Since the 1980s, there have been many changes in nurse education and in nursing practice in the UK. The changes have been reflected within nurse education programmes around the world and many of these changes have been extensively explored within nursing publications. Until 25 years ago, nearly all student nurses were employees of the hospital that provided their ‘vocational training’, an arrangement similar to that experienced in the 1870s during the Florence Nightingale era. In the 21®* Century, nurse education in the UK and most of Europe, as well as in many other countries such as the United States of America (USA), South America, South Africa, Australia, and Canada, is provided by Higher
Education Institutes (HEIs), with practice learning experiences gained within the healthcare provider setting.
During the last 25 years there have also been many changes to Registered Nurse (RN) role expectations. The role of RNs has become increasingly specialised in diverse practice areas, increasingly autonomous in many developed countries, and extended roles such as diagnostic physical assessment, onward referral, and prescribing medicines have become accepted practice (Department of Health (DH), 2006a). This evolution of the RN role has created a tension within the health professions and within public perceptions, with the enormous diversity of RN roles making it difficult to define what a RN is and what a RN does (Royal College of Nursing (RCN), 2003; RCN, 2004).
2.3.1 Developments in UK nurse education during the last 25 Years
In the 1980s and 1990s in the UK, nurse education moved into HEIs and over the subsequent few years student nurses shed the status of hospital employee for a supernumerary student status within their practice placements (Nursing and Midwifery Council (NMC), 2004) working towards a degree or diploma in nursing. During the 1990s the introduction of Project 2000 in the UK attempted to revolutionise nurse education, placing the emphasis on teaching students how to learn and analyse, so they could develop confidence in adapting to a changing healthcare environment (United Kingdom Central Council (UKCC), 1986). The Project 2000 students were students not employees and had far less time in practice settings than previous programmes. However, Project 2000 was criticised for creating nurses who were ‘not fit to practise’ when they completed (Templeton, 2004) and the curriculum was changed to ensure 50% of the programme took place in the practice setting, working under the supervision of specially trained nurse mentors (NMC, 2004).
In the UK, the NMC regulate the profession of nursing, with a mandate to protect the public (NMC, 2009). The UKCC preceded the NMC and had been responsible from 1983 to 2002 for maintaining a register of qualified nurses, providing advice and guidance, and managing complaints against Registrants. The UKCC worked alongside National Boards for each of the four UK countries who managed the quality of the education programmes. In 2002, the NMC took over the responsibilities of the UKCC and the National Boards, and since then has brought in increasingly explicit guidance for education programmes. The NMC has introduced education and practice standards, skills clusters identifying competency expectations at different progression points during the student’s education (NMC 2007a, NMC, 2010; NMC, 2010a), and also standards for practice education, with the recognition of formal mentorship in practice and education of mentors (NMC, 2006). Within the standards for nurse education are explicit requirements for skills development and competency in care, compassion and communication (NMC, 2010a). The NMC has also revised the nursing
Code of Conduct, providing guidance on performance and ethics in nursing practice (NMC,
2008) and has decided entry to the nursing profession in England will be at a minimum of degree level by 2015, with a supported period of preceptorship following initial qualification (NMC, 2009a). These changes in nurse education have taken place alongside the proliferation of Health Care Assistant (HCA) roles and the expansion of practice-based foundation degrees for assistant practitioners, roles that provide fundamental health and social care in hospitals or in the home (Thurgate et al., 2010; Smith, 2012).
2.3.2 Developments in UK nursing practice during the last 25 years
Nursing practice has also evolved substantially during the last 25 years and is set to continue evolving to meet the changing demands on healthcare services (DH, 2006a; DH, 2009b; DH, 2010b). Much of this change has been driven by cultural change and increasing demands on healthcare services, with the public becoming more aware of choice and having
expectations based upon an expansion in healthcare information availability, through the development of web based resources. The demand on UK healthcare services and therefore on nurses has also grown due to an aging population and with numerous advances in both technological and pharmacological treatments (RCN, 2004). Alongside these changes are expectations on the provision of compassion practice (DH, 2008a; DH, 2008b; NMC, 2010; NMC, 2010a), as explored within Chapter 3.
Nursing as a profession has grown in autonomy during the last 25 years, with an increasing evidence base for practice and growth in specialist roles (DH, 2007). Specially qualified nurses can now prescribe from the full formulary of medicines and are increasingly in roles where first line assessment, diagnosis and referral are required (DH, 2006). There is also a general understanding that the modernisation of the provision of healthcare over the last few decades has reduced the time patients spend in hospitals and thereby increased the patient acuity in both hospital and community based nursing settings within the UK (RCN, 2010a).
The time available for RNs to spend on provision of personal care compared to technical care is changing and the personal care is increasingly the responsibility of the Health Care Assistants (HCAs), individuals who are not RNs and undertake a basic education for caring for people (O’Driscoll et al., 2010). This increasing division of labour between the technical nursing of RNs and the social caring of HCAs has been the focus of much debate within the profession (Corbin, 2008; Griffiths, 2008; Castledine, 2010; Castledine, 2010a) with members of the profession expressing anxiety over the loss of ‘caring roles’ and delegation of caring activities that used to belong within nursing.
In order to meet the challenges that lie ahead, the future nursing workforce may require flexible and visionary approaches and be prepared to take risks. However, nurse education in the UK is currently falling short in achieving this objective due to ongoing confusion about the role of the RN and the definitions of competency to become a RN (Taylor et al., 2010). The profession is having difficulty providing clarity on the role boundaries of RNs compared
to HCAs. Nursing work, since its emergence as a distinct ‘occupation’ in the mid 19**^ Century and through its ongoing development toward professional status in the 20**^ Century (Henderson, 1964), has been a challenge to define; with nurses initially providing care that the layperson without training could not provide, and in the 21®* Century crossing so many boundaries with other health care professionals’ responsibilities that a ‘catch-all’ definition becomes challenging (RCN, 2003; Chitty, 2005). However, despite no ‘catch all’ definition of what a RN role entails, the NMC have developed, and continue to refine, guidance on the standards of performance, conduct and ethics of RNs within The Code (NMC, 2008).
The UK is not alone in facing challenges within nurse education and nursing practice. The nursing profession in the USA is also facing challenges, specifically confronting nurse shortages and ensuring initiatives increase the quality of nursing, and in providing excellence in student nurse education (Rich and Nugent, 2010). In order to overcome the challenges within their nurse education system, nurse educators are calling for the design of innovative and imaginative solutions that will turn challenges into opportunities. As Rich and Nugent (2010) state, nurse education is in a state of ‘crisis’ but a crisis can be the drive for change and improvement.
From this background information it was possible to identify that further research in nurse education in the UK is required to fully understand the 21®* Century challenges within nursing. In order to understand the challenges there needs to be an updated understanding of the socialisation experiences of student nurses within 21®* Century professional preparation.