Willis Commission 2012

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Willis Commission 2012

Quality with Compassion:

the future of nursingeducation

Report of the Willis Commission2012


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Title:Quality with compassion: the future

of nursing education. Report ofthe Willis Commission on NursingEducation, 2012.

Key words:Nursing, education, future ofhealth care

Target readership:Policy-makers and policy analysts;health service users and theirorganizations; nursing practitioners,

educators, managers, researchersand students; higher educationinstitutions; chairs, directors andmanagers of organizations providingand commissioning health services,education and training; regulatoryand professional bodies in the UK.

Publisher details:Published by the Royal Collegeof Nursing on behalf of theindependent Willis Commission

on Nursing Education.

2012 Royal College of Nursing.All rights reserved. No part of thispublication may be reproduced,stored in a retrieval system, ortransmitted in any form or by anymeans electronic, mechanical,photocopying, recording orotherwise, without prior permissionof the publisher. This publicationmay not be lent, resold, hired outor otherwise disposed of by ways

of trade in any form of binding orcover other than that in which it ispublished, without the prior consentof the publisher.

Website and archive:www.williscommission.org.ukuntil early 2013, thenwww.rcn.org.uk/williscommission

ISBN:978-1-908782-27-4

Printed on a mixture ofsustainably resourced papers


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Chairmans introduction 4

Summary 6

Part 1: Introduction 7

1.1 Why the commission was established 7

1.2 Terms of reference 9

1.3 The commissions programme of work 9

Part 2: An overview of nursing education 11

2.1 The story so far 12

2.2 Nursing education today 13

2.3 The higher education sector 15

2.4 Commissioning and funding nursing education 16

2.5 Changes in the nursing workforce 19

2.6 Regulation 22

Part 3: What we learned 23

3.1 Views from service users and carers 23

3.2 Other evidence and views 24

Part 4: The way forward 27

Theme 1 The future nursing workforce 27

Theme 2 Degree-level registration 29

Theme 3 Learning to nurse 32

Theme 4 Continuing professional development 36

Theme 5 Patient and public involvement in nursing education 39

Theme 6 Infrastructure 40

Part 5: Conclusions and recommendations 43

References 47

Appendices 51

Contents


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Health professionals in the 21stcentury work in multidisciplinaryteams to improve the quality ofcare and health outcomes. If patient-centred care in acute and communitysettings is to become the norm, asthe Briggs report recommended40 years ago, the nurse must be aprofessional among equals, and beseen as one, not a handmaiden toother professionals (Committee onNursing 1972). The need to producecompetent, condent, critical-

thinking nurses with the ability tolead, to question and to be questionedshould be at the heart of modern pre-registration education programmes.

Given the concerns expressed aboutthe modern nursing professionin many sections of the media,the decision by the Royal Collegeof Nursing (RCN) to establishan independent commissionto examine the health of pre-

registration nursing education wasa courageous one. The RCN is tobe applauded few professionsenjoy the public standing of nursingand any challenge to that standingshould be addressed.

It was my privilege to be entrustedto chair the Willis Commission,

with the freedom to take evidencefrom the widest possible groupof stakeholders, includingpatients. I would like to thank thecommissioners, expert reviewersand advisers, who gave their timegenerously to help prepare thisreport in such a short timescale.I must also pay tribute to thesignicant number of organizationsand individuals who contributedwritten and oral submissions,

demonstrating passion andcommitment to getting nursingeducation right.

Our brief was straightforwardand focused:

What essential features of pre-registration nursing education inthe UK, and what types of supportfor newly registered practitioners,are needed to create and maintain

a workforce of competent,compassionate nurses t todeliver future health and socialcare services?

It was neither new nor novel.Countless inquiries and reportshave been conducted over manydecades seeking ways to improvenursing education and training.Sadly, although many of therecommendations have beenblindingly obvious, there has been

insufcient political or professionalwill to implement them fully. Ihope that will not be the fate ofthis report.

We found the case for moving toan all-graduate nursing professionnot simply desirable, but essential.Indeed we found it totally illogicalto claim that by increasing theintellectual requirements fornursing, essential for professional

responsibilities such as prescribing,recruits will be less caring orcompassionate. Such accusationsare seldom made against otherall-graduate professions suchas medicine, midwifery or

Introduction from Lord Willis

physiotherapy, and there isabsolutely no evidence to support

them in nursing.

The roles of tomorrows nurseswill be even more demandingand specialised, and will requireeven greater reserves of self-determination and leadership ashealth care moves into a myriadof settings outside hospital. Oureducation system must producenurses who have both intellect andcompassion, not one or the other.

The foundations of high qualitymodern nursing education arealready in place. The new Nursingand Midwifery Council (NMC)standards command widespreadsupport, and universities haveresponded well to developcurriculums that reect changingpatterns of care. Service usersand their representatives should,however, be more closely involved

in both recruitment and education,as modern nursing must focusprimarily on them as individuals andnot simply on treating conditions.

Neither is the requirement to putevidence-based care at the heart ofnursing education fully met as yet.Nursing scholarship is relativelynew and research must play a moresignicant role in determiningbest practice. Encouraging nursesto question practice constantly

and look for evidence to improveperformance will improve patientoutcomes. Research must not beseen as an optional extra for thesake of a graduate programme.To encourage this vital part ofthe education process, greaterattention must be paid to the nextgeneration of nursing academicsand facilitating their work in bothacademic and clinical settings.

The commission was also struckby the persuasive argument thatthe pre-registration programmeprovides the basis on which to builda lifelong nursing career. The notionthat nurses can be educated in a


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silo, and that following registrationthey are the nished article, could

not be further from the truth. Thisis why high quality mentorship,preceptorship and continuingprofessional development are crucialto improving patient outcomes.Nursing education thrives whenall staff, from medics to healthcareassistants, are constantly havingtheir skills refreshed and updated including the development ofteamwork. We hope that policy-makers, employers, universities

and professional bodies recogniseand act on this challenge.

Finally, we have been bothhumbled and excited by theenormous dedication, intellect,compassion and altruism that shonethrough the many submissionsand presentations. Indeed themessage was the same whereverthe commission took evidencethroughout the UK the desire to

provide tomorrows nurses with thevery best opportunities to offer thevery best care. Nowhere was thismore apparent than when we metnursing students, whose ability toarticulate their ambitions and theirdesire to nurse was awe-inspiring.Valuing what students bring to theireducation is crucial: they are theleaders of tomorrow and it is theirvoices that must be heard.

Lord Willis of KnaresboroughCommission chairman

Acronyms used in this report

CPD Continuing professionaldevelopment

CQC Care Quality CommissionEU European UnionHCA Healthcare assistantHEE Health Education EnglandHEFCE Higher Education Funding Council

for EnglandHEI Higher education institutionIPE Interprofessional educationLETB Local education and training board

MPET Multiprofessional education andtraining levy

HCSW Healthcare support workerNHS National Health ServiceNIPEC Northern Ireland Practice and

Education Council for Nursingand Midwifery

NMC Nursing and Midwifery CouncilNMET Non-medical education and

training levyNQN Newly qualied nurseNVQ National vocational qualication

OU Open UniversityRCN Royal College of NursingRN Registered nurseSHA Strategic health authoritySIFT Service increment for teachingSVQ Scottish vocational qualicationUKCC UK Central Council for Nursing,

Midwifery and Health VisitingWHO World Health Organization

All quotations in italics in this report aretaken from written and oral evidence

submitted to the commission.


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Patient-centred care shouldbe the golden thread that runs

through all pre-registrationnursing education and continuingprofessional development. The focusmust be on helping service users,carers and families to manage theirown conditions and maintain theirhealth across the whole patientpathway. Involving service usersand carers as much as possible inrecruitment, programme designand delivery is a key way ofachieving this.

The commission did not nd anymajor shortcomings in nursingeducation that could be held directlyresponsible for poor practice or theperceived decline in standards ofcare. Nor did it nd any evidencethat degree-level registration wasdamaging to patient care. On thecontrary, graduate nurses haveplayed and will continue to play akey role in driving up standards and

preparing a nursing workforce tfor the future.

Nurses and their organizations muststand up to be counted, to restoreprofessional pride and provideleadership and solutions to thechallenges of poor care and a declinein public condence. Their inuenceon the next generation of nurses iscrucial at this critical moment in theprofessions history.

Nursing education should foster thisstrong emphasis on professionalism.It includes embedding a caringprofessionalism that has patientsafety as its top priority, and respectsthe dignity and values of serviceusers and carers. It requires aconstant commitment to quality,with a willingness to engage withand help extend the evidence basefor practice, and to develop reectivepractice and critical judgement.

