"REALISING THE POTENTIAL" Briefing Paper 1 "CREATING THE POTENTIAL" A Plan for Education

Transcription

1 "REALISING THE POTENTIAL" A Strategic Framework for Nursing, Midwifery and Health Visiting in Wales into the 21st Century Briefing Paper 1 "CREATING THE POTENTIAL" A Plan for Education "to ensure that pre and post registration programmes in Wales are conceived and planned in recognition that future health care provision will require adaptable and flexible practitioners with reflective, lifelong learning skills" December 2000

2 Further copies of this document can be obtained from: Jacqui Sharples Nursing Division National Assembly for Wales Cathays Park Cardiff CF10 3NQ Tel: (029) Designed and Typeset by Text Processing Services ISBN January 2001 Crown Copyright

3 FOREWORD In July 1999, I launched "Realising the Potential", A Strategic Framework for Nursing, Midwifery and Health Visiting in Wales. This was the first major document produced by the National Assembly for Wales, and set out, in a patient/client focused way, a framework to enable the nursing, midwifery and health visiting professions in Wales to maximise their distinctive contribution to health in Wales. To achieve the aims of the Framework and the health objectives of the National Assembly, it is essential that the education of nurses, midwives and health visitors at pre-registration, continuing education and advanced levels be based on sound education principles. Furthermore, systems must be flexible enough to provide practitioners with the knowledge, skills and competencies necessary now, as well as for future decades. I am therefore pleased to support the vision and strategy set out in this first briefing paper 'Creating the Potential'. This document represents the first real strategy for nursing, midwifery and health visiting education for Wales. It has been produced by a collaboration of service and education. The document underpins and supports the aims of 'Realising the Potential' and it provides a clear direction for the development and provision of professional education in Wales. There is a clear direction for the future, which will assist both education and service providers to work in partnership to deliver the skilled and qualified nurses, midwives and health visitors required to meet the health needs of the people. I would commend this paper to all those who have a responsibility, managerially and professionally to deliver the health agenda of the National Assembly for Wales. Finally I would like to take this opportunity to thank the members of the Nurse Education Forum without whom this document could not have been produced. Assembly Secretary Health and Social Services

4 CONTENTS Page Executive Summary 1 Section 1: Introduction 5 Section 2: Present and Future Needs Changing needs Fitness for practice, purpose and award A competent practitioner Matching needs with resources Ongoing education and development 14 Section 3: The Way Forward Key Principles 15 Conclusion 19 References 20 Section 4: Implementation Plan 21

5 1. The ability to deliver nursing, midwifery and health visiting services depends fundamentally on the way in which practitioners are prepared, both during their initial education which leads to registration, and in their post registration education and continued professional development. Education and training provision must be responsive to the knowledge, skills and competencies required for present and future health care delivery. 2. This briefing paper provides the direction for nursing, midwifery and health visiting education in Wales which is necessary to achieve the goals set out in "Realising the Potential", (National Assembly for Wales [NAW] 1999). It is for this reason that the paper is entitled "Creating the Potential". The purpose of the paper is therefore; I. To support and complement the Strategic Framework for Nursing, Midwifery and Health Visiting in Wales into the 21st Century, "Realising the Potential" (NAW1999). II. To acquaint key stakeholders with the main issues in nursing, midwifery and health visiting education, and to propose how education should be developed to promote and achieve service objectives, which contribute to meeting the health needs of the people in Wales. III. To set current thinking and aspirations about the future of nursing, midwifery and health visiting education in Wales into the context of European trends and challenges, to ensure that the needs of the public, the NHS and other care providers contribute to and drive the education and training agenda in partnership with Higher Education Institutions (HEIs). 3. The intention is that the briefing paper will be a working document which will assist both education and service providers to engage in joint planning initiatives for the future. The paper considers both the Report of the United Kingdom Central Council (UKCC) Commission for Nursing and Midwifery Education, Fitness for Practice (1999), and also the government's proposals for education in England set out in "Making a Difference" (Department of Health 1999). However, it is clear that the needs of Wales are different and therefore require particular consideration. A briefing paper that clarifies the confusion and sets a clear direction for the future is therefore timely. Present and Future Needs EXECUTIVE SUMMARY 4. Today's students are preparing for practice well into the new millennium. Nurses, midwives and health visitors must be able to respond to changing demographic needs, changing patterns of health and illness, rising public expectations, new technologies (especially information technology), new ways of delivering health care, and a rapidly changing knowledge base. Nurses, midwives and health visitors must therefore be prepared to work in a variety of settings and to develop transferable skills which can be adapted to different situations and changing requirements. As part of the public health agenda the ability to work in new ways, in new partnerships and with other organisations will be essential. 1

