TRAINING OF HEALTH CARE SPECIALISTS IN THE UNITED KINGDOM David Thomas Cowan PhD, Reader, Department of Leadership & Practice Innovation, Faculty of Health & Social Care, London South Bank University, London, UK Introduction This paper addresses the training of health care specialists in the United Kingdom (UK). In doing so, the examples of three groups of health care specialist are cited; nurses, operating department practitioners and physicians. Using these examples, the paper describes and discusses concepts that are pertinent to the past, present and future. The Past Traditionally, in the UK the training of various health care specialists, such as nurses and operating theatre technicians (or operating department assistants, now known as operating department practitioners or ODPs), was undertaken within the hospital-based 'apprenticeship' system. This entailed students being employed directly by a hospital, where they were primarily based and where they worked for much of their training, learning practical skills 'on the job' and were utilised as part of the hospital workforce. Certain 'block study' periods would be allocated whereby the students would attend a school of nursing or a technician training centre for the academic content of their training. This was also usually located somewhere within a hospital. Nurses qualified either as a 'State Enrolled Nurse' (SEN) after two years training, or as a 'State Registered Nurse' (SRN) after three years training. The pre-entry qualification requirements (grades achieved at secondary school) were higher for acceptance into SRN training. Once an SEN was qualified there was not much scope for promotion, although in some hospitals SENs became 'Senior SEN' after a considerable number of years service. Conversely, an SRN had a clear career pathway, rising from 'Staff Nurse' to 'Senior Staff Nurse' to 'Sister' 75
(females) or 'Charge Nurse' (males), then to 'Nursing Officer' to 'Senior Nursing Officer' to 'District Nursing Officer' and so on. Operating theatre technicians qualified as an Operating Department Assistant (ODA, now ODP) after two years and were awarded a technical certificate of proficiency in anaesthetics and surgery at 'pass', 'credit' or 'distinction' level. ODAs had a limited career pathway compared to SRNs, with the opportunity to rise to 'Senior ODA'. Many ODAs would eventually go to work abroad where in some countries they would work with greater autonomy as anaesthetists (Cowan 2003, 2005) or would make career changes in pursuit of personal advancement. Indeed, many ODAs ended up as sales representatives for pharmaceutical companies or manufacturers of medical equipment. With regard to physicians, the system was somewhat different. Medical students were based in schools of medicine linked to a university, where initially they would undergo intensive academic preparation. They would subsequently be seconded to various hospitals where they would acquire the relevant practical skills and experience necessary for the successful continuation of their training. Once awarded a medical degree after some six years, the career pathway for hospital doctors was clear. They would begin as a 'House Officer' rise to 'Senior House Officer', then to 'Registrar' then to 'Senior Registrar' then to 'Consultant'. Other career pathways outside of hospitals were available such as going in to practice as a family doctor known as a 'General Practitioner' or GP. The Present More recently, the preparation for practice of health care specialists other than physicians, has been relocated into institutions of higher education. For example, in the UK the Project 2000 report on new preparation for practice (UKCC 1986) indicated that nurses would benefit from training that was based in universities, similar developments having occurred in other parts of the world, including the United States (US), Canada, Australia and New Zealand (Watkins 2000). The intention of this transition was to advance the nursing profession towards the highest possible achievement and it was assumed that a shift away from the old apprenticeship system would address the need for a broader knowledge base than could be provided by the former (Chapman 1999). Also, this would facilitate replacement of some of the ritualistic aspects of nursing practice, with a view to providing nurses whose practice would be underpinned by research evidence and informed by a more critical, analytical approach (Watkins 2000). Accordingly, the emphasis became less upon 'training', this term being perceived as suggestive of limited preparation for practice. Indeed, Watson (2002) raised the concern as to whether nurses are to be merely trained or properly educated, 'training' in this context perceived as a short term undertaking, intended to do nothing more than prepare nurses for a particular task at a given time (McAllister 1998). 76
Subsequent to the shift of nursing education, a similar transition took place within the area of ODA training, or preparation for practice as was the new term. A new grade, the Operating Department Practitioner (ODP) was introduced, initially with an emphasis on vocational training, with a new type of award, a National Vocational Qualification (NVQ). However, ODP preparation underwent several further changes during the late 1990's and early 2000's and ODPs are now university educated in a similar way to nurses. Thus, both grades of health care specialist, the nurse and the ODP, are now educated at university level. They now enrol at a university and are seconded to hospitals for their practical experience. They now have the opportunity to graduate with a bachelor's degree after three years and in this way enjoy a certain parity with the medical profession, although physicians under go six years preparation and have been educated to degree level for some centuries longer. However, preparation for practice for physicians has not been without change. For example, St George's Medical School, the top rated Medical School in London has recently introduced a Graduate Entry Programme (GEP). The GEP is a four-year medical degree course open to graduates from any discipline (St Georges Medical School 2005). The