Nursing education programmesmust be better evaluated, and basedon extensive research that providesevidence on the correlations betweencurrent practice, entry criteria and

selection processes, attrition ratesand course outcomes. Rigorous

research on curriculum evaluationat the micro and macro levelshould investigate content, processand outcome.

Our future healthcare system willrequire graduate nurses to practiseand lead nursing and healthcareteams in a variety of roles, providingcare in many settings. There shouldbe a diversity of entry points andcareer pathways into nursing.

High quality recruitment campaignsshould be targeted at all potentialnurses, including graduates of otherprofessions, healthcare assistantsand mature people as well as school-leavers, to encourage the best possiblerange of applicants and ensure theyhave the potential to develop the rightcombination of critical judgment,practical skills and values.

Service providers in and beyond theNational Health Service (NHS) mustbe full partners in nursing education,and recognise that the culture of theworkplace is a crucial determinantof its success and a learningenvironment for all staff. Theirboards must be able to demonstratethat they pay full attention toeducation issues.

Universities should fully valuenursing as a practice and research

discipline and recognize itscontribution to their communityengagement. Vice chancellors shouldwork with nursing deans to developa collective narrative about andcommitment to the rightful place ofnursing in universities.

Sustained attention should be paidat national as well as regional andlocal levels to developing a strategicunderstanding of the nursing

workforce as a whole and as a UK-wide resource. Workforce planningand the commissioning of educationplaces must be conducted ineffective local and national strategicpartnerships between planners

and providers of health care andeducation within and outside

the NHS.

This work must be based onrobust evidence-based planning.A consistent data set should becreated and maintained across allfour UK countries that includesinformation from all sectors onnurses and healthcare supportworkers. Short-term measuresthat may create future shortagesshould be avoided.

Summary


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Part 1: Introduction

Part 1 describes why and how thecommission was set up and went

about its work. The focus here is onits scope and purpose, and how itachieved its objectives. The outcomesof the work will be discussed later inthis report.

1.1 Why thecommission wasestablished

Nursing is a demanding yetrewarding profession that asks alot of its workers. We are privilegedto have such a dedicated andcommitted nursing workforce inthe UK. Nursing is an incrediblyself-aware profession, constantlystriving to improve and givepatients the best possible care. It isimperative that nurses are providedwith the right education and skillsto equip them for their roles

Lord Willis of Knaresborough,commission chairman

The United Kingdom needs a nursingworkforce equipped to help meetthe complex healthcare challengesof today and tomorrow, to providecare and support in times of illnessand distress, and to help peoplestay healthy. How this workforceis educated is therefore a matter ofgreat importance.

High quality education for itsown sake confers huge benets onsociety and the individual, but pre-registration nursing education is notan end in itself: its primary purposeis to prepare the future nursingworkforce. Nursing education musttherefore be driven by decisionsand predictions about what futurehealth services could and should belike, and what knowledge and skillsnurses will need to meet individual

and population needs.

These needs are widely recognised.The major factors affecting the healthof the population and of individualpeople include the following (Prime

Ministers Commission on theFuture of Nursing and Midwifery in

England 2010):

demographic change (ageingpopulation and higher birth rate);

changing patterns of health anddisease;

rising expectations of the publicand health service users;

increased access and choice; the shift to delivery of more care

in community settings; continuing social inequality;

advances in care andtreatment; and

advances in technology forcommunications and care.

Many of these trends underline notonly the need to scale up efforts topromote health and prevent illness,but also the huge and growing needfor skilled care for people with long-term conditions and addictions, thecomplex needs of ageing, vulnerable

groups, the early years, and manyothers. People are living longerand often have a mix of illnessesand disabilities that require skilledsupport, management and treatment.

Meeting these needs in cost-effective ways that match peoplespreferences requires major shiftsof focus, not least in professionalattitudes and expertise, as well ascloser collaboration and integrationbetween health, social care and other

sectors, and different professions.Current policy proposes that thesystem should be better integratedaround service users, their carersand families. It should provide bettersupport for self-care, and delivermore care closer to home, from thecradle to the grave.

This means service users and carersshould be integral members of theircare team. They will be increasingly

likely to hold a personal healthbudget and should be fully involvedin planning their care and makingdecisions if they so choose. Goodhealth will result from co-production professionals sharing skills and

knowledge to help service usersachieve the best health possible.

Box 1: A note onterminology

This report generally uses theterm service user to describeany health and social careservice user who requires theprofessional services of anurse for health promotion,illness prevention, care or

treatment. Service userscomprise hospital patients,clients, care home residents,and all similar categories.

We follow the Institute ofMedicine denition of patient-centred care: care that isrespectful of and responsive toindividual preferences, needs,and values, and ensuring thatpatient values guide all clinical

decisions. It encompasses allaspects of how services aredelivered in all settings, includingcompassion, empathy andresponsiveness to needs, valuesand expressed preferences, andinvolvement of family andfriends (Kings Fund 2011).

The term nurse refersexclusively to people registeredas nurses with the NMC. It doesnot include healthcare support

workers, a generic term for non-registered staff who often workunder nurses supervision todeliver direct patient care.

Nurses work in the NHS andfor many other health-relatedorganizations. We use the termhealth system to mean the sumtotal of all the organizations,institutions and resources inthe UK whose primary purpose

is to improve health and provideend-of-life care.


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When they are at their mostvulnerable, patients rely on

caring, compassionate and well-educated, competent nurses toensure they receive the care theyneed. Preparing nurses for thisessential role is a top priority. Thecurriculum must reect the needsof patients and be immediatelyrelevant and applicable to thecentral role of nurses: caring forpatients Patients Association

Patient-centred care, as the

foundation of good nursing, isenshrined in the code producedby the Nursing and MidwiferyCouncil (NMC), the professionsregulator (NMC 2008a). All nursesare required to uphold the code,which says, Make the care of peopleyour rst concern, treating themas individuals and respecting theirdignity. It is also central to the NHSConstitution, which sets out the

rights of patients and the public,and promotes values such

as respect, compassion andcommitment to quality of care(Department of Health 2012a).

Despite these good intentions,stories of unsafe, poor and heartlesscare are heard daily, in the media,at professional conferences and ineveryday conversations. To take oneprominent example, nurses neglectedand humiliated patients at StaffordHospital, where death rates were

signicantly higher than average(Mid Staffordshire NHS FoundationTrust Inquiry 2010). These deathswere attributable to systemic as wellas individual failures. The inquiryfound that the culture of the trustwas not conducive to providinggood care for patients or providinga supportive working environmentfor staff; problems included bullyingand low morale.

As other stories of appalling careand mismanagement unfold,

questions are being asked about thequality of pre-registration nursingeducation and the competence ofnewly qualied nursing graduates.Some critics blame the problemsexplicitly on the move to degree-level nursing education. The tnessfor purpose of nursing education isonce again under scrutiny, at a timewhen it is already in the middle of afar-reaching improvement process.

Patient-centred care is not just amatter of personal qualities suchas being kind, but depends onmany factors including working ina positive practice setting; havingthe right number and mix of staffwith the right skills, knowledgeand attitudes; and supporting,educating and developing staff.To acquire those skills, knowledgeand attitudes, patient-centred care

NursingPractice

Qualitymonitoring and

accreditation

Technology

Demography andepidemiology Research Environment

LegislationRegulation

LeadershipManagement Working

conditions

Nursing

Education

Healthcare systemOrganization

FinancingTechnology

Decentralization

Economic resourcesGross National Product (GNP)

Percentage GNP for healthTotal nancial resources for health

Political, social and cultural factorsStatus and education of women

Political commitmentEthical concerns

Human resourcesfor health

Division of labourRole diffusion

Rapid role changes

Figure 1: The dynamic context of nursing education(Source: WHO 2003)


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must also be the foundation of goodnursing education.

Nursing education, like the qualityof care, cannot be fully understoodin a vacuum or as a stand-alonephenomenon. As conceptualised bythe World Health Organization, itoperates in a dynamic, ever-changingcontext and is itself continuallychanging (Figure 1, adapted fromWHO 2003). This understanding ledthe commission to consider the widerange of issues outlined in this report.

As in the gure, patient-centrednursing practice was the goldenthread that it followed throughout.

To explore these questions andchallenges, and help ensure thefuture nursing workforce is tfor purpose, the Royal College ofNursing (RCN) the UKs leadingprofessional association and tradeunion for nursing invited LordWillis of Knaresborough to chair

an independent commission onnursing education.

1.2 Terms ofreference

We know that the vast majorityof nurses deliver excellent care.However, rather than refuse toaccept that there may be issues

in some areas, the RCN askedLord Willis to look at the formand content of education andpreparation needed to provide anursing workforce that is t for thefuture. The work of the commissioncomes as the RCN considers howthe profession can meet futurehealthcare challenges PeterCarter, chief executive and generalsecretary, RCN

The Willis Commission onNursing Education was launchedon April 25, 2012 with coverage inthe national and healthcare media.Hosted and funded by the RCN, thecommission worked independently.