6 5. General education is also changing just as rapidly. As educational aspirations and public expectations rise, nursing, midwifery and health visiting education must continue to respond with more flexible curricula, which will usually be modular, often undertaken on a part time basis, and delivered by alternative methods. Higher Education is expected to exploit the new information and communication technologies and to use them to achieve greater responsiveness and flexibility in delivery. 6. There are many different stakeholders whose priorities legitimately differ and have to be reconciled. Meeting their needs requires close and continuous partnership to ensure that the selection of future practitioners, the content and quality assurance of their preparation and their continuing professional development, is appropriate to the ever changing requirements of health care provision. 7. Although there are staff shortages in particular areas and particular specialities, Wales does not currently suffer from a serious shortage of qualified nurses or midwives. Recruitment of students is also buoyant. However, the process of workforce development and planning is in need of constant review to enable accurate commissioning of future student places and to monitor staff retention and career patterns. 8. Key Principles Principle 1: Achieving fitness for practice, purpose and award Fitness for practice is the responsibility of the Regulatory body, (currently the United Kingdom Central Council), as part of its role for public protection. Fitness for purpose represents the particular requirements of employers. Fitness for award is the requirement that the student has achieved the level of attainment specified by the awarding body. Preregistration education must produce a safe and competent practitioner who can demonstrate the competencies specified by statute and can be held accountable for his/her decisions and actions. Since nursing, midwifery and health visiting are practice based professions, clinical competence is as important as and should be valued as highly as, theoretical excellence. Clinical placements are an essential part of pre-registration education programmes/courses but the quantity and quality of provision depends greatly on service providers. Existing and future practitioners need to be prepared for team working across professional and organisational boundaries, for flexible working outside current role boundaries, and to be able to make the best use of the range of skills and knowledge which they will have developed as new roles and organisational structures emerge. Quality assurance activity to ensure fitness for practice, purpose and award for pre-registration and post registration courses, must be undertaken in a streamlined way, and in partnership with all stakeholders. 2

7 Principle 2: Development and leadership of practice and education Nursing, midwifery and health visiting need strong leaders with drive and enthusiasm in order to address current problems and prepare for future challenges. They must be seen to be effective and relevant not only to their nursing, midwifery and health visiting colleagues but also to politicians, managers and other health professionals. A commitment to lifelong learning is a professional responsibility which is a challenge to be undertaken by each individual, but resources also need to be made available to facilitate such initiatives. In addition to appropriate educational provision, nurses, midwives and health visitors should have the same opportunities and entitlements to protected time for continuing professional development as other health professionals. Principle 3: Expanding the research and education environment The preparation of nurses, midwives and health visitors must be at the same academic level to that of other health professionals with whom they will be expected to work as members of a multi-professional healthcare team. This is in line with the National Assembly's policy for graduate entry into practice. As much as possible of the programmes should be shared with other professionals with recognition given to the skills and knowledge which all staff can bring to patient/client care. The development of nursing and midwifery knowledge through research is an essential prerequisite for clinical effectiveness, evidence based practice, and clinical governance. The education system must, therefore, enable the development and testing of knowledge through research in addition to the transmission of knowledge through teaching. Principle 4: Meeting future human resource requirements The supply of places on education programmes or courses of preparation and funding arrangements to support them must take account of the requirements of service providers and society's need for qualified nurses, midwives and health visitors. Education and service providers must work together in partnership, with the practitioners, to ensure that future needs are met. Furthermore the processes involved in workforce development, workforce planning and data collection are the focus of current attention that will continue to influence the education and training agenda. Conclusion "Creating the Potential", based upon the Strategic Framework for Nursing Midwifery and Health Visiting, "Realising the Potential" (NAW 1999), together with its associated action plan, is realistic and feasible, but it will require sustained commitment and investment. The National Assembly for Wales supports these initiatives believing that education is an investment capable of producing high returns. 3

