In the introductory preamble to Future Nurse: Standards of Proficiency for Registered Nurses it is emphasised that by ‘reviewing the standards, we have taken into account the changes that are taking place in society and health care, and the implications these have for registered nurses of the future in terms of their role, knowledge and skill requirements’ (Nursing and Midwifery Council (NMC), 2018: 3). These standards were produced through public consultation (Glasper, 2017; Loveday, 2019). Due to its national remit, this educational framework substantially influences the future of the UK nursing profession. In this article, the authors aim to broadly quantify the educative efficacy in future-proofing the nursing profession that the framework has achieved to date.
In their article, published shortly before the 2018 standards were implemented, Leigh and Roberts (2018) suggested that the significant changes instigated by the new framework were likely to have both benefits and drawbacks in an academic context. The potential positives highlighted included the framework's electronic assessment components and their accessibility, alongside the licensing of a wider variety of placements in accordance with less proscriptive criteria for assessors (Leigh and Roberts, 2018). Expected challenges included differing levels of preparation by educators, and a need for efficient communication channels between the newly introduced practice assessors and academic assessors. Subsequently, this article seeks to provide an initial evaluation of the successes and learning points from the proficiencies framework's implementation.
Method
In order to gather and collate the views of both educators and students with experience of education journeys under the 2018 standards, a pair of closely linked service evaluations were disseminated. Both groups of potential participants were contacted as a result of purposive sampling, in the form of an email invite to participate in a service evaluation via Microsoft Forms. Those contacted were, respectively, educators at higher education institutions and social care organisations across the Cheshire and Merseyside region, and students at the University of Chester. The students contacted were from across all levels of undergraduate study. In both instances participants were self-selecting, and the total period of data collection spanned a period of 3 months. In the qualitative results reported within this article, all identifiable aspects of data have either been redacted or anonymised to ensure the privacy and confidentiality of participants. Where relevant, grammatical and spelling errors in direct quotes have been corrected.
Both Microsoft Forms questionnaires consisted of 13 questions, covering a range of quantitative and qualitative enquiries. Questions between the two sets had been designed to mirror each other as closely as possible. For instance, where students were asked to provide detailed responses on questions pertaining to their experiences in achieving the proficiencies to date; educators were instead asked about experiences in the assessment and support of students with regard to the proficiencies. Thematically, this parallelism allows for direct analysis of student and educator concerns, providing insights into the differing perceptions of both sides of the supervision process.
Following data collection, the results were coded by the authors, allowing for thematic analysis. This theming process was also aided by the built-in corpus analysis tools of Microsoft Forms. Although these two service evaluations were undertaken within one particular region, the findings of this article should broadly be relevant nationally, given that the Standards of Proficiency for Registered Nurses are consistent across regions.
Participant characteristics
The total number of respondents was 199, with an almost even split between students (n=94) and educators (n=105).
Among the participating educators, there were a wide range of roles undertaken (Figure 1). Those undertaking the practice assessor role proved the most frequent respondents by a significant margin, comprising more than half of the entire educator dataset (56%, n=59). Almost all educators were working either within closely defined NHS settings (n=84), or at a higher education institution (n=17) (Figure 2). A follow-up question elicited further detail for responses of ‘other’. Based on this follow-up question, the lack of direct numerical correlation between those identifying as academic assessors and those working primarily at a university was attributable to role misperception, indicating that the new role titles specified in the framework continue to be a source of confusion.
Demographically, students were almost evenly spread between level 4 (n=25), level 5 (n=41), and level 6 (n=28) in terms of their years of study, with a slight weighting in the data towards second-year students – namely those who had had 2 full years' experience of the framework (data collection took place at the end of an academic year) as a means of structuring their undergraduate nursing training.
Findings
When rating their own knowledge of the proficiencies framework, there was a high level of confidence among educators (Figure 3). This indicates an overall 84% (n=88) confidence factor across those educators participating, whereas those indicating low levels of knowledge and/or confidence are conspicuously in the minority (n=17). This suggests that the proficiencies framework has, over the course of the last 5 years, come to be understood at least to some extent among those responsible for administering it. Nevertheless, it is noteworthy that the most represented confidence level indicates ‘some level’ of knowledge, as opposed to the ‘high level’ of understanding that would most closely fit both operational and NMC ideals (NMC, 2018). As one educator noted about the framework:
‘I have printed it off, but it's a large document for me to read at present.’