Its work feeds into the This isnursing project sponsored by

the RCNs Nursing Practice andPolicy Committee.

The commissions independencewas assured by the appointmentof Lord Willis as chairman and apanel of seven experts from acrossthe UK, comprising service userrepresentatives, nurse educationists,managers and practitioners. It wassupported by special advisers, anda secretariat comprising RCN staff

on secondment and an independentconsultant (Appendix 1).

The commission considered thefollowing question:

What essential features of pre-registration nursing education inthe UK, and what types of supportfor newly registered practitioners,are needed to create and maintaina workforce of competent,

compassionate nurses t todeliver future health and socialcare services?

The commission wanted todetermine what excellent nursingeducation should look like and howit should be delivered, identifyinggood practice and sharinginformation. It paid attentionto the legal and operationalframework of nursing education,including the potential impact

of its recommendations on theindependent sector. It was alsomindful of the wider goals ofdeveloping relationships with futureservice providers, and achievingnancial sustainability.

Its recommendations should providean impetus for real change byaddressing the following challenges:

Help policy-makers to determine

what human and nancialresources for pre-registrationnursing education are needed toproduce a nursing workforce t forthe future.

Help education providersand commissioners to remove

or minimise the barriers to bestpractice in pre-registrationnursing education.

Identify suitable practice learningexperiences that provide effectivesupervision and support fornursing students.

Help the employers of newlyregistered nurses to provideappropriate support, includingpreceptorship.

Promote an accurate and positive

public image of pre-registrationnursing education.

The commission did not startout with pre-formed ideas orassumptions. It was also mindfulof the new NMC standards forpre-registration nursing education(NMC 2010a). The huge challengeof implementing them is wellunder way, but has by no meansbedded down, and they will not be

incorporated in all programmesuntil 2013.

Opportunities to test them andevaluate their impact are limiteduntil the rst nurses graduatefrom the new programmes over thenext few years. Nevertheless thecommission hopes that its ndingswill help to shape the progress andeffectiveness of the reforms.

1.3 Thecommissionsprogrammeof work

The commissions extensive andbusy programme of work spannedthe summer and autumn of 2012.Web pages and email addresses were

created to facilitate communicationwith the commission, initiallyhosted on the RCN website and thenon an independent website(www.williscommission.org.uk).


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At the commissions request, areview of the UK literature on

pre-registration nursing educationpublished from 2010 to early2012 was carried out. The majordatabases were searched usingbroad search terms, and 52relevant articles were reviewed onnumerous topics, reecting manychallenges and improvementsin nursing education. Manyrelated to programmes deliveredbefore the 2010 NMC standardswere introduced. Reviews were

also conducted on leadership,mentorship and preceptorship.These background papers are listedin Appendix 2.

Lord Willis and the panel were alsokeen to engage with stakeholders.Individual letters were sentto around 200 organizationsrequesting short writtensubmissions and backgroundmaterials. Over 80 responses were

received within the deadline from awide range of stakeholders includingNHS trusts and other employers,universities, professional bodies androyal colleges, regulatory bodies,patient organizations, charities andothers. They included responsesfrom England, Scotland, Walesand Northern Ireland, and otherscovering the whole UK.

Personal submissions from thepublic, professionals and students

were also invited through mediacoverage, the websites and at events,and 43 were received from nursingstudents, lecturers, practisingnurses, retired nurses andservice users.

Following scrutiny of the technicalpapers and submissions by the chair,panel and independent analysts,23 key organizations and expertswere invited to give evidence during

oral hearings on 12-14 June. Thesessions were transcribed verbatimand checked back with witnesses toensure accuracy. All respondents arelisted in Appendix 3.

The chair, panel members andsecretariat members attended and/

or organised various events acrossthe UK to publicise the commissionand exchange views and information(Appendix 4). Meetings were heldwith stakeholders including the fourUK governments chief nurses. LordWillis attended RCN Congress andlistened to the debates, had informalmeetings with nursing students, andconducted an open listening exercise.

He also undertook a series of visits

across the UK, facilitated and usuallyhosted by panel members, where hemet stakeholders and saw examplesof good practice. Particular attentionwas paid to eliciting evidence fromall four UK countries, mindfulof their divergent approaches tohealth and nursing policy and theirdifferent histories and experiencesof nursing education.

Clearly these different sources

cover the gamut of types of data,from opinion and anecdote to majorresearch studies. Due attention waspaid to weighting these sourcesappropriately in our analysis. Thefull evidence can be viewed on thecommission website until May 2013,after which it will be archived bythe RCN for use in future work andsubsequent inquiries.

A great deal of information received,while interesting and informative,

was beyond the commissions remit.Much of this report is also relevantto midwifery and health visiting.

In conclusion, the commissionfollowed a tight and demandingtimescale from April to October2012. It set itself a clear mandate,engaged with many stakeholders,and reviewed and debated a largeamount of relevant evidence,including site visits to observe

good practice. This report is basedon the most robust evidenceavailable, and represents theindependent collective view ofthe chair and commissioners.


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Part 2: An overview of nursingeducationThis chapter outlines the historyof nursing education, its current

position and future plans. It isdiscussed in the context ofcurrent far-reaching changes inthe health and higher educationsectors, and in the current andfuture nursing workforce.

Box 2: Milestones innursing education

1860: The Nightingale

Training School for Nursesopened at St Thomas Hospital,London, establishing thepattern for professionalnursing education in the UKand many other countries.

1909: The University ofMinnesota bestowed therst US bachelors degreein nursing.

1939: The Athlone reportrecommended that nursesshould have student status.

1943: An RCN commissionchaired by Lord Horderexamined nursing education.

1947: The Wood Report saidnursing students should havefull student status and besupernumerary to ward staffduring their practical training.

This was not widely accepted,but the pressure to reform ledto the Nurses Act, 1949.

1948: The National HealthService was founded, offeringcomprehensive health care forall, free at the point of deliveryand funded through taxation.

1960: The University ofEdinburgh launched the rst

bachelors degree in nursing inthe UK, and a masters degreefrom 1973.

1964: The Platt report from

the RCN Special Committee onNurse Education said studentsshould not be used as cheaplabour, but be nanciallyindependent from hospitalsand eligible for local educationauthority grants.

1969: The University ofManchester offered anintegrated degree programmein nursing, health visiting,

district nursing and midwifery.

1971: The University ofEdinburgh appointed MargaretScott Wright to the rst UKChair of Nursing.

1972: The Briggs committeeon nursing recommendedchanges to education andregulation. Degree preparationfor nurses should increase, to

recruit people with innovativeair and leadership qualities,and nursing should become aresearch-based profession.

1972: The University of Walesappointed Christine Chapmanto develop the rst nursingdegree in Wales. In 1984 shewas appointed to the rstChair of Nursing in Wales,and became the rst nursedean in the UK.

1974: The University ofManchester developed therst bachelors nursing degreeprogramme in England, andappointed Jean McFarlane tothe rst Chair of Nursing atan English university. Degreecourses began at Leeds,Newcastle and London SouthBank universities.

1985: The Judge reportfrom the RCN Commissionon Nursing Educationrecommended the transfer of

nursing education to higher

education, and said studentsshould be supernumerary.

1986: The United KingdomCentral Council for Nursing,Midwifery and Health Visiting(UKCC) launched Project 2000,a wide-ranging reformof nursing education.

1988: The WHO Europeannursing conference in Vienna

supported degree-levelnursing education andsubsequently provided detailedcurriculum guidance. Nursingeducation in many countriesworldwide continued to movein this direction.

1990s: Nursing education inthe UK gradually moved tohigher education as Project2000 was implemented.

Delivery was mostly throughthe diploma route.

1997: The Nurses, Midwives andHealth Visitors Act was passed,requiring the UKCC to determinethe standard, kind and content ofpre-registration education.

1999: The UKCC Commissionfor Education report,Fitness forpractice, evaluated the results ofProject 2000. It recommended

a one-year common foundationprogramme and a two-yearbranch programme.

2000s: The number of graduatenurses grew steadily. Some partsof the UK moved to offeringbachelor programmes only.

2001: Degree-level pre-registration nursingprogrammes began in Wales.

All its pre-registration nursingprogrammes moved to degreelevel in 2004.


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2002: The new Nursing and

Midwifery Council (NMC)replaced the UKCC.

2004:Agenda for Change setout a new pay structure fornurses and other NHS staff thatwas also a rudimentary careerstructure.

