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Some are more equal than others?

March 26, 2015

Alarm bells usually start ringing when medicine is held up as the model nursing should aspire to. Continuing family problems (it never rains but it pours) meant I had to miss the #shapeofcaring Twitter chat on Monday night, but reading it through afterwards, it was good to see nurses engaging in such vigorous – but still respectful – debate. In particular, my eye was caught by a thread about the proposal that the current ‘four fields’ model of nurse education should be replaced with a 2+1+1 model (two years whole person core training, one year chosen specialism, one year preceptorship).

Some tweeters welcomed it as a chance for nurses to move out of ‘silos’ – but others felt the term ‘silo’ was itself an unhelpfully pejorative way to describe interventions performed by people who are, in effect, independent practitioners at the top of their game. ‘Are heart surgeons in silos too?’ bristled one contributor. My answer to that would be ‘quite possibly’. More specifically though, it’s not a fair comparison. After years of intensive training, heart surgeons have presumably arrived at the apogee of their careers. Student nurses, on the other hand, are just starting out on theirs. Why not give them a grounding in every facet of human health?

Defining nursing is notoriously difficult, but one thing most of us can agree on is that it should be about delivering care that is person-centred and holistic. And while some heart surgeons might sign up to this, others arguably don’t; for nurses though, it should be the sine qua non of all our practice – up to and including that of the most skilled and knowledgeable clinical specialist. It’s also why I see the proposal for ‘whole person core training’ as a step in the right direction.

That is not the same, however, as saying I see it as unproblematic. From the Twitter chat it was plain that Mental Health and – particularly – Child and Young Person (CYP) nurses were worried that two years common foundation will in practice mean two years of immersion in Adult Nursing in the acute setting, with a scant one year to consolidate specialism-specific knowledge tagged onto the end.

There were concerns that there are insufficient Mental Health lecturers to accommodate such a major change, inevitably leaving the slack to be picked up by Adult Nursing. And CYP was making the case that their branch of the service is so different from any of the others that one year simply isn’t enough to pack in all the specialist knowledge required – and for what it’s worth, I think this is a cavil that has some merit. On the other hand, although I don’t pretend to be an expert in CYP, I can’t see why the same model couldn’t be applied in microcosm, as it were, to this speciality. Why would it be not be a good thing to see students spending their final year specialising in child mental health, for example?

There was also anxiety that any shift to the new dispensation would not be research based. For a discipline which has spent (literally) decades trying to re-invent itself as a research-based humanitarian endeavour, this is a particularly cutting criticism. And certainly, Lord Willis’s rationale for proposing the abolition of the ‘four fields’ model seem to rest nothing more scientific than a few cosy fireside chats: ‘Discussions with students have raised concerns that the four fields do not lead to parity of esteem between mental health and physical health’ (p42). I also question the basis for deciding that the first part of the course should last two years. To me it sounds a bit long. Is ‘2+1+1’ just a round number slogan that sounds a bit catchy?

But the biggest problem we run up against here (again) is the fact that nursing has never really defined what it is. So if we don’t know what we are aiming for, how can we research the best method of producing it? Added to this is the reality that healthcare is not just a target that is moving at an ever-accelerating speed, but also one buffeted by unpredictable political whim. If implemented, the Shape of Caring Review would provide the template for educating nurses who would be qualifying ten or fifteen years from now. What kind of nurses will give us the best fit for the healthcare landscape of 2025? Specialists or generalists?

My own view is that there are two other questions lurking in the background here. Firstly, the final ‘+1’ of the proposed new model, while full of interesting possibilities, relies on a heavily on the availability of a beefed-up preceptor grade to ‘provide both informal and formal education and training to encourage the development of additional skills, knowledge, competence and confidence’ (p45). But while this could potentially signal the arrival of an exciting new career pathway for nurses, suggestions on the development of the role and how staff would be prepared for it are hard to come by. How many ward nurses are equipped to give teaching that would ‘credit towards a postgraduate degree’? How would we get them to the point where they would be?

Secondly (and this links back to last week’s post) how does the ‘2+1+1’ model tie in with the proposal in the same review, that an undefined length of time spent working as a health care assistant could entitle prospective students to complete a nursing degree in eighteen months? How exactly is this going to work? Nine months common foundation and nine months specialism? Will that be really enough to equip anyone to be a nurse? Is what we have here a lack of joined-up thinking? Or the stealth introduction some kind of two-tier degree system?

So – while I give a welcome to Lord Willis’s ideas, it is a qualified one. I think there is a good (although admittedly not evidence-based) chance that their broad base offers an antidote to the worst aspects of ‘silo’ mentalities, while the emphasis on post-graduate education balances this with opportunities for specialisation from early in the career. All this should benefit patients. However, we need to be watchful that it does not come at the expense of dividing nurses or devaluing the degree. Nursing is complex and difficult. Nurse education must reflect that.

One Comment
  1. RGN007 permalink

    One of the things the Open University used to sell itself on, prior to the “specialised” degrees they had to introduce rather than the “open” tag to their prior degrees (Even if someone had specialised in all the right psychology modules) was that it broadening the horizons of those who set out with little idea of what academic path they really wanted. They could think they fancied science, but then the next module could be music. I used to think this was odd until I realised that doing a degree what not necessarily knowing a lot about one subject, but learning how to question and that we never really know enough.

    OK, this is really an analogy, but the point I am trying to make is that students setting out in nursing might not actually know what they are good at or where their interests may lead. How do you know what you don’t know? (I once did a module including that).

    I don’t think we ever can complete a course and think, “That’s it, I know all that now”. Hopefully, in this lifelong learning we never have to do that, and what is amazing, is how one area of study or experience can bring so much insight into another.

    In my humble opinion, I don’t think nursing needs a more than a safe and eager to learn nurse and the core training should be around being safe to let loose and knowing what we don’t know, so we don’t take on things we are not competent to do. We then grow into our experiences of caring and what we feel we have to offer before choosing the next direction.

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