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9 SECTION 1 INTRODUCTION 1.1 In July 1999 the National Assembly for Wales (NAW) published a Strategic Framework for Nursing, Midwifery and Health Visiting in Wales into the 21st Century, "Realising the Potential". The strategic goal is stated as: "to realise the full potential of nursing, midwifery and health visiting in order to meet, in collaboration with others, the future health needs of people in Wales." p1 1.2 The ability to deliver nursing, midwifery and health visiting services depends fundamentally on the way in which practitioners are prepared, both during their initial education which leads to registration, and in their post registration education and continued professional development. Realising the Potential (NAW 1999) includes among its aims: "To ensure that all nurses, midwives and health visitors develop their practice in a reflective and evidence based manner, founded upon a standard of education which enables them to practise as equal partners with other healthcare professionals, supported by continuing professional development and clinical supervision." p1 1.3 This paper considers the Report of the UKCC Commission for Nursing and Midwifery education, "Fitness for Practice" (1999). The spirit of their recommendations, many of which reflect current practice in Wales, are supported. The government's proposals for education in England set out in its own strategy, "Making a Difference" (Department of Health 1999), are also considered. However, the needs of Wales are different and require particular consideration. A briefing paper which clarifies the confusion and sets a clear direction for the future is therefore timely. 1.4 This paper provides the direction for nursing, midwifery and health visiting education in Wales which is necessary to achieve the goals set out in "Realising the Potential" (NAW 1999). It is for this reason that it is entitled "Creating the Potential". The paper focuses on pre-registration preparation and also considers issues surrounding continuing professional development and clinical governance. The intention is that it will be a working document which will help both education and service providers to plan together for the future, to ensure the supply of an appropriately qualified nursing, midwifery and health visiting workforce to provide the highest quality service for the people of Wales. 1.5 The purpose of this briefing paper is therefore; To support and complement: the Strategic Framework for Nursing, Midwifery and Health Visiting in Wales into the 21st Century, "Realising the Potential" (NAW 1999). To acquaint key stakeholders who have an interest in the development of health services in Wales, with the key issues in nursing, midwifery and health visiting education. 5

10 To propose how this education should be developed in Wales and within the wider UK context in order to promote and achieve NHS and intersectoral service developments and objectives thus contributing to meeting the health needs of the people in Wales. To set current thinking and aspirations about the future of nursing, midwifery and health visiting education in Wales into the context of European trends and challenges, to ensure that the needs of the public, the NHS and other care providers contribute to and drive the education and training agenda. 1.6 This paper attempts to achieve these aims by setting out the present and future educational needs of practitioners to work in an ever changing health care arena. Section 3 sets out the key principles which must underpin nursing, midwifery and health visiting education in Wales, if we are to meet the needs identified. Finally, Section 4 sets out an implementation plan which will enable the targets set out in "Realising the Potential" (NAW 1999), and the principles identified here, to be achieved. 6

11 2.1 Changing needs SECTION 2 PRESENT AND FUTURE NEEDS Today's students are preparing for practice well into the new millennium. Nurses, midwives and health visitors will require the skills to access, understand and evaluate information, both to inform their own practice and also to help patients and clients make fully informed choices about their own care 'Realising the Potential' [NAW1999], sets out a "Glimpse into the Future" both of nursing, midwifery and health visiting and of healthcare. Many others have also set scenarios for the future. All agree that future professionals must be able to respond to changing demographic needs, changing patterns of health and illness, rising public expectations, new scientific and technological breakthroughs, new technologies (especially information technology), new ways of delivering health care, and a rapidly changing knowledge base. The World Health Organisation Strategy for Nurse Education [WHO 2000], proposes that nurses, midwives and health visitors must be educated and trained to meet the challenges posed by a new emphasis on health promotion and disease prevention, community development, multidisciplinary team working, the provision of health services closer to where people live and work, and equality of access. It is therefore, essential that practitioners are above all, flexible and able to adapt their knowledge and skills appropriately While a commitment to lifelong learning and continuous professional development will facilitate the maintenance of competence and the development of new skills, it is important to recognise that the initial preparation must provide the cognitive and transferable skills on which continuing education will build. It is for this reason that 'Realising the Potential' [NAW 1999] envisages that in future, entry to the nursing and midwifery professions must be, as for all other health professions, at graduate level. At the same time it is important to value the knowledge, experience and skills of the existing workforce General education is also changing just as rapidly as educational aspirations and public expectations rise. The targets for participation in higher education which the government has set are already being exceeded. Nursing and midwifery must maintain a wide entry gate, especially for mature entrants, but it must also be attractive to the most able school leavers. Information technology is revolutionising methods of teaching and learning. Client choice Flexible and adaptable practitioners Graduateness Flexible learning 7