2005: The NMC register, withits 15 sub-parts, was revisedto just three parts: nurses,

midwives and specialistcommunity public health nurses.

2008: The NMC decided thatthe minimum academic levelfor all pre-registration nursingeducation would in future be abachelors degree.

2009: UK government healthministers endorsed theNMCs decision.

2010: After extensiveconsultation, the NMC issuednewStandards for pre-registration nursing education.

2011: All pre-registrationnursing programmes in Scotlandmoved to degree level only.

2013: By September, all UKpre-registration nursingprogrammes will be at

degree level.

2020: A relevant degree willbecome a requirement forall nurses in leadership andspecialist practice roles.

2.1 The story

so far

Caring is not for amateurs Florence Nightingale

Box 2 shows some milestones inthe evolution of nursing education.As established by FlorenceNightingale, apprenticeship wasthe model for professional nursingeducation in the UK and many other

countries. Knowledge delivery,and the exposure to and deliveryof nursing practice, was usuallyundertaken in stand-alone schoolsof nursing and nearby hospitals.Nursing students were pairs of handsand learned mainly from moreexperienced clinical colleagues.What they learned and practisedoften had no scientic foundation,and was often inadequate andsometimes unsafe. They had few

opportunities to develop criticalthinking and reective skills, gainclinical experiences in other caresettings, or learn from andconduct research.

The question of what educationallevel nurses need has been hotlydebated ever since, often linkedwith explicit or implicit assumptionsabout the education of women andthe nurses subordinate role as thedoctors assistant. The rst bachelors

degree in nursing was establishedover a century ago in the USA, butit was many decades before nursingwas considered a suitable subjectto be taught in universities in theUK, as a distinct discipline with itsown knowledge base and domain ofpractice (Eaton 2012).

A succession of expert committeesrecommended moving nursingeducation into higher education

but made little headway untilthe watershed of Project 2000(UKCC 1986). This wide-rangingreform established a single levelof registered nurse, with a highereducation diploma as the minimum

academic level. Nursing studentswere to have supernumerary status.

The shift to higher educationinstitutions (HEIs) gatheredpace in the 1990s as Project2000 was implemented. TheNHS commissioned universitiesto deliver nursing educationthrough time-limited contracts.The majority of nursing educationhas been delivered through three-year diploma programmes, with asmaller proportion of commissions

for three-year degree programmes.The old training schools vanishedand variations appeared across thefour UK countries.

The growth of universitydepartments of nursing wasaccompanied by a signicantexpansion in practice development,scholarship and research, andthe appointment of academicleaders of nursing as professors

and deans. Nurse teachers becamepart of an academic workforce andneeded to satisfy academic andresearch criteria to gain promotion.Nursing research and evidence-based practice began to blossom,with a much sharper focus onpatient-centred care. Many nursesembraced the new educationalopportunities with enthusiasm,often taking courses in their sparetime and at their own expense.

Yet there was growing disquiet thatthe education reforms of the 1990sfailed to deliver skilled nurses forthe modern healthcare system.The publication of yet anothercommission report,Fitness forpractice (UKCC 1999), came at atime when the UK government andthe NHS were expressing anxietyover whether newly qualied nurseswere t for purpose (Kenny 2004).

Such anxieties persist, as reectedin the establishment of thiscommission. Yet little if any robustevidence was found to justify theconcerns: as the Peach reportsaid, While misgivings may exist


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In 2008 the NMC announced thatthe minimum academic level wouldin future be a bachelors degree

(already the case for midwifery).It reasoned that nursing mustbecome a graduate profession tomeet the needs of complex caredelivery in an increasingly fast-paced healthcare system thatdemands exible, responsiveand highly skilled practitioners.It said this reected the gradualtransformation of nursing practicethrough better evidence, strongerprofessionalism, developments intechnology, scientic advances and

responsiveness to individual andpopulation healthcare needs.

The UK government endorsed thedecision (Department of Health2009). Degree-level educationwill provide new nurses with thedecision-making skills they need tomake high-level judgments in thetransformed NHS. This is the rightdirection of travel if we are to fullour ambition to provide higher

quality care for all, said healthminister Ann Keen.

about tness for practice at thepoint of registration, there is

much agreement that the currentprogrammes produce registrantswho are better able to adapt tochange and implement evidence-based practice than those trainedunder the old, apprenticeship-stylemodel (UKCC 1999).

The move to degree-levelregistration gained momentum.The NMC, responsible for protectingthe public by setting standards of

education, conduct and performancefor nurses and midwives, beganextensive public and professionalconsultations on the future ofpre-registration nursing educationin 2007 (Box 3, NMC 2010a).The four UK government healthdepartments were active partners inthis review, which was inextricablylinked withModernising nursingcareers, a major project of thefour UK government chief nurses

(Department of Health 2006).

Box 3: What thepublic wants

The NMC consultation foundthat the public wants nurseswho will:

deliver high quality, safe,essential care to everyone andmore complex care in their

own eld of practice; practise in a compassionate,

respectful way, maintainingdignity and wellbeing, andcommunicating effectively;

protect their safety andpromote their wellbeing;

be responsible andaccountable for safe,person-centred, evidence-based practice;

act with professionalism

and integrity, and work withinagreed professional, ethicaland legal frameworks andprocesses to maintain andimprove standards;

act on their understanding

of how peoples way of lifeand the location of caredelivery inuence their health;

seek out every opportunityto promote health andprevent illness;

ensure that decisions aboutcare are shared throughworking in partnershipwith service users, carers andfamilies, as well as withhealth and social care

professionals and agencies;and

use leadership skills tosupervise and manage othersand contribute to planning,delivering and improvingfuture services.

2.2 Nursing

education todayTo meet public expectations, andgive care that is safe and effective,nursing practice must be basedon evidence, knowledge, andanalytical and problem-solvingskills NMC

Degree-level registration isalready the norm in Scotland,Wales and Northern Ireland. By

September 2013 only degree-level pre-registration nursingprogrammes will be offered in theUK. This is the biggest change innursing education for many years.

All programmes must now lead toa degree-level qualication, so thatevery successful candidate willgain a rst degree in nursing, andbe eligible to apply to join the NMCregister. All programmes must be

approved and running against thenew standards from September 2013.At the time of writing, approvedprogrammes were offered by 71 UKuniversities in one or more of thefour elds: adult nursing, childrensnursing, learning disabilities nursingand mental health nursing.

The NMCStandards for pre-registration nursing educationspell out the changes and howthey will be embedded, including

the academic level at which pre-registration students study, thecontent of the standards forpre-registration nursing, andthe curriculum delivered by theapproved education institutions(NMC 2010a).

As required by European Union(EU) directives, all courses mustcomprise at least 4600 hours,split between 50% theory and 50%

practice (including communityand hospital practice learningexperiences), and must coverspecied subjects.Most programmes take three years


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but there is a growing variety ofoptions, including open learning

and integrated programmes. Allapproved HEIs must adhere to theNMC standards, but they have someautonomy on recruitment criteriaand the structure and curriculumof their programmes. There is nonational curriculum.

The European dimension

There have been minimumstandards for pre-registration

nursing education in general careacross the EU since the late 1970s,within the regulatory framework formutual recognition of professionalqualications. Their prime purposeis to assist free movement ofprofessionals. All adult eld pre-registration programmes in theUK must comply.

The current EU legislation doesnot specify whether nursing

education should be deliveredin HEIs (although this is theEuropean trend), nor the level of thequalication (diploma, bachelorsdegree, masters degree). Theframework is being reviewed: in2011 the European Commissionproposed legislative changes whichwould open the way for minimumeducation requirements to includecompetencies, and for a minimumentry requirement of 12 yearsgeneral education or equivalent.

The 1999 Bologna declaration,a pledge by 29 Europe countriesincluding the UK to reform thestructures of their higher educationsystems in a convergent way, wasalso a key driver of degree-leveleducation for nurses across Europe(European Commission 1999).

Differences across the UK

The NMC is the UK regulatory bodyand all programmes must meet itsstandards, but there are differencesacross the four UK countries.

The process of applying to a pre-registration nursing programme

varies by country. The NMC setsbasic entry requirements but eachuniversity determines its ownadditional requirements; thesevary considerably, from the OpenUniversity (OU) that has no setrequirements, through to three highA-level grades. Some universitiesconsider applicants with a nationalor Scottish vocational qualication(NVQ, SVQ) in health at level 3,but others do not.

Selection processes also vary,across and within countries. As aminimum, the NMC requires HEIsto ensure that the selection processprovides an opportunity for face-to-face engagement between applicantsand selectors, and that it includesrepresentatives from practicelearning providers. In Wales allnursing students are required tosupply a character reference in

addition to the academic referencerequired by the UCAS process.Many HEIs are using a variety ofmethods to assess applicants valuesand capacity for compassion.

