The intention of this paper is to encourage debate on the future of pre registration training particularly to ensure that the care of older people is included in this debate. It is argued that greater consideration needs to be given to promote a more positive approach amongst educationalists, student nurses and qualified staff, to encourage nurses to view working with older people as a positive career move. This paper also highlights the responsibilities that educationalists have in both preparing and supporting pre registration students to consider older people from a gerontological perspective.
The National Service Framework for older people (NSFOP, 2001) set out an ambitious programme of action and reform to address problems facing older people and to deliver high quality services for older people (DH, 2001). For many practitioners this document was seen as a positive step forward in improving services for older people and whilst the NSFOP was not legislative it was a valuable tool in arguing for improved services for older people.
In relation to nurse training the English National Board for Nursing, Midwifery and Health Visiting (ENB) presented a paper in 2001 just after the publication of the NSFOP that reviewed the implications of the NSFOP for the education and training of student nurses and considered how to implement the eight standards contained within the NSFOP into nurse training curriculum (ENB, 2001). The ENB itself, whilst acknowledging that the board would not exist beyond 2002, recognised that the information contained within the report was relevant to the future development of training and education particularly in respect of the NSFOP. In reality the recommendations in this document appear to have been largely ignored.
The Royal College of Nursing (RCN, 2004) produced its first ever strategy ‘Caring in partnership’ promoting the contribution that nurses could make to meet the needs of older people. The aims of the strategy the RCN stated were that:
“The RCN wanted to establish its vision for nursing older people, develop a work plan and ensure that the strategy document would inform good nursing practice by equipping nurses to contribute more effectively to the changing pattern of services delivered to meet the needs of older people in all care settings” RCN (2006)
The strategy identified a set of principles to underpin nursing practice, from these principles a three year action plan was developed which was designed to raise awareness of the nursing needs of older people.
More recently documents such as ‘Modernising Nursing Careers’ (DH, 2007) suggests that future nurses will need to have the skills and competencies to care for older people and people with long term conditions, who may have both physical and mental health needs. This vision for the not too distant future includes the view that nurses will work across a range of settings spanning hospital and community care and considers the development and use of telemedicine. Nurses should also be better equipped to use preventative and health promoting interventions (DH, 2007). This document suggests a shift in focus away from a nursing workforce focussed on hospital based care to care taking place in and outside the hospital setting with the nursing workforce moving between. It also suggests that nurses should start their careers in the community.
It is clear that radical changes are needed within pre registration nurse education if these challenges are to be met. Given the demographic profile of the UK as an increasingly ageing population; to do nothing is not an option. Indeed the Department of Health (DH) itself suggests that educational systems
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with a one size fits all approach that struggle to balance academic, practical learning and reflective practice of a health care system today is not the way forward (DH, 2007). The vision for the future is seen as more of a flexible based curriculum that is built around patient pathways, with a strong academic foundation and interdisciplinary learning (DH, 2007). Drennan et al. (2005) considered what key knowledge and support was required by nurses experienced in the management of long term conditions to work in primary care contexts. Interestingly this small scale study identified that there was a view that there should be a course of preparation for working in the community and that whilst some nurses were very experienced in clinical activity gained within the acute hospital setting, they felt that they had become novice practitioners in the community which was a completely different environment to the acute hospital setting (Drennan et al., 2005). Whilst this study primarily considered qualified nurses, there are important implications for supporting student nurses who may be starting their placements in the community setting in the not too distant future rather than the more historical traditional pattern of acute hospital experience first. These considerations need to be included in any changes made to the pre registration training of student nurses and also in relation to student nurse mentors who will be guiding new students on their community placements in their first year.
The Royal College of Nursing policy unit produced a briefing paper in 2007 that considered the review of pre registration education by the Nursing Midwifery Council (NMC) (RCN, 2007). This document highlights that the NMC review proposes five career pathways:
- Children, family and public health;
- First contact, access and urgent care;
- Supporting long term care;
- Acute and critical care;
- Mental health and psychosocial care.
The suggestion is that nurses would major in one pathway and would develop core competencies in cross cutting themes such as:
- Health promotion;
- Preventative, long term conditions management or crisis monitoring;
- Safeguarding vulnerable people and those in need;
- End of life care;
- Holistic care.
Care needs to be taken that we consider older people from a gerontological perspective that considers how we can facilitate older people to self manage, that takes account of a persons life history and coping mechanisms and focuses on what a person can do rather than what they can’t irrespective of their age. There is a danger that inadvertently we continue to perpetuate a traditional biomedical model of old age that views older people from a negative stance of illness and bodily decline and focuses on deficits rather than strength and ability. The population trends for the next 20 – 30 years indicate that the majority of people who will be using health and social care services will be older people; surely this will support the view that older people need to be clearly visible within curriculums for student nurses. The demographic changes in the UK mean that politically the ‘grey vote’ will be very difficult for successive governments to ignore and could potentially change the landscape for older people to become a very powerful group in which to lobby successive governments on issues in relation to health and social care that perhaps in the past have been largely ignored. Universities ignore this at their peril.