12 Nursing, midwifery and health visiting education must respond with more flexible curricula, which will usually be modular, often undertaken on a part time basis, and increasingly delivered by alternative methods such as video-conferencing, Internet access and other forms of distance and open learning. Higher Education Institutions are expected to exploit the new information and communication technologies and to use them to achieve greater responsiveness and flexibility in delivery. Methods of supporting students to enable them to use more flexible learning modes must also be considered To prepare for future challenges, nursing, midwifery and health visiting will need strong leaders with drive and enthusiasm. They must be seen to be effective and relevant not only to their nursing, midwifery and health visiting colleagues but also to politicians, managers and other health professionals. Education has a duty in developing and supporting present and future leaders to help steer the many changes that face health care provision. Leadership 2.2 Fitness for Practice, Purpose and Award The primary purpose of nursing, midwifery and health visiting education in Wales is to prepare and provide a workforce sufficient in both quantity and quality to meet the Principality's need for their services. There are many different stakeholders whose priorities legitimately differ and have to be reconciled. Stakeholders include the NHS, other employers, higher education institutions, the public, the nursing, midwifery and health visiting professions, and the students themselves. Meeting their needs requires close and continuous partnership between education and service providers as well as the local community, to ensure that the selection of future practitioners and the content of their preparation and their continuing professional development is appropriate to requirements The Report of the UKCC Commission for Nursing and Midwifery Education [UKCC 1999] notes that fitness for practice is different from fitness for purpose and fitness for award. Fitness for practice as a registered nurse or registered midwife means the ability to provide professional nursing or midwifery care to many kinds of people in and across a variety of environments. It involves autonomous clinical decision making, and personal accountability for decisions and actions. It is not limited to the care of the physically sick in hospital; it includes working with individuals, families and communities in a variety of settings to prevent illness and promote health. It is not limited to the performance of tasks; it includes assessment, risk management, planning and coordinating care, evaluating outcomes, and delegating to, and Working in partnership Fitness for practice 8

13 supervising the work of, assistants. Ensuring fitness for practice is necessary to protect the public and is the primary purpose of professional regulation. The requirements for professional practice at the point of registration as a nurse, midwife or health visitor are specified by statute and are the responsibility of the UKCC and any successor body established by current changes. The remit of the UKCC Commission for Nursing and Midwifery Education was "to propose a way forward that enables fitness for practice based on health care needs", and their recommendations on this issue are supported Fitness for purpose represents the particular requirements of employers, who will legitimately have needs for specific roles. Different employers will have different requirements which will change in line with service changes. Fitness for purpose must ensure that nurses, midwives and health visitors are equipped with the skills, knowledge and attitudes to deliver the services that patients, clients and their families expect. Acknowledging that expectations change rapidly it is imperative that education can keep pace with both short and long term targets for change. Implementation of the principles contained within this paper must ensure that present and future practitioners are able to meet the health needs of the people in Wales, in light of existing needs of the NHS in Wales, and current analyses for the future [Better Health Better Wales 1998; Access and Excellence NAW 2000] Fitness for award is the requirement of the higher education institutions that students achieve the level of attainment specified for a particular award. Fitness for award is the responsibility of the awarding body, not of the employer nor of the body responsible for standards of professional practice. In the case of academic awards, the awarding bodies (i.e. the universities) are required to ensure consistency of standards across disciplines, while the Quality Assurance Agency is responsible for ensuring consistency across institutions. The QAA is currently developing benchmark information on threshold standards which articulates the abilities and skills expected of graduates in different subjects including nursing, midwifery and health visiting; specifications and criteria will be set for professional programmes which are comparable with those set for other university courses. Skills of delegation Fitness for purpose Fitness for award Whilst examination has been given to each focus of fitness for practice, purpose and award as separate, the principles are considered as inextricably linked For UK nurses and midwives, the recommendations of the European Union are particularly important, because the requirements for free movement of labour for nursing and 9

