The UK, unlike most other countries, retains four specific pre-registration routes to the nursing register: adult, children and young people (CYP), mental health and learning disability nursing. However, although the 2010 standards for pre-registration nursing education from the Nursing and Midwifery Council (NMC) listed separate competencies for each of these fields (NMC, 2010), the 2018 Future Nurse standards of proficiency for registered nurses are structured as a generic set of standards ‘designed to apply across all four fields of practice’ (NMC, 2018a:6).
It is this application that is a cause for concern because educational institutions and their practice partners are given significant and unprecedented leeway to decide how much of the curriculum should be generic or field of practice specific when designing their own programmes (NMC, 2018b). Undoubtedly exacerbated by the ongoing COVID-19 pandemic and the requirement to move swiftly to remote learning, disquieting reports are circulating that teaching content pertinent to the smaller fields of practice is being undermined and replaced by adult-nursing-centric tuition. Here, we discuss the issue through the lens of CYP nursing.
Background
Undergraduate nursing programmes in the UK are currently designed to prepare students for registration with the NMC in one or more of the four fields of nursing practice. The NMC specifies that all programmes that lead to registration as a nurse must include routes that are specific to the relevant fields of nursing practice for which approval is being sought. The adult nursing field of practice must also include the content and competencies specified in relevant European Union legislation, including a directive that contains the provision for a range of competencies necessary for the training of general care nurses (split equally between theoretical and clinical) (NMC, 2018b). The NMC has already commissioned independent research to investigate any potential changes to the current programme standards following Brexit (NMC, 2021).
The bodies responsible for nursing regulation have always favoured generic nurse preparation, and history illustrates the difficulties that sick children's nursing in particular has experienced in terms of maintaining a distinct presence on the register.
As early as the late 19th century there was strong opposition to the inclusion of sick children's nurses on a supplementary register. Ethel Gordon Fenwick, a nurse who founded the British Nurses' Association and who advocated for the professionalisation of nursing through nurse registration, initially proposed a supplementary register that included male nurses, mental nurses and fever nurses only (Glasper and Carpenter, 2019). Sick children's nurses (RSCNs) were eventually allowed direct entry to the supplementary part of the nursing register in 1919. Many general nurses supported the notion that entry to the register for sick children's nurses should be via the post-registration route and it was not long before the direct entry route was again under threat (Glasper and Charles Edwards, 2002a; 2002b).
Although Sir Harry Platt, as the chair of the committee considering the welfare of children in hospital in the 1950s, highlighted the need for sick children to be cared for by specially trained children's nurses, he also recommended that paediatric ward sisters should hold a State Registered Nurse qualification. This requirement to hold an additional general nursing qualification for career enhancement became one of the final nails in the coffin for direct entry to the register for children's nurses, along with the lack of shortened adaption courses.
In the 1960s the 3-year direct entry RSCN courses were gradually phased out, apart from in Scotland, and would not be reinstated until the advent of Project 2000 in 1989. Small cohorts of nursing students in the larger children's hospitals were able to achieve dual registration by following an integrated course lasting 3 years and 8 months.
However, this meant that the children's units in district general hospitals relied heavily on general nurses to staff the wards. In context it should be remembered that pre-Project 2000 general nursing students would have received up to 12 weeks of clinical practice in children's wards and departments, unlike today's adult nursing students who may receive little if any hands-on clinical experience with children.
So what has gone awry?
The COVID-19 pandemic has undoubtedly severely affected the delivery of teaching to undergraduate nursing students, with all universities moving to online learning to fulfil their obligation and commitments to their fee-paying students. The business model of many universities favours generic teaching because it is less resource intensive during lockdown and delivers content to larger numbers of students in one virtual classroom—particularly as lecturers struggle with the production of online materials.
However, the driver for this article was the disquiet voiced by many CYP nursing lecturers that the generic online lectures that they had seen were adult nursing-centric rather than truly generic in terms of age ranges or reflective of the experience of all four fields. The authors have been contacted by a number of academic colleagues expressing serious concerns that the CYP nursing students were missing out on vital information pertinent to their field of practice. The starting point of any children's nursing programme is that children are anatomically, physiologically and psychologically different from mature adults, which makes caring for them when they are sick very different.
