NMC Future nurse education consultation: UNISON policy overview

Transcription

1 NMC Future nurse education consultation: UNISON policy overview Introduction UNISON has submitted detailed responses to the NMC s Future Nurse Consultation questions, but we believe the question format does not provide the opportunity to identify some of the broader themes and issues raised by the consultation. We are therefore making this additional submission which draws on the results of general member engagement and an on-line survey carried out over the summer with UNISON student and employed members. A summary of the survey findings is presented in Annex A. Key UNISON concerns 1) Nurse education in its wider context One of the NMC s stated aims is to embed at the point of entry to the register higher level skills and knowledge that are currently only considered postregistration. UNISON is concerned that this will not take place in a vacuum from other key policy issues affecting nursing recruitment and retention. In the current context of poor staffing levels and inadequate workforce planning, the profession is extremely demoralised. While nurses continue to have a drive and passion for patient care, it is challenged within an environment which has seen their pay fall below that of other professions both in the UK and internationally. Nurses are rightly accountable for patient safely and public protection but they are working in a system which is constantly failing them, both as individuals and as a profession. The impact of public sector pay restraint, together with the removal of student bursaries and imposition of tuition fees in England, are major factors affecting whether the nursing profession will be able to attract students capable of attaining these skill levels. Unless these wider issues are addressed they will continue to undermine the policy aim of raising the skills, leadership capabilities and status of nurses for the future. Aside from the issue of pay restraint, incorporating higher level skills into initial nurse training could have implications for job design and pay banding within the NHS that need to be worked through, planned for and resourced. 2) Existing workforce The changes envisaged for future nurse graduates cannot be implemented without addressing the skills and knowledge levels of the existing nurses they will work alongside. Their initial education will have been quite different. This will prove particularly challenging to address unless the current cuts to budgets for CPD are reversed. 1

2 3) Role of the regulator and impact of funding and capacity constraints We are concerned that some of the NMC s proposals appear to be an attempt to respond to operational capacity and resource restraints, rather than driven by the principle of maintaining standards. In particular the proposal to allow substantially more practice learning to take place through simulation appears to be a response to the current strain on practice placement capacity, with no positive rationale put forward for why and how the figure of 1,150 hours was arrived at. Similarly we are concerned that removing prescribed proficiencies and training requirements for mentors will lead to cost and corner-cutting driving further inconsistency in standards. It will also make it more difficult for nurses to secure the time and funding they need to train and prepare for mentor/assessor roles. The current funding environment means that cost considerations are likely to be the driver, rather than creative and innovative approaches driven by quality considerations. 4) Implications for post-qualification The consultation does not talk about how the changes proposed will impact on preceptorship. We believe there is a danger that nurses educated to the new standards will be seen as having higher level skills and able to do more from the point of qualification (prescribing, common standards across the four fields). This could have the effect of eroding preceptorship and opportunities for specialist and advanced practice. In fact the changes will mean there is a greater need for ongoing supervision, reflective practice and support to put the higher skills into practice. 5) Importance of cultural competence The consultation gives some direction to understanding culture. We believe that cultural competence, understanding and confidence should be at the core of all nursing and midwifery education and therefore given a greater emphasis for all the protected characteristics in the Equality Act This would allow for nurse education to explore innovative ways to learn how to work, treat and care for diverse groups and individuals. We believe that an education programme that demonstrates greater emphasis on cultural understanding and competence would provide better safety and care standards to the public and would also attract people from diverse backgrounds to nursing and midwifery. 6) Student support It is clear that there are still significant shortfalls in the support students receive especially those with particular learning support needs. We are concerned that with the greater demands of the proposed new standards and the attempt to squeeze more content into degree programmes, these shortfalls could get worse. 7) Use of students as fill-in healthcare assistants Many current students and the nurses who mentor them are raising concerns about the fact that students are routinely being deployed to fill in for healthcare assistant (HCA) shortages. This is particularly a problem for students who have previously worked as HCAs and/or for students who also work bank shifts as HCAs. This means that they are not exposed to the range of learning opportunities that they should be getting, and the sense of inequity around this 2