14 midwifery are laid down in Directives which specify relevant qualifications, the minimum length of training, the ratio of theory to clinical practice, and the content of programmes leading to registration. The EU Advisory Committee on Training in Nursing (ACTN) and the Advisory Committee on Training in Midwifery (ACTM) have recently recommended changes to the original 1977 Directives in line with the trends outlined above. A survey of nursing and midwifery education in Europe undertaken by the ACTN and ACTM [EU document XV/E/9432/7/96-EN] shows that nursing and midwifery education in the UK differs from that of other EU members in a number of respects. For example, the UK is the only country in Europe which does not prepare a generalist nurse and, although the current pre-registration Adult Nursing Branch programme currently meets the requirements of the existing Directives the other three branches do not The recommendation of the UKCC Commission for Nursing and Midwifery Education that "the current programme of four branches of nursing should be reviewed in the light of changing health care needs, and that the review should consider a range of options including.. generalist nurse preparation", is welcomed. EU requirements Branch programmes 2.3 A Competent Practitioner Nursing, midwifery and health visiting education are an integral part of the legislative and regulatory framework for the professions. Both education and practice must be underpinned by values focusing on the promotion and maintenance of health in individuals, families and communities and on individual and holistic care of those who are ill. Professional education must promote non-judgemental care that is sensitive to the social, cultural, economic and political contexts. Regulatory framework and core values Pre-registration education will in the future be based on defined competencies. However, the concept of competency is complex. It is important to recognise that for professional practice (in any profession) the definition of competency is broader than that specified for vocational training, and must include the intellectual competencies required for clinical decision making. The EU, ACTN and ACTM which have recommended competencies for nurses and midwives across the European Union, defines competencies as; "the personal attributes (knowledge, abilities and attitudes) which enable individuals to function autonomously in the workplace, to improve their performance continuously, and to adapt to a rapidly changing environment" (EC XV/E/8481/4/ 97-EN 1998) 10

15 2.3.3 The development of pre-registration programmes in the UK arise from the premise that nursing, midwifery and health visiting are practice based professions that recognise the primacy of patient/client well-being and respect for individuals. From this stance the competencies for entry to the Register for nurses are focused in the following domains; I. Professional/Ethical practice II. Care delivery Competency domains III Care management IV Personal/professional development There are however, a number of core competencies that can be identified as essential to enable fitness to practice as a registered nurse, midwife or health visitor. These include technical skills, critical thinking, communication skills, assessment, and commitment to continuing professional development. Technical skills are immediately and universally recognised as essential, but it is important to note that in nursing, midwifery and health visiting, technical skills must be underpinned by the cognitive and social skills that are necessary for the clinical judgement that any particular task should be undertaken at all, by whom, when, and how. While registered nurses and midwives must be able to exercise such skills themselves, they must also be able to delegate, teach, supervise and monitor the performance of others. Skill development should focus on the mastery of core principles, so that as practice changes and particular tasks become obsolete, the practitioner is able to adapt and apply the skills to new circumstances and in different contexts. Critical thinking underlies clinical decision making; it includes finding and using knowledge through the cognitive processes of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, problem solving, intuition, and creativity. These are the features of graduateness, which is the level at which nurse, midwives and health visitors will need to be educated. Communication skills are essential for building the relationships with patients and clients within which nursing, midwifery and health visiting practice takes place. Appropriate relationships with colleagues are necessary to enable care to be shared. The public health agenda will require skills to enable Core competencies Technical skills Critical thinking Communication skills 11

16 dialogue across organisational boundaries. Communication skills include listening, oral, and non-verbal communication, teaching and counselling, and written communication skills. Assessment involves gathering information about patients', clients' and communities' health status, needs, and wishes, analysing and synthesising this data, making judgements about interventions based on the findings, and evaluating outcomes and service availability locally. Practitioners must be able to identify their own professional development needs by engaging in activities such as reflection in and on practice and lifelong learning. They must also be willing to share experiences with colleagues and patient/clients to identify additional knowledge/skills needed to manage new and challenging situations, taking action to meet any deficits These competencies must be achieved by the point of registration as well as be maintained throughout the practitioner's practising life. To meet the requirement of fitness for practice in pre-registration, the foundations, especially in the cognitive competencies concerned with critical thinking, must be established from the very beginning of the programme, with each successive module building on what has been achieved in earlier modules. The new fitness for practice programmes will enable students to achieve a common level of outcome at the point of entry to the branch programme, and students who leave the programme at this point will be accorded credit for their achievement. For this reason, it is essential that pre-registration education continues to be seen as a three year preparation for practice. Stepping on and stepping off arrangements must overcome the potential for fragmentation and discontinuity of competence development However, to enable students who leave the course to take advantage of the experience gained in the first year, their achievements should be accredited. Achievements may be measured against the standards and criteria of the National Occupational Standards (NOS). Profiles of individual student achievements, which relate to the cognitive, affective and psychomotor skills acquired during the first year, can be made available by the educational institution. All evidence of achievement in practice, including the underpinning knowledge from the course, should be incorporated into the student's portfolio of development and retained by the student as evidence of his/her achievement. Any mapping of experience to join a pre-registration programme at year 2 must ensure compliance with UKCC outcomes to join a branch. This new flexibility for entry and exit points will affect workforce planning. Assessment Continuing professional development Maintaining competence Stepping on Stepping off Portfolio development 12

