We are writing this at a time when nursing is in the spotlight as never seen before. Members of the nursing profession in the UK and globally are providing nursing care in the context of the COVID-19 pandemic, which is throwing up immense challenges to the way that person-centred care is delivered in those clinical settings that have rapidly changed to meet acutely ill patients' needs.
In a time of crisis, the Nursing and Midwifery Council (NMC) together with each of the four UK country commissioning partners and NHS Staff Council, mobilised the student healthcare workforce through implementing emergency standards and creating national roles such as aspirant nurse (Health Education England, 2020; NHS Staff Council, 2020; NMC, 2020). Taking on these roles, there have been amazing examples of student nurses supporting patients as they died in hospital without loved ones and comforting patients crying through sadness, fear or pure exhaustion (Leigh et al, 2020).
September 2020 will see the removal of the NMC Emergency Standards, with the NMC reverting to its 2018 Standards (NMC, 2018a). We expect that providing person-centred care during a pandemic or yet another crisis will become the new normal. Indeed, managing major incidents is highlighted within the NMC (2018a: 23) educational standards, as a proficiency that all new graduates must master:
‘6.12 understand the role of registered nurses and other health and care professionals at different levels of experience and seniority when managing and prioritising actions and care in the event of a major incident.’
So, the intention for nurses to be confident in these situations will remain in place.
Although an extreme example, the COVID-19 pandemic can be used as an example of how higher education institutions (HEIs) and partner healthcare organisations have needed to think creatively about delivering nurse education and have demonstrated how, when working collaboratively, student nurses have transitioned into their first registered nurse role. Universities have also needed to rapidly replace first-year students' practice hours with theory due to their practice learning being paused (NMC, 2020). Even though students can resume their practice learning, the capacity of healthcare organisations to accommodate students is still greatly reduced and this is due to reconfiguration of healthcare services and a reduction in the offer of community learning opportunities. Universities in September 2020 will be welcoming the next cohort of student nurses, compounding the need for further placements, providing the perfect storm around bottlenecks for quality practice learning opportunities for all student nurses.
Thinking about the pipeline for registered nurses and the transition of students to registered nurse: what if we were to create a perfect nurse education curriculum?— something that we feel is currently elusive. What if HEIs and their healthcare partners were not constrained by student fees and numbers, or by securing practice learning opportunities for first- and second-year students? What could we do with nurse education? Yes, we would have to take risks, but let's just think about what might be possible if we were able to be bold and brave with our curriculum design.
We are clear that we are advocates of graduate nurses who are critical thinkers. We are also clear that, during their pre-registration nursing programme, students must be provided with a quality nursing curriculum and practice learning experience. In this exploration we will not be debating the issue of work contracts, paid learning experiences, student rights or the debate around whether low-paid, on-the-job nursing student training will take the profession backwards. Others such as Leary (2020) have already provided this discussion. Instead we offer our thoughts around the future curriculum possibilities, and we welcome further discussion on the issues we raise and recommendations that we make. We want the profession to have a clear vision for nursing—to be bold about the role of the nurse and be clear about the future of nursing. We fully acknowledge that the NMC did develop the new educational standards following a 2-year consultation process, wherein 1563 responses to consultation 1 (including 268 responses from organisations) and 706 responses to consultation 2 (including 120 responses from organisations) were received (NMC, 2018b). However, to put that in context, in September 2019 there were 706 252 individuals on the register (NMC, 2019).
Learning from the structure of the medical model
What if we could have a model that imitates the structure of medical education? Medical education in the UK is wide and diverse. On average, undergraduate courses last between 4 and 6 years. After their undergraduate training, newly qualified doctors undergo 2 years of foundation programme training before choosing a specialty. The programme was set up to ensure that all newly qualified doctors followed a structured programme of study and practical experience before progressing to specialist training. This approach acknowledges that learning is a lifelong process and contains a number of transitional and developmental stages. After successful completion of the first year, the General Medical Council grants the individual full registration with a licence to practise as a doctor in the UK.
Taking the core structure of medical education as our starting point, we propose a nursing programme structure (see Table 1 and Table 2).
| Year 1 | Introductory theory, taught through real world case studies and narrative pedagogy, supported by immersive simulation. Reflecting on practice to build on knowledge | Student status |
| Year 2 | Introductory theory, taught through real world case studies and narrative pedagogy, supported by immersive simulation. Reflecting on practice to build on knowledge | Student status |
| Year 3 | The emphasis remains on the student as learner. |
Graduate status: Licence to practise NMC registration granted |
| Year 4 | Paid deployment |
Fully registered nurse |
| Year 5 | Postgraduate development of expertise in evidence-based clinical practice. Translation fellows (Masterson et al, 2020), practice-based learning and education, or leadership and influence (NHS Leadership Academy, 2020). Accompanied by an integrated postgraduate programme; supported 1 day a week protected learning time in university (or equivalent). Freedom to seek out learning opportunities and work alongside other experts in the field; including industry and entrepreneurs, or a career trajectory into higher education | |
| Year 6 | Focused on innovation and evaluation of impact in chosen field of expertise | MSc, recognised on the Register of Expertise |
Features of year 1, 2 and 3: student status to graduate nurse
Concept based curriculum: based on nursing concepts
According to Repsha et al (2020: 67) a concept-based curriculum avoids an overcrowded curriculum as it ‘focuses on teaching core ideas or concepts threaded throughout a curriculum to encourage critical thinking and deeper learning’. The approach tends to favour problem-based learning, team-based learning, case studies, and reflection in order to promote deeper learning. When implemented successfully, the approach is said to empower students in their learning, fostering increased autonomy and greater engagement, and to enable learners to integrate knowledge and apply it to clinical practice (Repsha et al, 2020).