England has a mixed economy ofacademic level for pre-registrationprogrammes, offered by around 54universities. Around 85% of nursingstudents in England currently obtaina diploma in higher education ratherthan a degree. By September 2013

only degree-level pre-registrationnursing programmes will be offered.

Universities in Scotland haveoffered degrees for a number ofyears. Six universities full theScottish Government contractfor nursing education, andve other non-commissioneduniversities deliver pre-registrationprogrammes, including the OU.Scotlands chief government nurse

is currently undertaking a review ofnursing and midwifery education,and the Scottish Funding Councilis undertaking a separate reviewof nursing education and researchprovision in the university sector.

InWales, all pre-registrationnursing programmes have been at

undergraduate level since 2004.The ve HEIs that offer theapproved programmes have workedin partnership since 2002 to developcommon tools and procedures forevaluation and assessment.

Northern Ireland offersdegree-level programmes in threeuniversities. Queens UniversityBelfast, the University of Ulster andthe Open University are introducing

new curriculums in line withthe NMC standards in 2012, andstakeholders are reviewing entryand selection processes.

From apprenticeship tohigher education

In the beginning, nursing was smalland invisible. Staff were practice/teaching orientated and nursingwas not a big player. When we won

the tender, which brought in a hugeamount of money, people woke up tothe importance of nursing - nursingis now the largest income in theuniversity nursing dean

Nursing educations journey intohigher education was not easy,and the university environmentwas not quite what the pioneersof academic nursing expected.Academic standards concernedgrant income, PhD funding and

completion rates, and the numberof quality publications, rather thanprogrammes impact on nursingpractice and on service users healthand wellbeing. The professiondid not have a strong traditionof scholarship and research, andsome universities had doubts abouthosting a practice discipline thatsome thought would dilute academicesteem, research metrics andperformance. There were complaints

that universities remained male-dominated and had deep-seatedprejudices about nursing.

Furthermore, the universities wereundergoing enormous changes,


15/56B15


mergers and restructurings,and becoming highly regulated,

increasingly corporate andcommercially focused. Nurseeducationists many of whombelieved they were embarking on agreat academic adventure becameincreasingly confused about whothey were and what they could orshould be doing (Rolfe 2012).

Fledgling nurse academics ndthemselves in an environment wherethey need new skills, experience

and support to develop scholarshipin a practice discipline. They tendto be older, like those in otherpractice disciplines in universitiessuch as teacher education or socialwork. Most develop a clinical careerbefore teaching in a university. Thatworkforce is ageing and not beingreplaced fast enough. There isno clear career pathway foracademic nursing.

Recent interviews with 10 nursedeans/heads of departments inEngland and Scotland provideinsight into the challenges (Ross,in press). Clear differences wererevealed between the views of deansworking in Russell group universitiesthat offered nursing programmesbefore 1992, and those in post-1992universities where nursing was thenew kid on the block.

The study highlights the perception

that the authority and credibility ofnursing is often related to studentnumbers and revenue, since nursingeducation is purchased, rather thanfunded by the higher educationfunding councils. Nursing studentsare the second largest student body,after business students.

The deans talked of having to workin two worlds for two masters - theuniversity and the NHS, leading

from the front and pushing fromthe rear. Managing the employer/university interface needednavigation skills through both setsof agendas, and the ability to argueand negotiate for nursing. The risk-

averse and over-regulated systemmade it harder to be inventive.

The deans had different viewsof the future. Some talked aboutthe risk of universities disinvestingin nursing, in response to reducedcommissioning funding. Othershighlighted different sorts of risk.As the differentiation betweenresearch-intensive and teaching-focused universities continues,some thought nursing mightstruggle when competing with

other disciplines for resourcesin pre-1992 universities. Themore optimistic deans wantedto refashion relationships withhealth service providers, workacross the boundaries of healthservices and the university, buildnew partnerships for knowledgeproduction, and use evidenceto effect change in nursingpractice. They were developingapplied research to shape

innovative services.

Nursing research

The link between the quality ofresearch and the funding receivedposes particular difculties foruniversity nursing departments,most of which began their existencewith no nursing research capacity.The Research Assessment Exerciseof 2008, undertaken on behalf of thefour UK higher education funding

councils, evaluated the qualityof HEIs research. The rankingswere used to inform the allocationof research funding. The resultswere interpreted in contradictoryways, both as an indicator of poorperformance, and as a promisingsign of the growing capacity andcredibility of academic nursing.

Under huge pressure to perform,many nursing departments have

made good progress. There were 36submissions to the nursing panel, andManchester, Southampton, Ulster andYork achieved 4* excellence in overa third of outputs. These are strongcentres with research concentration,

nurses leading large multidisciplinaryresearch teams doing patient-focused

research, and notable researchleaders who can stand alongsideleaders from other disciplines.

The teaching and utilisationof research has become anincreasingly important componentof pre-registration courses, layingfoundations for future improvementsin research excellence.

In my undergraduate genetics

degree, the culture was research.All lecturers seemed to do it, andresearchers would give lectures.As nursing has moved intouniversities to facilitate evidence-based practice, good training inresearch methods would be agood way of changing attitudes Paul Dalpra, nursing student

2.3 The higher

education sectorOften the relationship betweenuniversities and the NHS is oneof tension, which can becomeadversarial rather than mutuallysupportive. We need to build onthese partnerships to developmutuality, reciprocity andconstructive criticism if we are toestablish sustainable relationshipsable to meet student expectations,

support mentors and designrelevant programmes FionaRoss, nursing dean

Universities are currentlyexperiencing an unprecedentedvolume, velocity and variety ofchange. The drivers can be groupedunder the headings of funding,quality, social mobility and fairness,and technology (Coiffait 2011).Around the world the cost-sharing

mix for university funding ischanging, with the burden shiftingfrom public sources to privateones such as parents, students,businesses and donors. The UK hasexperienced one of the biggest such


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shifts, accelerated by Lord Brownesindependent review of higher

education funding and studentnance (Browne 2010).

HEIs are responding to thatshift, and to reductions in publicspending, in a variety of ways.These include reducing staff andremoving courses that will notgenerate income. The future impacton nursing departments is difcultto quantify. On the one hand,applications to nursing programmes

are likely to benet from thedifferent funding of student supportand the likelihood of ndingemployment soon after graduating.On the other, nursing departmentsare already being affected byreductions in teaching numbers,infrastructure and other resources.

The drive to deliver programmesin more cost-effective wayswill also affect the way nursing

education is constructed. Coiffaitsays technology promises to be themost revolutionary driver of changein higher education, and the keyto solving the other three issues.Though the technological revolutionin higher education is only beginning,staff and students are already betterconnected than ever before, makinglearning an increasingly social andvirtual enterprise.

The performance of universities

is closely managed for the valuefor money/quality of their nursingprogrammes. They are given targetsfor recruitment, attrition, outputsand a range of other measuresincluding partnership working.As an example, from 2012-13 NHSLondon expects better performanceand has introduced new measures,including on service userinvolvement. These were establishedin partnership with universities and

owed from the tender process.

The number of students wholeave pre-registration educationwithout completing their courseis a key indicator of the quality of

a programme, and an importantdeterminant of the future supply of

qualied staff. Attrition rates varyhugely from one HEI to another,although exact gures are difcultto obtain from many, differentdenitions are used, and the dataare inadequate.

The only systematically reporteddata, from NHS Scotland, showattrition rates for pre-registrationdiploma students of around27% for the three most recent

cohorts. Scotland uses a differentdenition and way of measuringthan England, so its attrition ratesappear much higher. Data forEngland suggest that the proportionof students dropping out by theend of the second year fell fromover 12% for the 2008-09 intaketo over 8% for 2009-10 (but thesegures exclude the nal year anddo not cover London). Overall thepercentage of students who fail to

complete their studies appears tobe falling, owing to signicantlybetter screening of applicants andimproved support for students(Buchan & Seccombe 2012).

2.4Commissioningand funding

nursingeducation

Employers want to know whatstudents can do at different stagesof the programme, and what theycan expect of a newly qualiednurse. Universities want thefreedom to develop curricula thatreect the autonomy and choiceof degree-level programmes.Commissioners (who fund

the programmes), employers,universities and their partnerorganizations want educationprogrammes that are exible andadaptable to local needs NMC

Major challenges ow from hownursing education is commissioned

and funded. Unlike medicaleducation, which is university-led, the commissioning of nursingeducation - the process by whicheducation priorities are setand resources are allocated - isemployer-led using a purchaser-provider model. It is deliveredin partnership by health serviceproviders and universities.