As this distribution shows, there is still room for the majority (69%, n=72) of educators to better understand the standards to some extent at least. It may be of particular concern that there are even a few active educators (n=3) who consider themselves to have no understanding of the nurse proficiencies.
Meanwhile among the students surveyed, the most statistically significant factor cited as a barrier to their achievement of the proficiencies was felt to be practice assessors themselves. In particular, there were recurring concerns and frustrations raised around the inability or perceived unwillingness of educators to sign off proficiencies in particular settings, and in some instances, at all. Correspondingly, there was a persistent sense of frustration among students that they were required to complete a set of proficiencies that their educators were not consistent in interpreting or facilitating.
Related to this, a lack of consistency in the application of the standards was frequently referenced in the qualitative responses of both students and educators. For one student:
‘Placements consistently do not perform or have access to proficiencies. Some practice assessors are hesitant to sign off proficiencies they don't use in practice. [Some placements] have been extremely hard to arrange.’
Likewise, another student's experience was that there was:
‘No consistency in teaching, all teach to a different standard.’
These concerns pertaining to educator competence suggest that many students have highly inconsistent experiences of quality nurse training under the new framework, which are largely set by staff understandings of the standards at each individual placement location. A need for improved consistency was likewise cited as a factor by one educator, who voiced that there need to be:
‘Cross site training/meetings – so the university and practice placements are consistent in the skills training, so that one group knows what the others are training/assessing.’
Another educator noted that:
‘Many staff in clinical practice do not understand the SSSA [Standards for Student Supervision and Assessment] and also do not have the skills to assess the proficiencies; this leaves inconsistencies in application of the standards and assessment.’
The Standards for Student Supervision and Assessment (NMC, 2023) form a separate document from the Future Nurse proficiencies but are part of the supporting suite of standards first published along with them.
In addition to a lack of consistency, difficulties in undertaking procedures related to the standards were regularly referenced across both participant bases. Across all qualitative responses, the most frequently cited adjective or opinion used to describe the 2018 standards was ‘difficult’, with a total of 37 direct usages. Contrastingly, its antithesis ‘easy’ had only one usage across all quantitative questions in relation to the standards. Specifically, dissatisfaction with the standards often stemmed from the perceived difficulty in students obtaining a complete set of standards for final sign-off, due to sites having limited specialisms. For one educator:
‘[The standard for] oral suction is difficult to achieve on our transitional community placement, as is blood transfusion (however one of my students was proactive, and swapped to a hospice).’
Nevertheless, this reported solution would not be replicable on a large scale, and likewise implies that the intractability of the standards can lead to situations where it becomes the responsibility of the pre-registrant learner him- or herself to mediate and structure their own quality nursing education.
One student, meanwhile, was not:
‘… Given opportunities to meet certain proficiencies such as the insertion of NG [nasogastric] tubes which caused myself and fellow students additional pressures and stresses. I spent two days with the nutrition nurse and to my disappointment no patients were referred for NG insertion, I was unable to spend any further days with her [due to] fellow students all wanting to meet the same proficiency. I also found the chest auscultation proficiency difficult to meet as no nurse felt competent in that area — I spent the day with the respiratory nurse who said even she was not competent in chest auscultation.’
As this account underscores, the tick-box attributes of the standards are often not comprehensively achievable due to the everyday array of happenstance circumstances in care contexts.
This mismatch between the priorities of patients and pre-registrant leads was elsewhere referenced as leading to deadlocks where students needed to sign-off one or two final standards, but practice supervisors did not feel professionally justified in doing so since they had not seen the skill demonstrated first-hand. As this implies, considerations of accountability in the event of future malpractice come into play in such situations, making what should be a simple sign-off process difficult for all involved. Equally, one student stated that they became uncomfortable with:
‘… Assessors and supervisors assuring me that they are happy to sign things that I need. Despite being grateful for their kindness I find it disturbing that student nurses feel they need to falsify documents in order to pass/qualify. If I have not inserted/managed devices and equipment on a patient, I am not comfortable to say that I have.’