Narrative pedagogy
Teachers seek to establish partnerships with students in a lifelong quest for knowledge. Together they form a reciprocal community of learners who explore how and in what ways one becomes a nurse. The teacher uses real-life practice narrative (as case studies) to reinforce the centrality of the lived experience and learning is said to take place through dialogue and attention to nursing practices (Nehls, 1995). The person is the focus of the dialogue, ensuring the centrality of humanistic person-centred discussions. The underlying assumption to this concept is that the teacher is also a learner. As teacher and students share personal practices, the students come to appreciate that nursing knowledge can evolve by reflection on experience. By examining their own experience as well as that of others it is suggested that the students begin to recognise where they need to focus their attention. The narrative pedagogy seeks to establish dialogue and connections between members of the group, which enables the students to see the importance of reflecting on practice not only to learn but also as a means to contribute to nursing knowledge. Also, applying the concept of signature pedagogies ensures that all teaching is fundamentally organised in a way that ensures student nurses are educated in readiness for their new profession.
In years 1 and 2 of the nurse education programme, students would learn the theory of nursing and begin to apply the theory through the judiciously selected case studies. The people described within the case studies would then be ‘brought to life’ through standardised patients and mannequins as students meet those individuals within simulated or immersive learning environments. The curriculum is driven by a series of unfolding case studies as described by Mills et al (2014). Here students could begin to learn how to apply the theories that they have learned about to realistic low-risk situations. Students could move between classroom and immersive experiential learning in a fluid manner in each week of the programme. Each period of simulation would be built upon through structured debrief and reflection on practice; thus, expanding the students' nursing repertoire and knowledge. Theory and practice are merged and the (artificial) boundaries between the two become blurred.
Assessment
We recommend authentic methods of formative and summative assessment, those that mirror what student nurses may encounter as an NMC registrant. Take, for example, the Patchwork Text Assessment whereby teachers carefully guide students through a sequence of short assessment tasks (or patches) relating to a range of pre-determined activities designed to cover the intended learning outcomes of the module (Scoggins and Winter, 1999; Winter, 2003; Leigh et al, 2013). Each patch is complete and the overall unity of these component sections, although planned in advance, is finalised retrospectively when they are ‘stitched’ together at the end of the module (Winter, 2003; Wesson, 2013)—through, for example, the reflective critical commentary.
It is recognised that existing graduates whose ambition is to become a registered nurse may fast-track year 1 and 2.
Clinical experience
In year 3, students will have the opportunity to gain broad clinical experience in a series of quality practice learning experiences in contemporary healthcare/voluntary, community and social enterprise (VCSE) settings. Supernumerary status is supported by practice supervisors with protected time to teach (NMC, 2018b). Interprofessional practice experience is a fundamental and key component of year 3 and we propose the concept of academy areas, characterised by a clear commitment to inter-professional practice learning; the presence of highly skilled committed health professionals who actively seek out teaching opportunities with learners; and have a track record of person-centred practice and associated development. At the end of year 3, graduate status is granted and once programme requirements are met the student is granted NMC registration.
For fast track programmes, graduate status will take 2 years (year 3 becomes year 2).
Features of year 4: the fully registered nurse
As the fully registered nurse, year 4 consists of paid deployment. The internship provides the opportunity for the registered nurse to both work and learn in practice. Organised in two 3-month placements in areas of the students choosing, this is followed by 6 months' intense transition into a substantive post. Our internship will mitigate the longstanding problems associated with shock when transitioning from student to registered nurse (Darvil and Leigh, 2018), often characterised by new graduates engaging in a professional practice role and being confronted with a broad range of emotional, physical, intellectual, developmental and socio-cultural changes (Kramer, 1974; Boychuk Duchscher, 2007).
Years 5 and 6: postgraduate development
Our model for postgraduate development of expertise can be initiated at any point in a nurse's career trajectory; recognising that some nurses will remain as a fully registered nurse (after year 4) for many years, whereas others may wish to progress to expertise immediately. Our postgraduate development trajectory (Table 2) offers clinical, leadership and higher education pathways
Conclusion
Educating nurses during a global crisis may become the new norm and indeed this piece was written after reflecting on nurse education that is currently in the spotlight due to the COVID-19 pandemic. We have offered our thoughts around the future possibilities of nurse education and we recommend a clear vision for nursing—being bold about the role of the nurse that is clearly embedded within a pre-registration nursing curriculum. We suggest imitating the model of UK medical education. To avoid overcrowding, we recommend implementing a concept-based curriculum that will focus curriculum design on teaching core ideas or concepts that are threaded throughout a curriculum. Application of narrative pedagogy will enable students to see the importance of reflecting on practice, not just to learn, but also to contribute to new nursing knowledge. Applying the concept of signature pedagogies also ensures that all teaching is fundamentally organised in a way that ensures student nurses are educated in readiness for their new profession. Our nursing programme structure re-thinks nursing and provides the trajectory from student nurse through to graduate nurse. The balance of theory, authentic assessment and quality practice learning experiences coupled with an internship will promote the smooth role transition from student to fully registered nurse.
Postgraduate trajectories are exciting as we propose academy areas ensuring that our nurse academics (teachers) remain in close contact with practice areas, meaning that our postgraduate nurses are supported through different pathways such as research, clinical, leadership and higher education.
We welcome further discussion on the issues and recommendations that we make; and offer this discussion piece in the spirit of seeking to constantly improve nurse education, and nursing practice.