The true cost of nursing education

is rarely quantied. The estimatedcosts associated with pre-registration nursing and midwiferyeducation and support in Englandwere almost 1bn in 2008-9,comprising over 568m for tuitioncosts and over 352m for bursaries(Prime Ministers Commissionon the Future of Nursing andMidwifery in England 2010). Thefour UK countries allocate andmanage these resources differently

and through different bodies.

Commissioning

Although policy changes,demographics and increasingmigration suggest that therequirement for adult nurses willcontinue to increase, many strategichealth authorities are decreasingcommissions. This poses a potentialrisk to service delivery There is asignicant risk that this could lead

to future shortages Centre forWorkforce Intelligence

The number of nursing studentplaces commissioned is the keydeterminant of future intakes toeducation and subsequent labourmarket supply. The number of placesavailable across the UK for 2012-2013 fell again to around 21,400.This will also mean reductionsin the numbers of lecturers and

courses, and threats to the viabilityof some university programmesand departments.

This reduction in places will alsoreduce the new supply to the


17/56B17


workforce. Far fewer nurses arenow recruited from overseas, so the

supply of new nurses to the NHSand other employers comes mainlyfrom pre-registration nursingeducation. The predictability andsecurity of this supply is uncertainin the longer term.

Comparatively limited data areavailable on applicants and owsinto nursing education, and itis difcult to pin down precisetrends. It appears that more people

continue to apply to study fornursing qualications. Applicationsfor nursing degree courses wereup again by 25% in 2012, while thenumber of applications for diplomacourses continued to fall. Overallnumbers of applications (choices)for all types of pre-registrationnursing programme were 3% higherin 2012. The number of applicationsto nursing degree courses easilyexceeds those to all other higher

education courses, with the number

of UK-domiciled applicants at anall-time high this year of 58,123

(Buchan & Seccombe 2012).

What explains the continuingrise shown in Figure 2? Nursingprovides relatively secureemployment. There is uncertaintyabout how changes to highereducation funding arrangementswill affect nancial support forstudents. These factors may alsohelp to account for the changingage prole: the average age of a

nursing student is 29.

The impact of changes to pensionsand retirement policies is anotherunknown. Student funding supportis a further unpredictable inuenceon applications and attrition: onaverage, means-tested bursaries fornursing degree students are lowerthan non-means tested bursariesfor diploma students. The bursarysystem is different across the four

UK countries.

In summary, historically largenumbers of students are choosing to

apply for nursing programmes, withproportionately more applicationscoming from older cohorts - but thenumbers starting courses are fallingas the number of funded placesfalls. It is not yet clear whether themove to degree-level education willreduce the number of applicants,but there is little sign that it will.

A locally led approach

Employers have condencethat through a co-operative andcollaborative approach betweenservice and education providers,the future workforce will not onlycontinue to deliver quality care butwill also be equipped to develop anddeliver new and dynamic servicesfor patients NHS Employers

The government white paperEquity and excellence: liberating

the NHSsaid a top-down

Figure 2: Applicants for pre-registration nursing education at HEIs, 2000-2009(Source: UCAS)

2000

0

5,000

10,000

15,000

20,000

25,000

Applicants

30,000

35,000

40,000

45,000

2001

England Wales Scotland Northern Ireland

2002 2003 2004 2005 2006 2007 2008 2009


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management approach to fundingand commissioning health

professional education did not allowaccountability for decisions affectingworkforce supply and demand tosit in the right place (Departmentof Health 2010). It is time to giveemployers greater autonomy andaccountability for planning anddeveloping the workforce, alongsidegreater professional ownership ofthe quality of education andtraining, it said.

The government is committed tothe principle of tariffs for educationand training as the foundation of atransparent funding regime. It plansto introduce a tariff-based systemto enable a national approach to thefunding of all clinical placements(medical and non-medical) andpostgraduate medical programmes,to support a level playing eldbetween providers and professions.

The system will aim to ensurethat education and trainingcommissioning is alignedlocally and nationally with thecommissioning of services.Employers and staff will agreeplans and funding for workforcedevelopment and training; theirdecisions will determine educationcommissioning plans. All providersof healthcare services will meetthe costs of education and training(Department of Health 2010).

In England, the health educationcommissioning structure ischanging from 2013. Oversightof health professional educationhas been transferred from theDepartment of Health to a newbody, Health Education England(HEE). Its remit is to ensure thateducation, training, and workforcedevelopment drives quality publichealth and patient outcomes

(Department of Health 2012b).

Education commissioning fornurses, midwives, allied healthprofessionals, doctors, and otherswill be led nationally through HEE.

Employers will have greaterpowers through new local education

and training boards (LETBs),consisting mainly of regionalservice providers. They will makedecisions on commissioningworkforce and nursing numbers,NHS staff development, and wheretraining will take place. They willalso oversee quality and contractperformance management from2013, using the national EducationOutcomes Framework (EOF),perhaps supplemented with

additional metrics (Departmentof Health 2012c). The EOFdomains are excellent education,competent and capable staff,adaptable and exible workforce,NHS values and behaviours,and widening participation.

The LETBs will consult localeducation providers and otherlocal stakeholders. The focus in theHealth and Social Care Act on any

qualied provider is stimulatinga rise in the number and diversityof non-NHS service providers. Aspotential major employers as well aseducators of NHS-trained nurses,they will need to become integrallyinvolved in workforce planning.

I want local education and trainingboards to make a priority of theinterface and involvement of thepatients and the public. You do itby making it your purpose. If you

get that right and work with whatis in the NHS Constitution, you willprobably get nearer to being right Sir Keith Pearson, chairman, HealthEducation England

The NHS Commissioning Boardwill provide national patient andpublic oversight of healthcareproviders funding plans fortraining and education in England,and check that they reect its

strategic commissioning intentions.Clinical commissioning groupswill provide this oversight atlocal level. The Centre forWorkforce Intelligence willprovide information and analysis.

Experience in the 1990s, andagain in 2006 when drastic cuts

were made in nursing education tomeet a service funding shortfall,highlight the risks of the locally-led approach. Under cost pressure,local employers often take a narrowview of future requirements, andoverlook the stafng needs ofnon-NHS employers (Buchan &Seccombe 2012). Furthermore, thenursing workforce is in many ways apan-UK resource, with nurses oftencrossing internal UK borders to

train and work, including providingspecialist services.

Without a well-developedoversight process, there may be asignicant underestimate of futurerequirements. This could repeat thedamaging boom and bust cyclethat has long characterised nursingworkforce planning.

Funding

Funding for health professionaleducation comes from threestreams: student fees; highereducation funding councilallocations to medical schools forteaching; and the largest stream,the undergraduate medical anddental service increment forteaching (SIFT or equivalent) tohospitals and GPs (MEDEV 2011).

In England, the Department of

Health allocates SIFT, via the 10strategic health authorities (SHAs),to NHS trusts and general practicesto offset the service costs associatedwith teaching. Similar schemesare administered by the ScottishParliament - additional cost ofteaching (ACT); Welsh Government SIFT; and the Northern IrelandAssembly - supplement forundergraduate medical and dentaleducation (SUMDE).

SIFT is traditionally divided intotwo elements: facilities (around80%) and clinical placements(around 20%). Facilities mayinclude tangible assets and human


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resources; clinical placements mayalso be a form of facility. Clinical

placement budgets are required tojustify clinical placement paymentsbased on student weeks. Thepayment per student week varieswidely both within and betweenregions. The SHA has a learning anddevelopment agreement with mostrecipients of SIFT money, whichspecies the number of students andweeks, and may (but often does not)specify how SIFT is allocated.

It is important to ensure that SIFTfollows the student, enabling moreteaching to be supported outsidetraditional teaching hospitals, butthese changes need to be carefullymanaged to ensure that trustsare not destabilized HEFCE/Department of Health (1999)

SIFT is a component of themultiprofessional education andtraining levy (MPET), which also

includes MADEL (postgraduatemedical), D-SIFT (dental), NMET(the non-medical education andtraining levy) and some otherclinical specialties. In EnglandMPET had a budget of 4.9bn in2012-13, in addition to investmentby NHS organizations in theirown staff.

NMET funds tuition for nurses,midwives and allied healthprofessionals as well as the NHS

bursary scheme, 2bn in 2011-2012.In universities in 201112, 805m ofNMET paid for non-medical tuitionfees; 169m funded continuingprofessional development coursesoffered by universities; and 525mfunded the NHS bursary paid tostudents for maintenance support.Funding for nursing education is notring-fenced, and can be reallocatedto cover service funding shortfalls.This contrasts with medical

commissioning, which is centrallyfunded (through HEFCE) withfunding owing from the DH.