Medical School s introduced this course in response to the need to train more doctors in the UK by widening access to a variety of people other than school-leavers with science qualifications. The underlying assumption is that mature applicants who will have already undertaken a first degree in another subject and will have gained a wider experience of life, this facilitating them in becoming competent doctors. St George's envisage the recruitment of many students who were previously unable to apply for a career in medicine, yet who would be highly suited to the 'Tomorrow's Doctors' vision of medicine, with its mix of people skills and science (St Georges Medical School 2005). In another move to respond to shortages of doctors, this time at hospital consultant grade, the length of training required to become a consultant was shortened and a new grade, the 'Specialist Registrar' SPR was introduced as part of an accelerated pathway from Registrar to Consultant grade. However, the transition from hospital based training to university education has not been without problems. Indeed, this transition has created something of a tension of interests between educators of health care specialists (universities) and employers of health care specialists (health service providers, such as hospitals). Health service providers require health care specialists who, on entering employment are able to undertake specific tasks with the need for minimal further training. Conversely, in universities the emphasis is on the development of broad generic skills, the need to reflect upon practice and the embarkation upon a career of lifelong learning. This tension is probably less apparent with regard to ODP's because this is still a largely practice orientated occupation requiring students to spend considerably long hours in operating theatres in order to acquire the necessary practical experience. It is probably also less apparent with regard to the medical profession, due to the longer period of preparation and the ongoing training and 'on the job' experience that doctors 77
acquire after they have qualified, combined with many years of experience of seconding medical students from universities to hospitals. With regard to the nursing profession, as the competency-based approach to the assessment of nursing practice surfaced as a key policy (McAllister 1998, Chapman 1999), it was proposed that the development of competency frameworks may clarify role boundaries and promote professional accountability (McAllister 1998) thus, attenuating the said tension of interests between educator and employer (Chapman 1999). However, further dilemmas arose. According to Bradshaw (2000), since 1983, when the UKCC defined competence in very general terms, the broad objectives of nursing are now less clear, as they now include health promotion, disease prevention, organizational change, leadership and management. Bradshaw (2000) argues that individual institutions of higher education became free to interpret these general guidelines, which, however, Girot (1993) believed related to problem solving skills rather than levels of competence. Consequently, guidelines were further broadened to encompass academic and personal development, to include liberal arts techniques and skills, while practical procedures specified under the former apprenticeship system were excluded (Bradshaw 2000). Furthermore, there has been little consensus on the definition of the concept of competence with regard to nursing practice (Girot 1993, While 1994, Goorapah 1997, Milligan 1998, Eraut & du Boulay 1999, Bradshaw 2000, McMullen et al 2002, Mustard 2002, Watson 2002, Dolan 2003, Cowan 2005a). as Girot (1993) had noted, the main distinction between definitions of nursing competence remains as between that of a behavioural objective (Chapman 1999, Eraut and du Boulay 1999, Winskill 2000), which is also perceived purely as performance (While 1994), and that of a psychological construct including cognitive and affective skills, the latter perceived as less easy to measure (McAllister 1998, Chapman 1999). However, with regard to the complexities of nursing, it is suggested that this distinction is probably redundant, as may be the distinction between performance, competence or competency (Cowan et al 2005a). Illustrative of this, Bechtel et al (1999) emphasised that critical thinking skills as well as mechanical skills are each an integral aspect of nursing and one without the other is inadequate and perhaps even dangerous. The need to operationalise a consensually agreed working definition of competence suitable for use by nurses and other health care specialists has recently been highlighted (Cowan et al 2005a). If a definition drawing on the holistic conception of competence (Short 1984, Gonczi 1994) could be agreed upon and utilised, this could underpin the research needed into defining competence standards and instituting the national system of competence testing that has been called for in the UK (Bradshaw 1998, Norman et al 2002). Thus, this would enable nursing regulatory authorities to effectively convey to higher education institutions the requirements for nursing students in the form of stated competencies (Chapman 1999). Also, attempts are underway to develop a competency matrix suitable from trans-european use (Cowan et al 2005b, EHTAN 2005). 78
