Additionally, he calls for greater scrutiny of metrics related to attrition and a closer involvement of the independent and voluntary sector in workforce planning.
Conclusion The wide-ranging array of recommendations embedded in this review will be the subject of significant debate over the coming months. The education and training of nurses and HCAs needs to be aligned to a rapidly changing care environment, and they all need to be equipped with the appropriate skills, knowledge and attitudes to deliver care of the BJN highest quality. Cavendish C et al (2013) An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings. http://tinyurl.com/m3zr7pe (accessed 25 March 2015) Borsay A,Hunter B (2012) Nursing and midwifery in Britain since 17000. Palgrave Macmillan, London Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/bkgyem7 (accessed 25 March 2015) Glasper A (2012) The RCN commission on education: what does it mean? Br J Nurs 21(13): 752-3 Health Education England (2014) The talent for care. http://tinyurl. com/q598pdx (accessed 25 March 2015) Health Education England (2015) The Shape of Caring Review report published. HEE, London. http://tinyurl.com/6zodwq9 (accessed 25 March 2015) Nursing and Midwifery Council (2008) Standards to support learning and assessment in practice settings (SLAiP). http://tinyurl.com/ bsha436 (accessed 25 March 2015) Nursing and Midwifery Council (2010) Pre-registration nursing education. NMC, London. http://tinyurl.com/6zodwq9 (accessed 25 March 2015) Royal College of Nursing (2012) Quality with compassion: the future of nursing education. Report of the Willis Commission on Nursing Education, 2012. http://tinyurl.com/cvugp8t (accessed 25 March 2015) United Kingdom Central Council for Nursing Midwifery and Health Visiting (1986) Project 2000. A New Preparation for Practice. http://tinyurl.com/qyvbx3e (accessed 25 March 2015)
KEY POINTS n In March 2015, Lord Willis reported to Health Education England (HEE) and the Nursing and Midwifery Council (NMC) his views on whether the current education and training of care staff and registered nurses is fit for purpose n He has made 34 recommendations for the future education and training of nurses and healthcare assistants (HCAs) n Lord Willis is championing the notion of widening access to higher education for existing and future HCAs to allow them to embrace a health career n Lord Willis is proposing some radical shifts in the current training of nurses, but not, as was feared by many, the abandonment of the current four fields of practice model
415
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
414
Background There has been a number of recent reports and inquiries that all cite recommendations for improving the education and training of registered nurses and care assistants. Of the 630 000 nurses who are currently registered with the NMC, 323 486 are working in NHS hospitals and community care settings. Similarly, of the 1.3 million HCAs, 271 890 are currently supporting doctors and nurses throughout the NHS. It is perhaps worth reflecting on the historical aspects of the journey of untrained HCAs in the health service, to appreciate more fully today’s current dilemma of how this large and essential component of the workforce should be managed. In 1938, before World War II, Earl Athlone chaired a committee that wanted to recognise the assistant nurse through the development of a role within the then General Nursing Council. The threat of impending war caused these reforms to be shelved but a separate role for assistant nurses did become a reality as part of the 1943 nurses’ act. The creation of the enrolled nurse did not, however, stem the need for more and more nursing assistants and by 1958 enrolled nurses were outnumbered by untrained staff to the ration of 2: 1 (Borsay and Hunter, 2012). In 1986, the United Kingdom Central Council for Nursing Midwifery and Health Visiting, the direct descendent of the General Nursing Council, published Project 2000. A New Preparation for Practice, which radically changed the face of nurse education. When Project 2000 was introduced, the 2-year training of state enrolled nurses, which had been introduced to support state registered nurses, was also abolished and over the ensuing years they were gradually were replaced by HCAs who are not accredited by a regulator, and in many cases not formally trained. Despite this, it is salutary to note that the nurses’ part of the register, sub-part 2 (enrolled nurses) has not actually been closed by the NMC! The current four fields of nursing practice mandated through the NMC’s 2010 Standards for Pre-Registration Nursing Education are
adult, children, learning disability and mental health.Within these fields of practice, there is a wide breadth of roles and settings across health and social care, such as hospital, domiciliary and community. Lord Willis published his independent review in March 2015: Raising the Bar. Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants. This report will generate much discussion over the coming months, not least within the NMC and the 79 approved educational institutions (AEIs) who provide nursing and midwifery education on behalf of the regulator (Health Education England (HEE), 2015). Lord Willis has made 34 recommendations for the future education and training of nurses and HCAs, which are grouped under eight themes.