2.5 Changes

in the nursingworkforce

The landscape has changedconsiderably, with the need for asmaller, sustainable, retainable,graduate workforce trained andprepared to be clinical leaders inwhatever capacity, as medics are.Part of that training then is verymuch focused on how they support

and develop members of the teamthey lead nurse dean

To meet public expectations, andgive care that is safe and effective,nursing practice must be based onevidence, knowledge, and analyticaland problem-solving skills acquiredthrough degree-level education.Government-commissioned workenvisages the nurses of tomorrow aspractitioners, partners and leaders

(Maben & Grifths 2008):

skilled and respected frontlinepractitioners providing highquality care across a range ofsettings;

vital and valued partners in themultidisciplinary team,coordinating resources and skillsets to ensure high quality care;and

condent, effective leaders andchampions of care quality with

a powerful voice at all levels of thehealthcare system.

This vision was further expandedby the NMC consultation, whichconcluded albeit with a dissentingminority - that the necessarycompetences would best be acquiredthrough degree-level education(NMC 2010a) (Box 4). The newcadre of all-graduate registerednurses (RNs) will be expected to

provide linchpin clinical leadership;coordinate and closely supervisecare delivery; and deliver somecomplex care.

Nursing education issues were nota focus of the controversial Healthand Social Care Act 2012. Yet theact and other healthcare reforms inEngland are having a major, as yetunquantiable impact on nursingand nursing education. Scotland,Wales and Northern Ireland, whichsince devolution in 1998 have beenresponsible for determining healthpolicy, are not introducing major

NHS reforms and their policy andplanning environment for nursingeducation is more stable.

Box 4: Graduatenurse competences

The NMC says graduate nurseswill be able to:

practise independently andmake autonomous decisions;

think analytically, usinghigher levels of professionaljudgment and decision-making in increasinglycomplex care environments;

plan, deliver and evaluateeffective, evidence-based caresafely and condently;

provide complex care usingthe latest technology;

drive up standards andquality;

manage resources and workacross service boundaries;

lead, delegate, superviseand challenge other nursesand healthcare professionals;

lead and participate inmultidisciplinary teams,where many colleagues areeducated to at least graduatelevel; and

provide leadership inpromoting and sustainingchange and innovation,developing services and usingtechnical advances to meetfuture needs andexpectations.


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All four countries are deeply affectedby the economic downturn, whichhas led to policy decisions to makedramatic reductions in health andeducation funding. Policy-makers,including ministers and healthcareemployers, have important anddifcult decisions to make abouthealth funding priorities. On the plusside, they retain control over most

factors that will determine futureNHS nursing numbers.

In the past, nursing shortageshave been tackled by having morenurses. Over the next 10 years theemphasis will shift to having moreeffective nursing James Buchan,workforce expert

Nurses comprise the largest part ofthe workforce in the NHS - Europes

biggest employer - and the largestgroup of registered professionals inBritish health services. There arewell over 600,000 registered nursesin the UK, 90% of them women, andan unknown but growing number

of healthcare support workers whocarry out nursing duties undertheir supervision.

In 2011 NHS nurse stafng numbersfell for the rst time in a decade(Buchan & Seccombe 2012). Theoverall numbers of newly qualiednurses (NQNs) entering the labourmarket will fall as reductions in the

number of places commissionedaffect the numbers graduating.

The sheer size of the workforcepresents huge challenges to policy-makers, and to data collection,analysis and planning. Policyanalysis and response is constrainedby incomplete and outdated data,although policy choices have majorimplications for the size, shapeand sustainability of the nursing

workforce, for individual nurses,and for care (Buchan &Seccombe 2011a).

Robust baseline information isessential, but nursing staff are often

counted together in undifferentiatedgroupings that conceal their widerange of qualications, grades,roles and salaries. Nurses andmidwives may be counted andcategorized together, like registeredand non-registered staff. NHS dataon the nursing workforce cannoteasily be aggregated up to UKlevel because of differences in

denitions and collectionmethods in the four countries.

Disaggregated workforce statisticsare generally available only for theNHS, and thus exclude thousandsof staff in the independent andvoluntary sectors. Data on nursesemployed by nursing homes, privatehospitals, charities and othernon-NHS employers have actuallyreduced in coverage, quality and

completeness, despite the needto capture non-NHS employmenttrends and involve non-NHSemployers in workforce planning(Buchan & Seccombe 2011b).

Figure 3: NHS stafng, England, 2000-2010: qualied nursing staff, nursingauxiliaries and healthcare assistants (whole time equivalent)

(Source: NHS Information Centre 2012)

Qualied HCAAux

2000

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


21/56B21


The arrival of the graduate nurse isjust one of many drivers affecting

skill and staff mix, in the quest tond the combination of staff thatwill contain costs and make bestuse of expensive and sometimesscarce professional skills. Nurseshave always devolved tasks thatapparently required less expertiseto non-registered assistants, andindeed to nursing students untilthey became supernumerary. Sincethe foundation of the NHS, a rangeof non-registered staff has provided

hands-on care in settings, shiftsand places where it was difcult torecruit or pay for qualied nurses.These low paid, low status nursingauxiliaries and nursing assistants(now collectively called healthcaresupport workers, or HCSWs) delivermuch of the care, with greater orlesser supervision.

Although changes in the divisionof labour are nothing new, the

pace is accelerating. There is aproliferation of new roles andjob descriptions, creating orexpanding roles such as advancednurse practitioner, physicianassistant, assistant practitioner andhealthcare assistant (HCA). Theseroles and functions are very varied,sometimes poorly dened, andlack consistency across employers(Prime Ministers Commissionon the Future of Nursing andMidwifery in England 2010). In the

NHS NQNs start work at Agendafor Change band 5, while a supportworker may be paid at band 2 or3. Some trusts have introducedassistant practitioner roles inAgenda for Change band 4, andenhanced roles for other supportworkers in bands 1-4.

The scale of skill mix change ishard to quantify, and detailedcomparisons over time are difcult

because data on non-registeredstaff have always been scarceand remain incomplete. The NHSWorkforce Census, which providesgures on NHS staff in England,has a statistical category Support

to doctors and nursing staff thatcovers a diverse group including

healthcare assistants, assistantpractitioners, nursing assistants,nursing auxiliaries, nursery nurses,porters and medical secretaries(NHS Information Centre 2012).

The gures distinguish betweenHCAs and nursing assistants/auxiliaries, but it is not clear whatthis means in practice. Inconsistentuse of the HCA title and differentemployers use of alternative titles

for the same category of staffpreclude an accurate count of thenumber in the NHS. The numbersand trends outside the NHS, forexample in nursing homes, remainlargely unknown.

In 2011, the NHS in Englandemployed 53,140 HCAs (headcount;many work part-time and the full-time equivalent is 44,787), around4% of the workforce. There was an

increase of nearly 24,000 HCAs(82%) in 2001-2011, an averageannual rise of over 6%. This soundsdramatic but the evidence doesnot tell us how many HCAs werepreviously described as auxiliariesor assistants. Meanwhile thenumber of nursing auxiliaries andassistants has declined and some,perhaps many, have been rebadgedas HCAs (Figure 3).

Absolute numbers in any case can

only tell us so much, as it is essentialto know what people do, their rolein the team, the nature of the skillmix and the health outcomes.What has undoubtedly changed isthat HCSWs are receiving muchmore attention as an apparentlycost-effective way of deliveringcare. NHS employers claim thatthe move to degree-level nursingregistration will lead them to makemore use of assistant practitioners

(NHS Employers 2009), but thetrend is not new and is a global one(All-Party Parliamentary Group onGlobal Health and Africa All-PartyParliamentary Group 2012).

Overall, these skill mix changeswill challenge what we mean by

nursing (Buchan & Seccombe2011b) (Box 5).

The dilution of skill mix should be

viewed against the evidence on thelinks between well qualied nursingstaff and improved patient, nurseand nancial outcomes (Unruh &Fottler 2006). The research evidenceof the association between nursestafng levels and patient outcomesis compelling (Ball 2010). Studieshave found a direct correlationbetween a lower proportion of RNsand the delivery of lower quality ofcare, and afrm the economic valueof well qualied and effectively

deployed nurses. The best-staffedNHS trusts have signicantly lowermortality rates (Rafferty et al 2007),and better nurse stafng is associatedwith reduced risk of complicationsand lower mortality rates. Evidenceof the negative effect of inadequatestafng is even more striking asthe experience of Mid Staffordshiredemonstrates (Ball 2010).

The concerns and the evidence have

led the RCN and other opinion-leaders to call for more rationalplanning to ensure safe stafng, andsystematic training and regulationof some HCSWs.

Box 5: Skill mix andthe changing faceof nursing

Graduate nurses, possiblyfewer in number, inadvanced/specialist roles,managing cases and teams,

diagnosing and prescribing. Increasing use of support

workers, especially healthcareassistants and assistantpractitioners.