17 2.4 Matching need with resources Currently the National Assembly for Wales commissions an annual workforce survey of all non medical staff categories to identify the needs of the independent sector, the prison service, and general medical practitioner services as well as the NHS. However, workforce planning is a very inexact science, and adequate means of standardised data collection are essential Although there are shortages in particular areas and particular specialities, Wales does not suffer from the serious shortage of qualified nurses, midwives or health visitors. At 1/2/00 there were 753 vacancies in the NHS in Wales. It is estimated that the number of registered nurses, midwives and health visitors in Wales who are not working as nurses in the NHS is approximately There are however, around 14,000 beds in the private and voluntary sectors in which it is assumed many of these nurses are employed. Methods of attracting nurses, midwives and health visitors back into the profession may offer one way of addressing some localised recruitment difficulties. Standardised workforce planning Recruitment Recruitment of students is also buoyant. For example, in 1999 there were 8000 applications for the 1000 places on Diploma and undergraduate nursing programmes. All of the educational providers in Wales have waiting lists for their pre-registration programmes at both degree and diploma levels. Applications for post registration courses have also increased significantly in recent years Rates of attrition during training vary slightly from course to course and institution to institution, but the overall rate during the period was approximately 16.2%. This should be compared with the average UK attrition rate of 18% for students of other disciplines. Attrition from degree programmes is also lower than from Diploma programmes. However, figures are difficult to interpret in the absence of a common definition of attrition and standardised ways of measurement Workforce planning figures similarly need careful interpretation. Workforce studies have shown that the nursing, midwifery and health visiting workforce is ageing; staff turnover is too high, and is expensive. Furthermore, the requirement for different specialities can fluctuate. Hence, retention of nurses, midwives and health visitors is a greater challenge than recruitment. It is also difficult to track the career patterns of practitioners in Wales. Statistics are required to identify the percentage of the workforce that leave the profession annually and those that move between the private and independent sectors and within the NHS in Wales. Attrition Retention 13

18 2.5 On going education and development Healthcare professionals have a duty to keep their knowledge and skills up-to-date. The public have a right to expect nothing less. There is however, a challenge of matching employer requirements regarding a fitness for purpose workforce with a meaningful framework for continuing professional development (CPD). Furthermore, clinical governance demands a more systematic approach to CPD which ensures that priority is given to addressing learning needs linked to specific service quality issues. In developing local approaches to CPD as part of their learning plans, NHS Trusts will need to consider not only their local learning objectives and priorities but also the variety of resources needed to support CPD and how these are best targeted to ensure value for money NHS Trusts have a responsibility for the post-registration education of their practitioners. While this arrangement enables employers to ensure "fitness for purpose" in their staff, cost constraints mean that they may be unable to meet either need or demand. Unlike doctors, nurses, midwives and health visitors are not entitled to protected time for continuing education and professional development. In addition to appropriate educational provision, nurses, midwives and health visitors must have the same opportunities and entitlements to protected time for continuing professional development as other health professionals The nursing, midwifery and health visiting professions must continue to control the standard, kind, and content of its education. This is one of the defining characteristics of a profession and an integral part of professional self-regulation. It must, however, do so in consultation and collaboration with service providers, education providers, and the public. CPD Clinical governance Professional self regulation 14

19 SECTION 3 THE WAY FORWARD 3.1 Key principles This section sets out the fundamental principles which should underpin arrangements for nurse, midwife and health visitor education in order to meet future needs. These principles incorporate those set out by the World Health Organisation in its European Strategy for Nursing and Midwifery Education (WHO 2000) Principle 1 Achieving fitness for practice, purpose and award Pre-registration education must produce a safe and competent practitioner who can demonstrate the competencies specified by statute and can be held accountable for his/her decisions and actions. The registered nurse, midwife and health visitor should be able to practise at this level in any location and within any employing organisation. Changes in health needs and in healthcare, including the requirement for accountability and evidence based practice increasingly require higher level skills and those most commonly associated with graduate status. For this reason Realising the Potential (NAW 1999), recommends that in future, entry to the professions should be at graduate level Since nursing, midwifery and health visiting are practice based professions, clinical competence is as important as and should be valued as highly as, theoretical excellence. Clinical placements are an essential and integral part of pre-registration education programmes/courses, but their quantity and quality depend on service providers more than on the education providers. More consideration needs to be given to how students can be better supported in clinical areas, and how clinical competence can be assessed. The principle that those who teach these professionals should also practice is supported. There are many good examples of lecturer-practitioner and link teacher arrangements, and many more teachers would like to spend more time in clinical practice. However, structural barriers and the competing demands of teaching, research, administration and clinical practice make it difficult. All the recommendations of the UKCC Commission for Nursing and Midwifery Education on this matter, are supported and the resource implications noted Existing and future practitioners need to be prepared for team working across professional and organisational boundaries, for flexible working outside current role boundaries, and to be able to make the best use of the range of skills and knowledge which they will have developed as new roles emerge Quality assurance activity to ensure fitness for practice, purpose and award for preregistration and post registration courses, must be undertaken in a streamlined way, and in partnership with all stakeholders. 15

