Globally, the number of nurse vacancies is high, and there has been much scrutiny of the preparation of the nursing workforce. The World Health Organization (2020) has called for an acceleration of nurse education to meet future demands. In the UK, nursing is at a critical juncture. Post-pandemic attrition rates are high and, despite ambitious government targets, recruitment is unable to meet demand. A Nursing and Midwifery Council (NMC) report (NMC, 2022a) demonstrated that almost half the number of graduate nurses joining the register for the first time (48% of 48 436) completed nurse education outside the UK. Of this group, 66% were educated in India or the Philippines.
Nurse education in the UK is approved by the NMC, which currently follows the European Directive 2005/36/EC. This prescribes that nurse pre-registration programmes must total 4600 hours. Of these, 2300 must be practice hours, which are challenging to source due to increasing nursing and multi-professional student numbers and a heavy workload for those supporting students in clinical practice. There is a dearth of evidence to support this figure for optimal learning and little appetite to fund major evaluations of effective practice hours.
In the UK, nurses (and other professionals) are expected to teach alongside their clinical role (NMC, 2018a). Moreover, the preparation for this practice supervisor (teaching) role is miniscule and no longer recognised by a specific NMC-approved programme (Leigh and Roberts, 2021: 36). All pre-registration programmes in the UK must prepare students for a supervisory role at the point of registration – with teaching embedded in proficiencies and education (NMC, 2018a) but this does not necessarily prepare them for their future role as assessors of practice.
Post-Brexit, is it time for an overhaul of the UK's nurse curriculum to review whether the number of practice hours and the accompanying focus on proficiencies is required? Although the NMC is consulting on the decoupling arrangement following Brexit, it stops short of consulting on any reduction in practice hours. The authors call for a wider debate around the preparation of future nurses and the number of practice hours required for registration.
Practice hours versus competence/proficiency
Recent NMC registrant figures demonstrate that nurses working in the UK come from all over the world, despite variances in compulsory practice hours. Table 1 illustrates this and demonstrates that European student nurses are required to undertake considerably more practice placement hours compared with the USA, Australia or New Zealand.
Table 1. International comparison of required practice and simulation/skills hours
| Country | Programme duration | Practice hours | Simulation/skills hours |
|---|---|---|---|
| UK (Nursing and Midwifery Council, nmc.org.uk) | 3 years | 2300 | Up to 600 hours |
| New Zealand (Nursing Council of New Zealand, nursingcouncil.org.nz) | Usually 3 years | 1100 (Standard Seven – Emergency Events allows for up to 200 hours of paid clinical placement to be counted towards the total in a national emergency) | Practice hours are exclusive of simulation hours, with simulation hours not formally counted in practice hours |
| Australia (Nursing and Midwifery Board of Australia (professional standards), https://www.nursingmidwiferyboard.gov.au/) (Australian Nursing & Midwifery Accreditation Council, http://anmac.org.au/) | Usually 3 years | 800 | Practice hours are exclusive of simulation hours, with simulation hours not formally counted in practice hours |
| USA (American Nursing Association, nursingworld.org) | 3 years | Varies according to state, up to 868 | Up to 50% of programme hours |
| India (Indian Nursing Council, www.indiannursingcouncil.org) | 4 years | 4656 | 580 hours |
| Philippines (Philippine Nurses Association, pna-ph.org) | 4 years | 1887 | 800 hours+ |
Despite the variance in practice hours, graduates become registrants and practice safely and effectively, so what is the evidence for the NMC-prescribed 2300 practice hours? Should there be a focus on a learning framework that demonstrates proficiency rather than the prevailing ‘tick-box, time-served’ ethos? Brexit has presented the NMC with an opportunity to reconsider the prerequisite of 2300 practice hours.
The number of practice hours to ensure competence at the point of registration could be at the discretion of the regulatory body, as in Australia, New Zealand and the USA. These countries are not influenced by the EU Directive 2005/36/EC, which aims to standardise nurse education throughout Europe to facilitate migration.
In the USA, there is wide variety in programme delivery, evidenced in national studies (Hayden, 2010; Pittman et al, 2022). Pittman et al (2022) found variation in the quality of nurse education and reported a focus on pass rates of the National Council Licensure Examination, which leads to registration. They suggested that this is an insufficient measure of quality as it is one-dimensional yet, ultimately, this is the main driver for pre-registration programmes in the USA.
In 2021, the American Association of Colleges of Nursing (AACN) published guidance that heralded a transition towards a new model and framework for nurse education using a competency-based approach (AACN, 2021). Each competency is categorised as entry level or advanced practice level. Although the number of practice hours is not specified for entry level education programmes, advanced practitioners must have a minimum of 500 practice hours (AACN, 2021).
In 2007, with increasing pressure on quality placements, the NMC, following a pilot study that demonstrated that students were not disadvantaged (NMC, 2007a), identified options for alternate placements, including the replacement of 300 practice hours with simulation-based education (NMC, 2007b). Although this study did not measure long-term outcomes, a longitudinal, randomised, controlled study replacing clinical hours with simulation in prelicensure nursing education was undertaken in the USA by the National Council of State Boards of Nursing (Hayden et al, 2014). This study provides a robust evidence base showing that those students who had 50% of the traditional clinical experience replaced by simulation had no significant difference in terms of knowledge base, clinical competence, or readiness for practice despite an already low requirement of 800 hours. However, the authors stated that simulation is not a panacea to solve the challenges of placement shortages and best practice simulation guidelines such as those proposed by the International Nursing Association for Clinical and Simulation Learning (2011) should be followed.
The NMC has approved work through its Pre-Registration Programme Standards Consultation to explore changes in relation to increasing the flexibility regarding the use of simulation, with the potential to explore increasing simulated practice learning using a range of modalities, consulting on the figure of 600 hours (for nursing only) that is evident in the current NMC recovery standards (NMC, 2022b: RN6: 9). It is not clear which evidence base the NMC is applying when consulting on the issues surrounding practice hours. Indeed, for the first time in the UK, funding was awarded to a university by Health Education England in recognition of a simulation placement for each year of the pre-registration programme (Williams et al, 2022), accounting for 450 of the 2300 hours required. Early evaluative data indicated that students undergoing a simulated placement feel equally prepared for practice when compared with students undertaking a traditional placement at the same point of the programme (Williams et al, 2022). Table 1 provides a comparison of simulated skills/practice hours within pre-registration programmes around the world.
Conclusion
The authors argue that nursing is at an historical juncture where real changes to the nursing curriculum could be made. This article has highlighted key differences in international nursing curricula in relation to the number of practice hours and competency-based frameworks. Nurses migrate and practise effectively and safely regardless of the number of practice hours they have undertaken in their pre-registration programmes. Ultimately, nurses work within the NMC Code in the UK and are competent practitioners (NMC, 2018b).
Brexit presents the NMC with an opportunity to reconsider practice hours. The authors call for a robust evaluation that will inform the NMC's decision-making about changes to practice hours within its pre-registration nursing programmes across the UK. The authors argue that this evidence is currently lacking. The evaluation could also inform a learning framework that demonstrates proficiency, rather than what we have termed the prevailing ‘tick-box, time-served’ ethos.