Much more emphasis onself-care by service users.

Greater involvement offamilies and carers in care.


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2.6 Regulation

The regulatory landscapesof health services and highereducation are highly complex, andeven more so where they intersect inmatters that inuence the educationof health professionals. Theywill become even more complexin England as responsibilitiesdevolve to LETBs, with educationcommissioners requiringuniversities to satisfy expectations

for quality and contract value.

Furthermore, some regulatorybodies have UK-wide remits whileothers are specic to the differentUK countries, and do not haveidentical functions.

Like healthcare providers,universities are monitored andassessed by more than oneagency. The Quality Assurance

Agency audits HEIs and theirquality assurance processes everyve years, and the universitiesundertake internal quality reviews.Educators and their practice partnerorganizations must update theirprogrammes to comply withsystem requirements.

In health care there are broadlytwo types of regulation: ofprofessions, and of systems (Jaeger2011). Professional regulators

set standards for education andpractice, maintain registers ofqualied professionals and dealwith issues of misconduct. Withinthis eld, regulation can bestatutory or voluntary.

Statutory regulators such as theNMC have legal powers to makeregistration mandatory, and thedisciplinary decisions they take, forexample striking off, are recognized

in law. The Council for HealthcareRegulatory Excellence overseesthe work of the UKs nine statutoryprofessional regulators.

Systems regulators have differentpowers and remits across the UK,

but are generally concerned with thequality of healthcare environments.The Care Quality Commission(CQC), the independent regulator ofall health and social care servicesin England, is required as are theequivalent bodies elsewhere in theUK to ensure that care providedby hospitals, dentists, ambulances,care homes, and services in peoplesown homes and elsewhere meetsgovernment standards of quality

and safety.

The NMC standards for pre-registration nursing educationcomprise standards for competence(what nursing students must do andachieve during their programme)as well as standards for education(about the framework within whichprogrammes must be delivered).These mandatory requirementsinclude those relating to teaching,

learning and assessment of students.

NMC requirements underpin thestandards and must be met by alleducation institutions approved toprovide UK nursing programmes.The NMC normally approves aprogramme for up to ve years,checks compliance before allowingit to run, and monitors it. NMCquality assurance processes measurethe performance of HEIs and theirpartner practice learning providers

in programme development anddelivery. Educational audits of allnursing practice placements arecarried out every two years, andcompliance is checked annually.HEIs have processes for studentevaluation of placements that feedinto the processes for removaland reallocation of studentswhere necessary.

Educational audit is also

increasingly highlighting adverseclinical governance issues. TheNMC requires all HEIs to have anescalating concerns policy, whichmust be introduced to nursingstudents. Through the NMC code

(2008a) it also requires individualteachers to raise concerns when they

witness potential risk in clinicalsettings, and to take seriouslytheir responsibilities to deal withstudents concerns about the qualityof practice placements, especiallywhere these point to wider patientsafety issues (NMC 2012). Nursingstudents also have responsibilitiesto raise and escalate concerns ifthey think the care environment isputting patients at risk.

The CQC and the NMC havedeveloped a system for sharinginformation; their staff meetregularly; and they occasionallyconduct joint inspections whenthere is a major cause for concern.HEIs, the CQC and the NMCdo not routinely engage in jointdiscussions. HEIs should use CQCintelligence about these settingswhen they evaluate how they teachand assess students.

The burden of audit requirementson HEIs and healthcare providersis large, and growing. Thereis unnecessary duplication ofeffort with little added benet.The nancial cost of these auditprocesses to education providers,education commissioners andregulators is unknown. Thecommission supports ongoingwork to reduce this burden.

HEIs are currently reviewed onthe quality of their provision bya range of different stakeholders,including the regulatory bodyand education commissioners.These different quality assuranceprocesses all report on broadlysimilar issues and yet use arange of different formats whichplaces unnecessary pressure onHEIs. A single quality assuranceframework, incorporating both

HEI and practice components,would remove the duplication inreporting that occurs at present Open University


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Part 3: What we learned

This section ofthe reportsummarises the main points the

commission learned that lay withinits brief. It begins with a summaryof what was heard from healthservice users and carers, whoseneeds and involvement must alwaysbe the golden threads that runthrough all nursing education. Themain emerging themes from allsources are then outlined.

Overall, the commission learnedof a range of challenges to HEIs

and health service organizationsthat must be tackled to supportimprovements in nursing education,to ensure the new NMC standardsare fully implemented, and topromote high quality patient-centred care.

These challenges include providingadequate support and assessmentto ensure students continuingclinical skills and competence;

responding to changing regulations;strengthening nursing careerstructures and pathways; andsupporting academics and mentors.

There was also evidence ofsophisticated understanding ofthe needs of a practice profession,proactive engagement with theeducation process, and manyinnovative developments to addressthese challenges, despite thedifcult contexts of the health and

higher education sectors.

More high-quality systematicresearch, including longitudinaland multi-site studies, is neededto help ll the evidence gaps andassess how well nursing educationprepares future practitioners.

The commissions review ofthe evidence did not reveal anymajor shortcomings in nursing

education that could be held directlyresponsible for poor practice or theperceived decline in standards ofcare. Nor did it nd any evidencethat degree-level registration was

damaging to patient care; on thecontrary, there was evidence that it

has played and will continue to playa key role in driving up standardsand preparing a nursing workforcet for the future.

3.1 Views fromservice usersand carers

There is a perception amongst somepatients that because nurses aretrained more widely in technicalclinical skills, they do not feel thatfundamental care is sufcientlyadvanced for them to consider afull part of their role. There arealso concerns that the emphasison theoretical learning rather thanwell supervised practice does notgive nurses the skills and experiencethey need to provide care

Patients Association

Concerns about standardsof care were a constant theme inthe 11 written submissions fromorganizations representing healthservice users and carers, andoral evidence from four of them.This related partly to perceptionsthat nurses were sometimesunable or unwilling to deliver thefundamentals of care. They citednumerous patient stories and

reports (some going back overa decade) that revealed lack ofknowledge of the fundamentalsof care and their contribution toeffectiveness, safety and humanity.

Mind cited evidence that peoplesneeds in a mental health crisisfocused on human interaction. Theywanted to be treated in a warm,caring and respectful way, have timewith staff and to talk, and for staff

to be able to be themselves. Thiswas missing from many peoplesexperiences. There was also muchto praise, however.

The team that supports me believesfully that I have the right to decide

the treatment I need and this extendsto crisis. This allows me to workcollaboratively with them and I trustthem mental health service user

The chairman of the Commissionon Dignity in Care for Older People,Sir Keith Pearson, said NQNs werebetter aligned to the contemporaryneeds of older people than somenewly qualied doctors (LocalGovernment Association et al 2012).

They were providing a range ofsupport for older people that mightonly have been dreamed of 10 yearsago the evidence is there that theyare delivering that complexity.

The service user organizationsacknowledged that nurses weretrying to deliver good care despiteoften being understaffed, stressedand poorly supported. Someorganizations had made extensive

recommendations to NHS employersto improve staff care and support.

We were concerned that people wereworking with high demands andrisk without necessarily receivinggood leadership and support.Nurses own values and learningmay be undermined or corroded byorganizational cultures Mind

The organizations called for moreattention to be paid to their own

areas of work in pre-registrationcurriculums (care of older people;dementia; mental health; multiplesclerosis; diabetes; cancer; acuteand chronic pain; cardiac care;arthritis; and carer awareness).They praised and in some casesinvested in specialist nurses,including employing them asadvisers, employing them to deliverservices, and funding them oncourses, and deplored the impact

of health service spending cuts onspecialist posts.

It was recognized that the rightbalance was needed betweengeneralist and specialist education


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at undergraduate level. However,in view of the growing numbers of

people with long-term conditions,and the drive for patient-centredcare, they wanted generalistskills to respond to these trendsto be enhanced, including shareddecision-making and self-management.

People with dementia and carersdont expect nurses to have anin-depth knowledge of dementia.However, recognising the condition,

developing sensitive communicationskills, handling situations withdignity and respect and seeing theindividual rather than the diseasecan make a huge difference. Theseare the minimum skills that thepublic expect from a registerednurse Alzheimers Society

The impact on students of workingin different care settings, includingin the community, could not be

underestimated. It gave them thenecessary direct experience of caringfor and learning from people withparticular conditions. They alsobecame more aware of the rolesand needs of carers and families asmembers of the care team, especiallyin placements outside hospitals.

The service user organizationscalled for much greater public andpatient involvement in nursingeducation, and spoke of the

willingness of patients and car

Willis Commission 2012

Documents