20 Principle 2 Development and leadership of practice and education Nursing, midwifery and health visiting need strong leaders with drive and enthusiasm in order to address current problems and prepare for future challenges. They must be seen to be effective and relevant not only to their nursing, midwifery and health visiting colleagues but also to politicians, managers and other health professionals Nurses, midwives and health visitors who have the opportunity to move across clinical, management, education and research boundaries are likely to bring a broader perspective to the leadership role. This can be assisted by increased opportunities for joint appointments rotational posts and secondments involving Trusts, Health Authorities, Higher Education, Government, other Statutory agencies and the non-statutory sector and practice abroad. Personal and professional development opportunities should continue to be made available to those aspiring to leadership and/or management roles Nurses, midwives and health visitors who work in Higher Education are well placed to contribute to the development of the leadership role. However, in order to provide and contribute to leadership of the profession as a whole, they need to establish more meaningful links with practice, developing an appreciation of the real needs and concerns of nurses, midwives and health visitors delivering care With the ever-increasing diversity of roles and specialities, it is becoming more difficult to agree common standards for advanced practice. The establishment of an academy of subject based faculties which would have several functions needs to be considered. The functions might include the interpretation of standards for advanced practice, requirements for education and training etc. In addition the academy and its faculties could be the source of specialist advice at all levels in the service. It is envisaged that an academy could act as a focus for excellence in care, evidenced based care, the development of clinical leadership skills and the possible accreditation of continuing professional development and clinical learning environments A commitment to lifelong learning is an essential part of professional practice and maintenance of an adaptable flexible workforce. Lifelong learning is a continuous process of learning through study, experience, personal reflection and shared learning. It is not about going on courses. People should be encouraged to learn when, where and how it suits them best. To support lifelong learning, staff need easy access to a wide and flexible range of learning opportunities, including those which information technology is increasingly making possible Everyday work situations provide a rich source for creative problem-based learning opportunities to complement more formal training activities. Everyone with staff management responsibilities should be encouraged to think imaginatively about arrangements like secondments, rotational posts, work shadowing, learning sets and other innovative opportunities for learning. Teaching, mentoring and peer review all provide valuable opportunities for people to share their learning experiences. 16

21 Successful lifelong learning has to be convenient, relevant and planned. All nurses, midwives and health visitors should have the opportunity to discuss and receive guidance on their development needs and how these might be addressed. Wherever possible, people should be free to decide whether to consult an educational or clinical supervisor, their line manager, a colleague or mentor. The action agreed should reflect the needs, learning styles and preferences of the individual and must also be agreed by line management as part of a systematic appraisal which links individual need with the service priorities of the organisation The rapidly changing environment of health care requires practitioners to maintain their competence, to develop their knowledge base as knowledge expands and changes, and to adapt their skills to new circumstances. Continuing professional development is the responsibility of the professional practitioner, which is a challenge to be taken by each individual, but resources need to be made available to help. In particular nurses, midwives and health visitors should have the same opportunities and entitlements to protected time for continuing professional development as other healthcare professionals (Agenda For Change 1999). Principle 3 Expanding the research and education environments The preparation of nurses, midwives and health visitors must be equivalent to that of other health professionals with whom they will be expected to work as members of a multiprofessional healthcare team. There is value in promoting effective team working by encouraging methods of working and learning which support an integrated approach to patient/client care. As much as possible of the educational programme should be shared. Innovative schemes, in which the first year of the undergraduate nursing programme and the first year of the undergraduate medical programme are shared, demonstrate what can be achieved. However it is unrealistic to expect such sharing if the level, location and organisation of the two programmes and the educational level of the two groups of students are very different Nursing, midwifery and health visitor education must continue to be fully integrated within higher education. Students must not be required to be employees during their education and must enjoy a status equivalent to that of other university students. This implies that the same opportunities for development, including the establishment of links with other subject areas and the pursuit of research are equal to other disciplines The development of nursing and midwifery knowledge through research is an essential pre-requisite for clinical effectiveness, evidence based practice, and clinical governance. The nursing, midwifery and health visiting education systems must enable the development and testing of knowledge through research as well as the transmission of knowledge through teaching. The NHS funding for nursing, midwifery and health visiting education does not currently contain provision for research. 17

