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Making a Difference: the implications for nurse education

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VOL: 98, ISSUE: 20, PAGE NO: 38

Maggie Lord, MA, BSc, PGCEA, RGN, RNT, is a senior lecturer at the Faculty of Health Studies, Buckinghamshire Chilterns University College, Chalfont St Giles

When New Labour came to power it began to reform the NHS and higher education. The Department of Health published a number of papers on this theme, including The New NHS: Modern, Dependable (DoH, 1997) and The NHS Plan: A Plan for Investment. A Plan for Reform (DoH, 2000). The greatest impact on nurse education, however, came with Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare (DoH, 1999). This report was part of the evidence considered by the UKCC when compiling Fitness for Practice (UKCC, 1999).

In 2000, the model of nurse education proposed in Making a Difference was introduced at a number of pilot sites. Their experiences were shared widely and all new curricula were eventually required to incorporate the Making a Difference initiative.

In view of this, Buckinghamshire Chilterns University College incorporated the recommendations made in Making a Difference, the resulting course being commonly referred to as the ‘MAD’ curriculum. The college recognised the importance of mentorship and incorporated support for student mentors, through a series of workshops, when implementing the new curriculum. This is discussed after an outline of the history of nurse education.


After the adoption of Project 2000 in 1986, nurse education moved into universities while continuing to have a close relationship with nursing practice, largely in the NHS. This allowed the government to exert its influence in a ‘pincer’ movement, through NHS reforms as well as changes in the higher education sector (Traynor and Rafferty, 1999). Le Var (1997) presents a thorough analysis of the implementation of Project 2000, which affected the entire system of nurse education and training.

Yet Project 2000 was not the success the government had hoped. It failed to deliver its promise for a variety of reasons. One was money: when students stepped out of practice to study, the government provided enough funds for only half of them to be replaced on the wards. This led to skill-mix problems and the expansion of cheaper National Vocational Qualifications (NVQs).

Project 2000 aimed to change nurse education from a system that responded to the workforce requirements of the NHS to one that would expose its students to the effects of mainstream higher education, but many nurses could not see the relevance of this. Their rejection of the academic content of nurse education became a fundamental problem in the implementation of Project 2000.

For integration into higher education to occur, the profession had to accept that theory would enhance practice and not diminish clinical skills. Mackay (1998) identified the influence of individuals who felt that the old system, under which they had trained, was superior. Project 2000 was criticised mainly because the practitioners it produced were not seen as confident in practice.

Making a Difference

This view of practitioners’ lack of confidence was echoed in Making a Difference (DoH, 1999). The document claimed that both nurses and midwives were entering practice ‘without the full range of skills required for effective practice’ and that there was a need for stronger links between universities and the NHS. It also established the government’s priorities for change, which were:

- To develop a system of nurse training responsive to the needs of the NHS;

- To increase the level of practical skills in training programmes;

- To widen access to nurse education, particularly for under-represented groups;

- The creation of more flexible career pathways into and within nursing and midwifery;

- To strengthen opportunities for the continuing professional development of practitioners.

The message to the universities from the government was clear: there had to be a change of focus within nursing and midwifery education. It would be the NHS and purchasers of the service, rather than providers, who would dictate the structure and outcomes of nursing and midwifery curricula.

While curriculum development in response to Making a Difference was going on, the summary and recommendations of Fitness for Practice were published, followed by the full report. These recommendations became intrinsic to the new courses and curricula.

Fitness for Practice

Fitness for Practice confirmed the views of educators that the principles of Project 2000 had been weakened, on implementation, by changes in higher education and the NHS. However, the report stated that the main objective of Project 2000 should continue to underpin nurse education. It also confirmed that there was concern ‘that newly qualified nurses do not possess the practice skills expected of them by employers, and public perceptions are sometimes negative’.

Nevertheless, the full report confirmed that after three to six months any apparent skills deficits disappeared and that some qualified staff might have ‘unreasonable expectations’ of newly registered nurses.

The charge that the public had negative perceptions about the practical skills of new practitioners was an important admission and changes to the structure of preregistration programmes were recommended (see Table 1). The report was careful to clarify what was meant by ‘fitness for practice’. The aims of the educational programme and the expectations for practice in specialist areas of nursing were clearly stated, and the distinction between fitness for practice, fitness for purpose and fitness for award were elucidated (Table 2).