When asked to name enabling factors of the standards, students frequently focused on educators going above and beyond. For one student, one extraordinary factor that enabled them to attain their degree was ‘practice assessors/supervisors clearly striving hard to find even just a few minutes’ between other tasks to supervise and sign off their proficiencies. Likewise, multiple educators were characterised by their students as being willing to devote time to coach where necessary, and in some instances to provide skills days beyond the regular curriculum in order to aid sign-off. As one student stated, it became incumbent on supervisors and assessors ‘finding ways to overcome these barriers’ imposed by the standards.
Discussion
The findings here broadly confirm many of the concerns raised in preceding articles around potential flaws in the 2018 standards. The standards are underwritten by the assumption that all registered nurses should confidently be able to cover all potential nursing roles (Glasper, 2017). Yet, for Evans (2023), the standards subsequently have a tendency to make nurse training insufficiently specialised. As one educator commented:
‘I am not qualified to teach some of the proficiencies, for example, chest auscultation.’
Such situations lead to a loss of complexity and specialisms within the learning landscape. The standards are currently facing criticism from this angle (Evans, 2023), and these results provide further evidence that these concerns are justified.
Likewise, it has also been observed that the standards include numerous criteria that ‘remain a barrier to the migration of health professionals to the UK’ (Goldstone et al, 2023), such as the English-language competencies implicit in the framework. This implies a closed-mindedness belying the proficiencies framework's supposedly future-oriented character, which has the potential to feed through and negatively influence educator perspectives of international students. For one educator responding to the survey, international students themselves seemed to be a barrier to student attainment of proficiencies:
‘International students where English isn't the first language makes it a little harder.’
Likewise, the standards are keen to define definitive approaches to means of providing care, a tendency that does not promote cultural multiplicity (Goldstone et al, 2023). The difficulties that international pre-registrants already face in achieving parity are exacerbated by the standards in their present form.
Likewise, although the standards require less preparation prior to educators making contact with students, they increase time expenditure while students are present. As one assessor noted:
‘… Entering everything online has increased the time that it takes to submit evidence with the student. We fight against the additional workload on the wards and difficulties maintaining staffing levels to allocate the time required to complete all elements of the standards during a placement.’
As anticipated by Leigh and Roberts (2018), time expenditure remains a contentious and difficult-to-address issue with the standards. Nevertheless, there was no evidence in the dataset considered here suggesting that standards-led assessments of student competency were to any extent rushed or superficial, a potential issue (Leigh and Roberts, 2018) that appears to have been avoided.
The dataset here likewise supports the perspective that placements are at risk of becoming check-box exercises (Evans, 2023), since the standards require too much specialisation in certain criteria, and not enough in others. As one educator remarked, ‘we have only one specialist nutrition nurse for hundreds of students’, all of whom are expected to be signed off. Nevertheless, in contrast to Collins et al (2020), the evaluations here found no statistically significant data around themes of leadership in relation to the proficiencies, so we must assume that this was not a significant roadblock to the delivery or sign-off of the proficiencies.
Conclusion
In conclusion, these paired evaluations support earlier assertions that the institutional implementation of the proficiencies alone is not responsible for either their success or failure (Loveday, 2019). As the data illustrate, there are both success stories and spaces for improvement at the same institutions, and subsequently, attempts must be made to streamline the proficiencies themselves. As one educator suggested:
‘I believe we should offer some skills to be signed off as ‘competent in simulation’, as this would mean that university-based staff teaching the skills could sign off these proficiencies. This would provide reassurance that there is not the expectation that newly qualified nurses from this programme would be deemed competent to undertake these skills on patients without additional, post-qualification training.’
Although it is apparent that the implementation of the new standards has caused significant changes to nursing training over the past half decade, this article finds only sparse evidence that the standards have successfully future-proofed the nursing profession.
KEY POINTS
- The NMC's Future Nurse framework significantly influences the UK nursing profession, and this article evaluates its educational impact over the past 5 years
- Anticipated benefits of the 2018 standards include electronic assessments and broader placement criteria, while challenges involve varying educator preparation and communication issues
- A service evaluation involving educators and students provided direct insights into their perspectives on the 2018 standards
- Results indicate varying educator understanding, challenges in achieving consistency, and concerns about the practicality of certain proficiency requirements
- The authors suggest that there is need to streamline the implementation of the proficiencies across institutions.
CPD reflective questions
- Have the proficiency standards played into your post-registrant practice? If so, how?
- How could you effectively support a pre-registrant student in line with their attainment of the proficiency standards?
- Do you feel that the standards have achieved their stated goal in effectively future-proofing the nursing profession?