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Prioritising to safeguard the integrity of nurse education.

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Every so often the thorny subject of student numbers - and related issues such as student support, mentorship and the quality of clinical placements - surface as matters requiring urgent attention. And having surfaced, they then usually submerge again with very little reported evidence of a permanent resolution.


VOL: 101, ISSUE: 34, PAGE NO: 26

Robert A. Johns, PgDip SLT, PgDip MHI, MA, BSc, BA, RMN, Dip HSW, Dip ELS, is clinical placements project lead, Essex Workforce Development Confederation, Chelmsford.

Every so often the thorny subject of student numbers - and related issues such as student support, mentorship and the quality of clinical placements - surface as matters requiring urgent attention. And having surfaced, they then usually submerge again with very little reported evidence of a permanent resolution.



As a result, in response to a letter from the Nurse Directors Association expressing concerns about the pressures on available practice placement capacity in preregistration nursing, the NMC undertook to debate in depth practice quality and placement availability issues at their June meeting (NMC, 2004).



Safe student numbers
The NMC correctly diagnosed that capacity had reached saturation levels in some areas of the country, and that action was needed in order to ensure that the quality of education nursing students received was not compromised.



Yet almost a year later Chatterjee (2005) relates that an NMC spokesperson’s response to the concerns over nursing students’ practice placements expressed at the RCN Congress was a promise to put forward the notion for discussion at a nurse education coalition group.



As Chatterjee reports, what delegates at the RCN Congress in Harrogate (24-28 April) were calling for was explicit evidence-based guidance from the NMC regarding the safest number of students that can be on placement at any given time. Both the volume of students in clinical areas - which could number as many as 14 on a unit - and the shortage of qualified mentors available were cited as causes for concern, with one delegate further adding that there was not enough adequate support for existing mentors.



However, the same delegate’s argument that concentrating on student placement numbers detracts from quality issues requires deeper consideration. Quality cannot easily be resolved unless capacity and commissioning equations are stabilised. This is borne out by the findings of a survey of nursing students in the UK conducted for the RCN by MORI (MORI, 2003), in which close to eight per cent of respondents had not embarked on a specific practice experience due to clinical areas already being oversubscribed with students or a lack of available mentors.



As the volume of students increases, the potential for their qualitative experience reduces simultaneously, and although the Department of Health has in the past issued guidance on expanding capacity (DoH, 2001), this did not provide practicable answers towards permanently resolving placement capacity problems. If there are areas of the country that do not experience placement problems they have not been forthcoming in sharing their wisdom on placement administration best practice with a wider audience.



Meanwhile, the NMC laudably is developing a framework for mentorship standards (NMC, 2005). This said, however, the real problem is that many NHS trusts have failed to recognise mentorship as a priority for investment, and have not sponsored their staff to attend mentorship courses or updates.



With too few mentors in the first place, and until mentorship is developed quantitatively, the minimum standards proposed will merely be of relative value to the qualitative meaning of preregistration nursing.



Making placements central to preregistration nurse education
There are many factors involved in safeguarding the integrity of nurse education (Box 1).



However, the single element without which preregistration education cannot survive is clinical practice placements.



It is generally accepted that learning in clinical practice is crucial to nurse education, as for example is highlighted in key documents such as:



- Making a Difference (Department of Health, 1999),



- Fitness for Practice (UKCC, 1999),



- A Health Service of all the Talents: Developing the NHS Workforce (Department of Health, 2000).



Nursing students need to undertake placements in specific practice settings in order to acquire the necessary competence and skills needed to become safe practitioners (Neary, 1999).



Yet paradoxically all too often nursing curriculums are developed with placement capacity as an apparent afterthought. Undoubtedly, excellent, innovative programmes are devised and implemented. But the fact remains that no matter how good a curriculum may look on paper, it will be fundamentally flawed if it does not take account of placement availability.



To be administered appropriately, any curriculum must have sufficient clinical practice resources to support it.



Expanding the placement circuit
The need to expand the placement circuit has been recognised by Essex Workforce Development Confederation which, in a collaborative venture with Anglia Polytechnic University, has taken a pragmatic approach to increasing student numbers. An innovative project that has expanded the placement circuit is also a first step towards improving quality.



A new system was devised to make more efficient and equitable use of local resources. This involved staggering practice component commencement dates across the whole semester for students within each cohort.



This approach differs from traditional methods in that practice placements are designated according to the students’ academic timetabling which assigns each student cohort to either theory or practice ‘blocks’.



Because the new system ‘recycles’ placements in this way, capacity is now effectively doubled. For example, the semesters one, two, three and six capacity of one locality is increased from 112 to 224 without extra students needing to be in clinical settings at the same time.



In addition, intermediate care placements that were formerly used to make up shortfalls in acute placements are now freed up for use in a dedicated community semester because fewer acute hospital placements are actually required. In the locality cited above, around 40 intermediate care placements will be gained in this way.



Practice implications
If the new system is enacted according to its underpinning principles there could be a maximum of six nursing students in any clinical area across any given week. Exceptionally, a maximum of eight students could be acceptable where a placement historically has been audited to accommodate student numbers up to this amount.



The main threats to its success may thus come from idealistic dicta generated by external authorities. If important influential organisations such as the NMC and the Department of Health provide both advisory and directive functions, these need to be integrated and workable.



If these bodies make recommendations in response to perceived problems or act as the NMC does to advise higher education institutions as to what can and cannot be included in the content of preregistration nursing curricula, they need to ensure they do not encumber currently effective, creative placement solutions.



Expectations to increase nursing student numbers, or validation of curriculums are all very well, but those in positions of authority and influence need to take account of the capacity of NHS and private sector resources to support nurse education. The evidence to date remains that placement problems are perennial, despite awareness regarding these issues.



Preregistration nursing curriculums logically must be practice rather than theory-driven. The evidence of oversubscribed placements, lack of mentors and variable support for students would suggest that currently it is not.



Considerable efforts have been made in Essex to balance educational requisites with the accommodation of ever-growing numbers of nursing students. It would seem ironic indeed if the greatest threats to its success are from the very same validating authorities to which nursing frequently turns for guidance.



This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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