The most significant change was the introduction of a one-year competency-based common foundation programme that is followed by a two-year branch programme. The competencies to be achieved by the end of the common foundation programme corresponded with those achieved by care workers doing NVQs in health and social care at a minimum of Level 3 (ENB, 2000).

In view of the government’s stated priority of a more flexible approach to nursing and midwifery education, broader criteria for entry to programmes was considered along with accreditation of prior (experiential) learning (APEL). This time the universities sent a message to the government: flexibility was not possible without a change in the unpopular commissioning process - and bursaries would have to change. Individual institutions have been dealing with this problem in different ways and there has been encouragement for cadet schemes and sponsorship for health care assistants to follow programmes of nurse training (Radcliffe, 2002).

Practice placements

The nature of practice placements was also addressed in Fitness for Practice. At the time of publication, attrition rates for nursing courses were as high as 30% and some of the reasons for this were lack of support during practice placements, travelling difficulties and personal problems. There is an identified ongoing shortage of nurses (DoH, 2000), and although recommendation 10 of Fitness for Practice specifies that ‘consistent clinical supervision in a supportive learning environment during all practice placements is necessary’, this is becoming more difficult to achieve.

Support for students in practice has been strengthened by two documents that were published jointly in 2001 by the ENB and the DoH. These are Placements in Focus (2001a) and Preparation of Mentors and Teachers (2001b).


The development of educational policy always represents a compromise between different values and interests (Taylor et al, 1997). The context of practice for Making a Difference and Fitness for Practice is still developing. But one downside of these changes is that health care needs, rather than professionalism, are dictating the format of nurse education. Nurses are being prepared to meet current shortages and needs rather than being equipped for the future.

It could be argued that in focusing preregistration education on outcomes-based educational principles, nurses and midwives are not being trained to be critical of their profession and the NHS as a whole. This means students may not attain what Barnett (1997) defines as critical professionalism. However, in nursing and nurse education there is still a need to maintain safe standards of practice. Employers want nurses who have practical skills but can also be accountable without support. Educators, on the other hand, wish to retain critical-thinking skills and want to develop autonomy and competence in students.

The implications for students

The government aims to widen access to higher education, especially for women, working-class men and specific under-represented ethnic groups (Higher Education Funding Council for England, 2001). The DoH also aims to increase the number of nurse training places (DoH, 2000).

But how is this going to be accomplished? The National Audit Office (2001) indicates that while institutions have accommodated year-on-year increases since 1994-1995, full capacity is now being reached. Moreover, since students spend at least half of their programme in practice, it is vital to have practitioners who are willing to supervise them. Fitness for Practice indicated that trusts were reporting the worst nurse shortages in 25 years. The report identified the resource implications for service providers, emphasising the commitment needed to support and assess students, including mentor training.

The implications for mentors

Education for health care professionals must now focus on the skills and services needed by patients and clients. However, students who are in a supportive environment acquire better practical skills (ENB/DoH, 2001b). Although there has been some confusion over the roles of assessor, mentor, supervisor and preceptor (Neary, 1997), a new ENB/DoH (2001b) framework for the preparation of mentors has superseded previous requirements and replaced previous courses, such as the ENB 998. The role of mentor has now been clarified and specifically includes the assessment of students.

Mentors will now be practitioners with one year’s experience and new mentorship preparation programmes have been developed. The programme at Buckinghamshire Chilterns University College supports student mentors as they undertake their role. It focuses on teaching them how to facilitate and support others’ learning. Mentors support students through the process of learning, from identifying their educational needs to planning programmes of learning and negotiating learning contracts. The importance of assessment and providing feedback are addressed, and dilemmas that occur are discussed.

The importance of the mentor role has been acknowledged and practice educators have been introduced to support mentors and students. The practice educator will support the mentors who, in turn, are supporting students.


Although different stakeholders have different interests, they all contribute to educating nurses. Assessing clinical skills, with clear expectations for mentors and students, may make a difference. Students who ‘step off’ the course will have a firmer idea of their achievements in practice, which may reduce attrition and improve fitness for practice.

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