1: Enhancing the voice of the patient and the public Willis has made recommendations related to how patient and public involvement can be harnessed to support learning. In this context, a number of universities such as Southampton and Robert Gordon in Aberdeen are already involving patients in the assessment of student nurses in practice. Additionally, the NMC seeks assurances that service users are involved in curricular activities and this is assessed through their annual quality assurance monitoring activities of universities that offer nursing.
2: Valuing the care assistant role Willis makes a number of recommendations about HCAs, but principally reiterates many of the Cavendish review proposals such as the full implementation of the Care Certificate, which should be a mandatory requirement for HCAs, and that they must have completed this before they can work unsupervised in healthcare settings. Willis also supports Cavendish’s endorsement that HEE implement the Higher Care Certificate and develops competency standards for HCAs (NHS bands 1–4) in both health and social care, and works with
© 2015 MA Healthcare Ltd
I
n 2014, Lord Willis was commissioned by Health Education England (HEE) in partnership with the Nursing and Midwifery Council (NMC) to act as an independent chair of a review, whose aim was to determine if the current education and training of care staff and registered nurses is fit for purpose. The review was precipitated after a range of reports pertaining to healthcare delivery, ranging from The Mid-Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013) through to the Cavendish Review (Cavendish, 2013). Lord Willis, Baron Willis of Knaresborough, is a Liberal Democrat member of the House of Lords and formerly the Member of Parliament for Harrogate and Knaresborough in Yorkshire, who chaired the House of Commons Science and Technology Committee. As a former head teacher, he has a deep interest in education and in widening access to higher education. This is not the first time that Lord Willis has reviewed the nursing profession, and in 2012 he was commissioned by the Royal College of Nursing (RCN) to investigate the education of pre-registration nurses (Glasper, 2012).This commission found no impediments in the current system of educating nurses that could be implicated in recent media reports of poor practice and a decline in standards of care. It is also important to stress that this commission did not reveal any evidence that degree-level registration was in any way linked to deterioration in the standards of patient care delivered by nurses. Crucially, Lord Willis’s report showed that graduate nurses have played and will continue to play a key role in enhancing care standards and in developing a nursing workforce fit for future working in a variety of roles across many healthcare settings. Willis also emphasised that better evaluation of research into nursing education programmes is necessary to ensure a programme that is fit for purpose and that recruitment campaigns to the profession need to embrace widening entry and diversity to encourage the widest, best possible range of applicants.
British Journal of Nursing, 2015, Vol 24, No 7
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY employers to ensure that the NHS workforce is adequately trained to meet those standards. Crucially, Willis believes that it is for NHS England to consolidate and agree the myriad job titles that pervade the HCA community to meet the aspirations of HEE’s Talent for Care strategy for developing the health and social care support workforce (HEE, 2014).
he believes that the current standards for nurse mentors embedded within Standards to support learning and assessment in practice settings (SLAiP) ‘require amendment, predicated on the reality that 50% of nurse training occurs in the workplace’ (NMC, 2008).
3: Widening access for care assistants who wish to enter nursing
Willis is adamant that professional partners, such as the universities and employers, should work collaboratively to promote the need for the implementation of a year-long preceptorship programme for newly qualified registered nurses, which will meet requirements for revalidation with the NMC. He recommends that HEE consult and explore the membership and fellowship mode and subsequently, in partnership with universities, develop clinical membership and fellowship standards whereby members would follow an award-bearing postgraduate pathway/programme. Importantly, he believes that funding arrangements for postqualifying learning for registered nurses should be made more transparent.
Willis is championing the notion of widening access to higher education, which would allow existing and future HCAs to embrace a career that will enable them to access a degree course in nursing. He wants universities to use the existing NMC mandate which allows for APL to be applied for up to 50% of an undergraduate nursing degree course to help HCAs aspiring to professional nursing. Furthermore, he envisages that HEE could support more pioneering work-based learning routes to higher education nursing for HCAs that would continue to allow them to work in paid employment while studying.