Over a decade ago the English National Board (ENB) conducted a two year study that analysed the curricula for pre and post registration nursing educational programmes. This study aimed to explore the relationship between the content of educational programmes in nursing and the quality of nursing care for older people. In particular it considered if nurses were adequately prepared to promote patient/client autonomy when providing care for older people. Some of the main findings from the study found that programmes which appeared to focus more explicitly on the needs of older people for self determination shared some of the following characteristics:
- An emphasis on challenging attitudes and stereotypes;
- Content specifically aimed at developing the skills to challenge and change practice;
- A consistent emphasis on the participation of older people throughout the curriculum.
These characteristics the study identified were most apparent in the pre registration mental health branch programmes (ENB, 1997). The study also found that the use of the phrase ‘the elderly’ was commonly used within the curriculum and recognised that the phrase was disliked by older people and implied a negative view of old age (ENB, 1997).
The ‘Modernising Nursing Careers’ (NMC, 2006) document and guidance added ‘care of the old and geriatrics’ alongside home nursing to the guidelines for ensuring that knowledge, learning and experience required by the EU directives for general care were met in full (NMC, 2006). The irony of the EU directives is that whilst the NMC state that nurses wishing to practice in the UK have to demonstrate that they have achieved the required level of competency in the care of the old and geriatrics and home nursing, these principles are not truly embedded into the pre registration curricula in schools of nursing across England. It could also be argued that the terminology used by the NMC is in itself promoting an ageist view of the care of older people.
Older people are not a homogenous group of people. According to the Kings Fund (2003), examples of ageism include stereotypical assumptions that older people are a homogenous group; failing to appreciate individuality and diversity. The NSFOP acknowledged in standard 1 ‘rooting out age discrimination’ that both explicit and implicit ageism exists in health and social care (DH, 2001). The Kings Fund (2003) suggests that strategies to address implicit ageism should include raising awareness of age discrimination, ensure that age discrimination is covered in personal and professional development. It also recommends that ageism is covered in training and educational programmes (Kings Fund, 2003). These recommendations have implications for any review of pre registration nursing training.
Skills for Health (2007) have developed a competency framework around the skills needed to care for older people. Skills for Health (2007) suggest that the national workforce competencies are of use in the design of educational and training programmes.
“They can also be used in the management and development of organisations and individuals, for job design, recruitment, individual and team development, career planning and appraisal. Within the NHS across the UK they can also be used by employers and individuals to meet the
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demands of the knowledge and skills framework.” (Skills for Health, 2007)
Again the question could be asked why is greater use not being made of the competency framework in reviewing pre registration nursing curricula, particularly as it links to the KSF and will be relevant to newly qualified nurses in demonstrating how they are meeting the requirement of their first post on qualifying.
Conclusion
Too often there are debates in the NHS about not reinventing the wheel. However despite this we are still not good at looking for and learning from examples of good practice. If pre registration mental health programmes are getting it right why are we not learning and joining up our thinking around the development of nursing curricula. The skills for health competency framework is there to be used yet why is there so little reference to the framework for developing competencies around the care of older people within pre registration nurse training? Equally it could be argued that there is still huge scope to develop cross faculty teaching with our social work colleagues around shared teaching of student nurses and social workers and older people. In order to facilitate the Department of Health’s aim of an integrated approach to health and social care maybe we need to look closer to home and consider how to integrate nursing and social work training. We do, however, need to have more joined up thinking in order to drive curricula changes and inform educationalists.
The aims of the review of pre registration nursing education as outlined in the ‘Modernising Nursing Careers’ (DH, 2007) document were:
“To establish how we can ensure nurse training is safe, effective and fit for purpose in a changing healthcare environment marked by an ageing population, advances in technology and changes to the way in which service are provided” (DH, 2007)
The real challenge for nursing; lies in having a real open and honest debate about how we promote the care of older people in a more positive light. We all need to encourage the nurses of tomorrow to want to pursue a nursing career; that will be predominantly providing care for all of us as older people in the not too distant future.
References
- Department of Health (2001) National Service Framework for Older People. London: HMSO
- Department of Health (2007) The CNO Bulletin. Available from www.dh.gov.uk
- Drennan. V., Goodman. C., Leyshon, S. (2005). Supporting experienced hospital nurses to move into Community Matron Roles. Primary Care Nursing Research Unit. London: Department of Primary Care & Population Services.
- English National Board for Nursing and Midwifery (1997) Promoting autonomy and independence among older people: an evaluation of educational programmes in Nursing. Research highlights 27. July 1997. London: ENB.
- English National Board for Nursing and Midwifery (2002). Longitudinal study of the effectiveness of educational preparation to meet the needs of older people and their carers: The Advancing Gerontological Education in Nursing (The AGEIN) project. London: ENB.
- King’s Fund (2003) Auditing Age Discrimination. A practical approach to promoting age equality in health and social care. London: King’s Fund.
- Nursing & Midwifery Council, (2006) Guidelines for meeting the EU directives for general care required for nurses from overseas and EU countries seeking admission to the NMC register in the field of adult nursing. London: NMC
- Royal College of Nursing (2007). RCN Policy unit policy briefing. 15/2007. Two consultations from modernising nursing careers. London: RCN.
- Skills for Health (2007) Annual Review. Available from www.skillsforhealth.org.uk.
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