To further investigate the concerns raised by academic colleagues from the field of CYP nursing, One of the authors (AG) wrote to the membership of the Children's and Young People's Nursing Academics of the United Kingdom, which has representatives from all universities in the UK who offer undergraduate children's nursing programmes. They were asked for their own views on this issue and 12 corporate replies were received from academic groups from universities in England and Scotland.
It is important to explain that all nursing curricula are validated and approved by field of practice reviewers from Mott MacDonald on behalf of the NMC (https://nmc.mottmac.com). Nonetheless, the replies indicated that academics from the CYP community have consistently expressed concerns following the publication of the 2018 NMC standards that it was the larger adult field of practice that had the loudest voice during the Future Nurse curriculum development. They described a constant battle to embed CYP content into the generic modular structure, making it a challenge to ensure that CYP students receive child-focused content. During the first year in particular, reference to the healthy child and child development was much diluted, with some CYP students entering their second year with minimal knowledge of the healthy child to underpin their understanding of the care of the acutely ill patient.
Some of the respondents said they had undertaken mapping exercises to ensure that the curriculum and subsequent generic lectures accurately reflect the CYP field of practice. However, some reported that their CYP students confided in them that certain online generic teaching sessions were not really relevant to their field of practice. Others reported that lesson plans related to the teaching of clinical skills, which were formulated to meet the needs of all fields of practice, were primarily related to adults rather than children. For example, students were introduced to the nationally approved early warning score known as NEWS 2, which is an adult algorithm, rather than PEWS, which is a paediatric assessment tool and part of the Situation Awareness for Everyone (S.A.F.E.) toolkit produced by the Royal College of Paediatrics and Child Health (https://tinyurl.com/hhujzkaj) designed to reduce preventable deaths and error in children's hospitals.
Similar issues were raised about anatomy and physiology sessions that were taught simultaneously to students from all fields of practice, but with the use of primarily adult health conditions as examples, meaning that CYP students were expected to self-navigate around the childhood pathologies. The teaching of sexual health as a component of the reproductive system was seen to be focused on sexually transmitted diseases which, although highly relevant to young people, fails to address key childhood issues such as consent and the application of Fraser guidelines.
Unsurprisingly, perhaps, one university group of academics reported that their CYP students were apprehensive about being signed off for certain mandatory skills such as urinary catheterisation, venepuncture and cannulation (NMC, 2018b), which are an extended role in many paediatric settings, meaning that skills are acquired after registration.
This was not the experience of all universities. Notable exceptions were Manchester and East Anglia, who both reported satisfaction in the way that the generic curriculum had been interpreted to ensure that CYP students were not disenfranchised from their field of practice. These two academic groups think that their CYP nursing students have both a strong field identity and content tailored to their needs as learners. Some university academic groups also said that they had CYP academics in module leadership roles, which enabled them to directly influence the content of taught sessions, ensuring that the integrity of the field of practice was upheld.
A big part of the perceived problem is capacity. There are far fewer CYP lecturers compared with adult field of practice lecturers in many universities, especially where the cohorts are but a small part of the overall annual intake of nursing students. In these smaller academic groups the lecturers, often qualified as both adult and children's nurses, are thinly spread across two or more fields and may not be able to participate in field-specific seminars that often follow generic lectures. Given the small size of some of the CYP academic teams, it may be difficult for them to cover the vast parameters of childhood illness ranging from childhood skin disease through to childhood neurological disease and mental health issues.
Conclusion
Some academics are increasingly concerned that the generic aspects of the nursing curriculum have become overly adult nursing centric. These academics continue to have concerns that, although their qualifying CYP students will be technically skilled and knowledgeable in nursing at the point of registration, they may lack the underpinning specialist knowledge of their own field of practice.
Fears persist among academics from the smaller fields of practice that the NMC may be inexorably moving towards a single RN qualification entry to the nursing register. Here, expertise in CYP nursing is expected to be developed after registration but, given that post-qualifying programmes in children's nursing no longer exist, this raises the question of how exactly this expertise will be gained or funded
KEY POINTS
- The UK retains four specific preregistration routes to nursing
- Reports are circulating that teaching content pertinent to the smaller fields of practice is being undermined and replaced by adult-nursing-centric tuition
- The bodies responsible for regulation have always favoured generic nurse preparation
- The business model of many universities has favoured generic teaching in lockdown
- Given the small size of some of the CYP academic teams, it may be difficult to cover the vast parameters of childhood illness