4: Developing a flexible model
© 2015 MA Healthcare Ltd
Willis is proposing some radical shifts in the current training of nurses, but not, as was feared by many, the abandonment of the current four fields of practice model. Interestingly, Willis, in asking if the current four-field model is fit for the future, actually raises the possibility of additional fields of practice, such as community nursing. This is reflective of changing health patterns and the increase in the numbers of patients with longterm conditions, which in turn is indicative of the need to develop a workforce that is more community- and public-health focused. Although Willis falls short of suggesting the introduction of a totally generic nursepreparation programme, he does concede that more generic elements should be inculcated within all of the current fields’ of practice educational curriculum structures. Hence, on the one hand, he supports the need for some groups of nurses to have specific skills—for example, to care for sick children or those with mental health problems—and on the other, the need for more generic nurse preparation, which is more in line with the European perspective.
5: Assuring a high-quality learning environment for pre-registration nurses Willis recognises that tomorrow’s nurses will need an enhanced toolkit of skills to support the delivery of future patient care. To achieve this,
British Journal of Nursing, 2015, Vol 24, No 7
6: Assuring high-quality, ongoing learning for registered nurses
7: Assuring sustainable research and innovation Following in the wake of the excellent 2014 Research Excellence Framework (REF) results for nursing, it is no surprise that Lord Willis believes that HEE should develop greater links with the Academic Health Science Networks (AHSNs) to ensure that the workforce is able to adopt and use the latest research to inform and provide better patient care. His emphasis on the efficacy of nursing research and its link with improvements in patient care is an explicit acknowledgement of the coming of age of the nursing profession as a research-led community. In this context, Willis believes that there should be greater development of postgraduate doctoral centres to augment clinical research in
practice and, crucially, to increase the numbers of academics engaged in practice.
8: Assuring high-quality funding and commissioning In his final theme, Willis considers the professional collaboration of the various members of the healthcare team and urges HEE to further explore multiprofessional skill mix in its education and training plans for the workforce. Additionally, he calls for greater scrutiny of metrics related to attrition and a closer involvement of the independent and voluntary sector in workforce planning.
Conclusion The wide-ranging array of recommendations embedded in this review will be the subject of significant debate over the coming months. The education and training of nurses and HCAs needs to be aligned to a rapidly changing care environment, and they all need to be equipped with the appropriate skills, knowledge and attitudes to deliver care of the BJN highest quality. Cavendish C et al (2013) An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings. http://tinyurl.com/m3zr7pe (accessed 25 March 2015) Borsay A,Hunter B (2012) Nursing and midwifery in Britain since 17000. Palgrave Macmillan, London Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/bkgyem7 (accessed 25 March 2015) Glasper A (2012) The RCN commission on education: what does it mean? Br J Nurs 21(13): 752-3 Health Education England (2014) The talent for care. http://tinyurl. com/q598pdx (accessed 25 March 2015) Health Education England (2015) The Shape of Caring Review report published. HEE, London. http://tinyurl.com/6zodwq9 (accessed 25 March 2015) Nursing and Midwifery Council (2008) Standards to support learning and assessment in practice settings (SLAiP). http://tinyurl.com/ bsha436 (accessed 25 March 2015) Nursing and Midwifery Council (2010) Pre-registration nursing education. NMC, London. http://tinyurl.com/6zodwq9 (accessed 25 March 2015) Royal College of Nursing (2012) Quality with compassion: the future of nursing education. Report of the Willis Commission on Nursing Education, 2012. http://tinyurl.com/cvugp8t (accessed 25 March 2015) United Kingdom Central Council for Nursing Midwifery and Health Visiting (1986) Project 2000. A New Preparation for Practice. http://tinyurl.com/qyvbx3e (accessed 25 March 2015)
KEY POINTS n In March 2015, Lord Willis reported to Health Education England (HEE) and the Nursing and Midwifery Council (NMC) his views on whether the current education and training of care staff and registered nurses is fit for purpose n He has made 34 recommendations for the future education and training of nurses and healthcare assistants (HCAs) n Lord Willis is championing the notion of widening access to higher education for existing and future HCAs to allow them to embrace a health career n Lord Willis is proposing some radical shifts in the current training of nurses, but not, as was feared by many, the abandonment of the current four fields of practice model
415
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