3 will only grow now that students in England will be fully funding their education through student debt. 8) Assessors UNISON is concerned that the changes proposed will create uncertainty about who will have responsibility for setting standards for assessors and how this will take place. There is a considerable risk of inconsistency. We would like to know how this will be monitored, audited and evaluated. We believe that it is vital that there is a shared benchmark for deciding what makes assessors competent to assess students and whether they have currency of knowledge and experience. Furthermore we believe the changes could mean the loss of unexpected opportunities for assessment for example the supervisor might be present when a student carries out an ECG, but the assessor would not be there if this had not been planned. 9) Prescribing and medicines management We support using pre-registration programmes to start to build knowledge, theory and understanding of medicines and prescribing. However, we have serious concerns about whether there is sufficient capacity within the system for this to happen to a consistent standard. We are not supportive of moves to allow nurses to start community prescribing programmes immediately post-qualifying as we believe new graduates need time to establish themselves in their new roles. They need to develop their confidence in delivering safe and effective care and would benefit from time to adapt into their new surroundings and teams, whilst developing their competencies as registered nurses. Moving into this process too soon could place undue pressure upon them and could in the long term detrimentally affect their confidence. And reducing the time from three to one year post qualifying for independent prescribing also appears risky and should, we believe, depend on setting, supervision levels and overall competence. Removal of medicines management standards is something we strongly oppose as we believe it will drive inconsistency and weaken the hand of registrants. Registrants need clarity around their role and function in relation to medicines management and the NMC standards inform and underpin local policies, which help registrants to raise concerns locally. Key UNISON priorities 1. Upskilling We believe that government health departments need to convene early discussions with the NHS Staff Council and other relevant bodies to consider the workforce design and skill mix implications of the future nurse requirements. Ongoing employer engagement is vital. 2. Needs of the existing workforce We believe that government health departments, employers and workforce development bodies need to consider and address the implications of the new proficiency standards for the existing workforce and invest in CPD provision to support this. 3

4 3. Appropriate action to tackle constraints on practice learning capacity We believe the regulator should prescribe what is needed to uphold standards and patient safety while using its influence and standing to highlight where these are not being upheld by the organisations responsible. There should be an open debate about how practice learning capacity can be increased and service pressures addressed so that students still get the optimum practice learning for their needs and the needs of patients. The funding implications of this should be spelled out for government departments. 4. Simulation The proposal to increase permitted simulation hours by nearly 300% is causing concern for students, nurse mentors and educators. Even those with good experiences of simulation say it can never be a substitute for real life patient contact. UNISON is concerned that NMC has not set out an evidence base for extending the limit or explained how the figure of 1,150 hours was arrived at. Our feedback is that there is great variation in the quality of simulation facilities and resources available. There are big differences between the types of resources and expertise needed for physical simulation and those for mental health and learning disability. We believe that there should be minimum standards around the quality of simulation and ensuring that anything learned is followed up and put into real life practice. Any extension of simulation should be approached cautiously. We believe there should be targeted research to understand the quality issues, the best methods of using simulation, and how different skills should be handled. This could be followed by piloting and if an extension is supported by the evidence it should be done incrementally rather than in a big leap as the NMC is currently proposing. 5. Guidance on use of students as HCAs Learning must come first and we believe that the NMC needs to strengthen its guidance on the supernumerary status of students generally. This also needs to be reviewed to take account of work-based routes to qualification, particularly the nursing degree apprenticeship to ensure that those employed have clear protected learning time. 6. Practice assessor roles UNISON strongly believes that prescribed programmes and standards of proficiency need to be maintained. We are open to the idea of reviewing content with a view to encouraging innovation but we do not support the deregulatory approach the NMC is proposing because we believe it will lead to unacceptable inconsistency and cost-cutting approaches which will let down students and assessors alike. Nurses already struggle to access the training they need to fulfil mentor roles removing the requirements will only make this worse. We would also call for guidance on how registrants should raise concerns where they are not being supported or trained adequately for the role they are expected to fulfil. 4