22 Principle 4 Meeting future human resource requirements Workforce development has to start from the definition of the services and potential services that the public need. This leads to the debate on the skills and competencies required to deliver theses services and the numbers and types of staff required. The supply of training places and funding arrangements to support them must therefore take account of the requirements of service providers (NHS, independent sector, and other employers), and society's need for qualified nurses, midwives and health visitors. The nursing, midwifery and health visiting workforce must be seen as a global, not merely a local resource. Supply and demand must be estimated for the long term as well as for the short term, and must take account of labour mobility between employers, between fields of practice, and between countries. Education and service providers must work together in partnership, and with the practitioners, to ensure that future needs are met. To facilitate this the processes of workforce assessment, workforce planning and data collection require immediate attention The entry gate to preparation for nursing and midwifery must be wide enough to enable anyone who wishes to become a nurse or midwife and who has the ability to achieve the competencies specified for registration to do so. Universities in Wales are already committed to widening the entry gate to higher education, especially for mature entrants. Relationships with further education institutions, including access courses, are already well developed in Wales. Modularisation should enable programmes to be delivered in a variety of full-time and part-time modes, and to spread the programme over a longer period of time to accommodate those who have family commitments or who have to catch up on previously missed education Retention of students and of newly qualified practitioners is a particular challenge. Education and service providers must work together to ensure adequate support for students in the clinical environment, and to develop realistic arrangements for preceptorship and clinical supervision to support the transition from student to a competent and confident practitioner. The resource implications of such arrangements are considerable and should be recognised. The provision of opportunities and support for continuing education and professional development are an important factor for attracting and retaining qualified staff. Strategies for recruitment and retention must demonstrate career progression and job satisfaction which fulfils the needs and aspirations of nurses, midwives and health visitors It is important to promote staff development as an investment in quality by raising awareness among service providers and managers of the value of education, training and lifelong learning in the delivery of high quality services. Retention of a motivated and competent workforce is influenced, in part, by the maintenance of close liaisons between education and service. The importance of their partnership will need to be enhanced and further recommendations of the Human Resource Strategy, Delivering for Patients (NAW 2000), implemented. 18

23 CONCLUSION The following implementation plan provides a framework for ensuring that each of these principles is addressed. As Realising the Potential (NAW 1999) states, nursing, midwifery and health visiting in Wales will gradually develop a distinctive identity under the guidance of the Assembly. We share the aspiration of 'Realising the Potential' that in the future many nurses, midwives and health visitors may choose to come to work in Wales, where their professional aspirations can be realised in an environment which genuinely values high quality care and dedication to the interests of patients and clients. It is important to modernise education and training to ensure that all staff are equipped with the skills they need to work in a complex changing health care arena. This will require streamlined workforce planning and development which stems from the needs of patients/clients, carers and communities, not of professionals. This will involve the development of new, more flexible careers for staff of all professions and non professionals. Expansion of the workforce is needed to meet these future demands. The role of the National Assembly for Wales Education and Training Group and the Education Purchasing Unit will require careful consideration. The Wales Cyngor for Nursing, Midwifery and Health Visiting Education and Research (formally, Nurse Education Wales), and the Welsh National Board and/or its successor body, working with and through the Nurse Executive Wales group, and the nursing, midwifery and health visiting professions in Wales, is committed to working with the Assembly and its institutions to ensure that nursing, midwifery and health visiting education in Wales meets the needs of the people of Wales. Over the past decade much of the success of nursing and midwifery education in Wales has been due to careful strategic planning and a commitment to evolution rather than revolution. The principles set out in this document will not be achieved overnight. It will require sustained commitment and investment, including financial investment. The National Assembly for Wales is committed to education as a means of achieving excellence in all fields. The nursing, midwifery and health visiting professions in Wales are committed to achieving excellence in the service provided, as set out in Realising the Potential, by; "ensuring that all nurses, midwives and health visitors develop their practice in a reflective and evidence based manner, founded upon a standard of education which enables them to practice as equal partners with other health care professionals, supported by continuing professional development and clinical supervision" 19