5 7. Cultural competence There is an opportunity for nursing and midwifery programmes to be innovative and inclusive in the education programmes that will enable student nurses to practise cultural competence and engage with diverse communities. We believe that cultural competence should be a running theme throughout all nursing programmes. This can be explored in simulation of practice within AEIs before being tried out in practice. This would allow for student nurses to explore working in different and person-centred ways in a safe environment, gaining greater cultural competence for their practice and ultimately promoting safety to the public. 8. Non-medical prescribing and medicines management We believe that the NMC should not fast-track prescribing programmes in order to safeguard the period that nurses need to embed their skills and confidence in their own judgements. NMC should continue to publish medicines management, but should work with stakeholders including UNISON to update them and commit to regularly reviewing them so they maintain currency. 5

6 Annex A Future nurse education what are UNISON members priorities? We carried out an on-line survey over the summer which attracted 1,700 responses, broken down as follows: Students 12% Registered nurses 68% Healthcare support workers 15% Other 5% Students experience of current mentoring and clinical assessment One fifth of students rated the mentoring and clinical assessment as Excellent and a further 41% rated it Good. A third said they were experiencing some problems, while 7% said their experience was poor. The overwhelming majority of those with variable or poor experiences put these down to inadequate input from mentors usually due to lack of time/staff shortages, or lack of training, experience on the part of mentors. Views of registrants on the current mentorship system Among respondents working in registered roles, 30% believe the current mentorship system works reasonably well and delivers consistent standards of assessment. However 43% believe it works well in some cases but not in others. A further 28% said it is not working well with problems around quality and consistency. Many respondents pointed to lack of support from employers for mentors; pressures on time and staffing; and the burden of bureaucracy and paperwork. Learning content and methods, and support from education institutions and placement providers Respondents were asked what they think are the most important issues that the NMC needs to tackle. The most commonly occurring issues were: insufficient mentorship capacity/support for mentors including getting difficulties getting funding and release time to attend mentorship training students routinely being used as an additional healthcare support workers to fill gaps (especially if they have previously worked as a healthcare assistant or work HCA shifts on the bank). students having to travel long distances between placements and unsuitable placements insufficient practical learning opportunities Because of the shortage of nurses in mine and most areas I feel we give much less to students than we used to...i no longer have the time to complete my own mandatory [mentor] training...the Trust encourages staff to complete the...training in their own time 6

7 I think the mentors have too many students and too much work to allow them to work effectively with students. The time the students are supposed to use in learning new skills are being used in making them work as HCAs on any shift they are in. We are not saying helping hands are not to be given by students in areas of personal care but students are not meant to be counted as working staff by ward managers to make up for their low staffing levels. In terms of course content the need for more in anatomy and physiology came up frequently, while pharmokinetics and pharmacology, assertiveness training and counselling and psychological therapies were also mentioned Examples of other issues raised by respondents: Financial difficulties Removal of student bursary Learning support needs Need for more support for students with particular needs eg mental health issues, dyslexia Need to tackle bullying: rife, particularly with students Learning experience Need for more communication skills Need more hands-on experience eg being able to administer IV meds under supervision rather than just observing Need to take charge of patients earlier in the 3 rd year to prepare for postqualification Need more consistency on what students are allowed to do: there is great variation in what we are allowed to do meaning some miss out on vital skills/opportunities or puts students/patients in danger Systems Need to make assessment documentation more user-friendly and reduce jargon Need more standardised assessment methods Students cannot support themselves without having at least one part-time job. They are trying to fit in their practical placements around their jobs, which is unfair to them and the nurses. It is massively long-winded. Students come with huge amount of paperwork into time poor wards where the concept of protected time is laughable. Education and placement organisations keep changing paperwork and strategies practically every year. 7

8 Experience of simulated practice learning Overall 48% of respondents said they had experienced good quality simulated practice learning. However, 33% said they had experienced poor quality, with the rest having no experience. Among respondents who are current students, 71% said they had experienced good quality, and 28% said they had experienced poor quality. Comments from respondents reflect a common theme around variability in quality, and a concern that there is no substitute for time spent interacting with real patients and their families. Risks from allowing greater use of simulated practice learning Respondents were concerned that the quality of simulated learning could be undermined in cases where practice and equipment may not be up-to-date enough. They also identified a risk that students may not take some learning experiences seriously enough, or that this method does suit all learning styles, and if not done well (for example with too big groups) can reduce participation opportunities. Opportunities from allowing greater use of simulated practice learning Respondents highlighted how good use of simulation can support reflection and provide a safe environment to develop and consolidate skills. It can provide the chance to try out techniques as a precursor to practising them with real patients. The quality of simulated practice in my opinion is variable...it would be very easy for students to have less participation in a simulated environment. I trained in 1970s when...nursing tutors supplemented staff in placements so there was little need for simulated practice. I am aware times are very different so the need for good quality simulated practice is essential. It gave a safe environment in which to learn skill and could, if used appropriately, help to embed best practice. However, actual placement experience is vital. I used a simulated arm which had such large holes in the skin you could not help but put the needle in correctly. The preparation...was helpful but the actual cannulation itself was not helpful. This would be valuable because most students don t get a lot of hospital-based placements and it is hard to gain those skills. The negative was that they were shocked when comments were made about their practice within the simulated sign off and it was obvious that some people did not expect that the supervising practice teacher would make constructive criticism...it is not a fun activity although it could be enjoyable but a serious learning setting and they are there to learn. Simulated knowledge is usually taught in the form of the perfect situation. This is usually far from the truth. You can only apply knowledge in the practical situation. If this experience is missing then simulated knowledge is useless. Not realistic enough bordering on comedic. 8

9 Most and least suitable uses of simulation The following types of activity were commonly identified by respondents as MOST suitable for simulated practice learning: Life support CPR Catheterisation Cannulation, venepuncture Dressings Bed bathing Emergency situations The following types of activity were commonly identified by respondents as LEAST suitable for simulated practice learning: Mental health assessments Communications and counselling skills Bereavement and end of life care skills Person-centred care skills Nursing procedural skills Some 70% of respondents said they believed that specifying a list of nursing procedural skills as part of the standards of proficiency would be helpful. Comments included the opportunity to have greater consistency of skill levels between different education providers. Among the 30% who said they had some concerns about the procedural skills annex, the main issues were concerns that this would create unrealistic expectations about what nurses can be expected to do across the fields of practice concerns about the feasibility of covering all these procedures in preregistration training Concerns about the appropriateness for mental health Some of these should be included in basic training; others should remain part of the extended role of the nurse. Basic skills need to be secure before extending knowledge. There are other tasks on this list that would make me consider that I would...be training to be a...less well-paid doctor Concerns would be time and money. Some placements are not adequate while the pay rewards do not match the standards that will be required. I have huge concerns about chest auscultation as an advanced nurse practitioner with 15 years experience. This is a very advanced clinical skill that should be practised on a very regular basis before someone is deemed competent 9

10 Nurses already struggle to meet the demands imposed upon them. This is going to add to the expectations Very task-orientated...there is a lot more to being a nurse than just the tasks we perform Can t fit everything in. Medicines management standards Nearly two-thirds of respondents (62%) said that they find the NMC medicines management standards to be useful in their practice. Just over a quarter (26%) said that they did not use the standards at all and 11% said they did not find the standards useful. Those who found them useful cited the benefits of consistency and continuity and a baseline for local policies to elaborate upon. Allowing Trusts to set their own standards could have a contrary effect and see a drop in standards and an increase in errors They are useful as a basic but they haven t moved with the times. 10