The Future Reflective of the degree of parity that now exists among nurses, ODPs and physicians with regard to education at undergraduate level, similarly, there is now increasing opportunity for these professionals to undertake education at postgraduate level, thus affording greater parity still. For example, the author currently teaches a course in Research Methodology and Strategy as part of a multidisciplinary MSc programme at London South Bank University. This course is accessed by postgraduate students from a range of health and social care backgrounds including medicine, nursing, social work, mental health, public health and health services management. This method of postgraduate education is highly effective and health and social care professional would benefit from further development of generic interprofessional Masters programmes. This would then facilitate development of inter-professional mutual understanding, respect and empathy, understanding of differing theoretical perspectives and conceptual models, reduction of misunderstanding through shared perspectives and awareness of terminology, for example, a consensus on a universal definition of competence with regard to health care practice. Furthermore, because professionals already have experience and knowledge to disseminate to others, this would be useful in developing new ways of working, enhancing multi-professional collaboration and the substitution of roles. Indeed, the UK National Health Service (NHS) is currently seeking ways to enhance inter-professional working and the Changing Workforce Programme (CWP) is assisting the NHS and other health and social care organisations to test, implement and spread the concept of role redesign in order to enhance best practice in the most cost-effective manner (NHS 2005). For example, to address a projected shortage of anaesthetists (always a physician in the UK), a scheme is currently being piloted whereby non-physician Anaesthetic Practitioners (APs) are being prepared to take on functions previously performed by physicians (Cowan 2003, 2005). Many of these APs are likely to be drawn from the ranks of ODPs, thus further advancing parity between the different grades of health care specialist. Furthermore, nurses are also increasingly undertaking functions previously performed by physicians, such as prescription of certain drugs and carrying out small medical and surgical procedures, thus enhancing parity of roles yet further still. Conclusion This paper has examined some of the issues pertaining to health care specialist training in the UK, past present and future, drawing on the examples of three types of practitioner: nurses, ODPs and physicians. While previously these three groups followed different 'training pathways', it is apparent that there is now a degree of parity in their preparation for practice and increasingly in their postgraduate education and their actual way of practicing in hospitals. To 79
facilitate this further, more postgraduate multi-professional courses are needed. Furthermore, a working definition of competence specific not only to nursing, but to health care practice in general, needs to be agreed upon by all interested parties and operationalised. Clearly, health care practice requires the application of complex combinations of knowledge, performance, skills, values and attitudes. Thus, utilisation of the holistic conceptualisation of competence (Short 1984, Gonczi 1994) is necessary to underpin the research needed for the development of precise competency standards and the tools required for the measurement and assessment of such (Cowan et al 2005a). References 1. Bechtel G, Davidhizar R, Bradshaw M 1999 Problem-based learning in a competency-based world. Nurse Education Today 19 (3): 182-187. 2. Bradshaw A 1998 Defining 'competency' in nursing (Part II): An analytical review. Journal of Clinical Nursing 7 (2): 103-11. 3. Bradshaw A 2000 Editorial. Journal of Clinical Nursing 9, 319-320. 4. Chapman H 1999 Some important limitations of competency-based education with respect to nurse education: an Australian perspective. Nurse Education Today 19, 129-135. 5. Cowan DT 2003 From Anaesthetic Nurse to Nurse Anaesthetist: Is This Possible in the UK? British Journal of Anaesthetic and Recovery Nursing 4: 7-11. 6. Cowan DT 2005 Going Dutch: Anaesthetising In the Netherlands and Other Issues. British Journal of Anaesthetic and Recovery Nursing (In press). 7. Cowan DT, Norman IJ, Coopamah VP 2005a Competence in Nursing Practice: A Controversial Concept: A Focussed Review of Literature. Nurse Education Today 25, 355-362. 8. Cowan DT, Norman IJ, Coopamah VP 2005b European Healthcare Training and Accreditation Network. British Journal of Nursing 14, 613-617. 9. Dolan G 2003 Assessing student nurse clinical competency 'will we ever get it right'. Journal of Clinical Nursing 12, 132-14. 10. Eraut M, du Boulay B 1999 Developing the attributes of medical professional judgement and competence. Department of Health, London. 11. European Healthcare Training and Accreditation Network (EHTAN) 2005 www.kcl.ac.uk/nursing/research/ehtan 12. Girot E.A. (1993) Assessment of competence in clinical practice-a review of the literature. Nurse Education Today 13, 83-90. 13. Girot EA 2000 Assessment of graduates and diplomates in pracice in the UK-are we measuring the same level of competence Journal of Clinical Nursing 9 (3): 330-337. 14. Gonczi A 1994 Competency based assessment in the professions in Australia. Assessment in Education 1, 27-44. 15. Goorapah D 1997 Clinical competence/clinical credibility. Research on perceptions of the meaning of these terms to nurse teachers. Nurse Education Today 17 (4): 297-302. 80
16. McAllister M 1998 Competency standards: clarifying the issues. Contemporary Nurse 7, 131-137. 17. McMullan M, Endacott R, Gray M, Jasper M, Carolyn ML, Scholes J. Webb C 2003 Portfolios and assessment of competence: a review of the literature. Journal of Advanced Nursing 41, 283-294. 18. Milligan F 1998 Defining and assessing competence: the distraction of outcomes and the importance of educational progress. Nurse Education Today 18, 273-280. 19. Mustard LW 2002 Caring and competency. JONA's Healthcare, Law, Ethics and Regulation 4 (2): 36-43. 20. National Health Service (NHS) 2005 http://www.modern.nhs.uk/ 21. Norman, I.,J., Watson, R., Murrells, T., Calman, L., Redfern, S., 2002. The validity and reliability of methods to assess the competence to practise of preregistration nursing and midwifery students. International Journal of Nursing Studies 39, 133-145. 22. Short EC 1984 Competence reexamined. Educational Theory 34 (3): 201-207. 23. St Georges Medical School 2005 http://www.sgul.ac.uk/. 24. Watkins MJ 2000 Competency for nursing practice. Journal of Clinical Nursing (9) 338-34. 25. Watson, R. 2002 Clinical competence: starship enterprise or straitjacket Nurse Education Today (22) 476-480. 26. While AE 1994 Competence versus performance: which is more important Journal of Advanced Nursing (20) 525-531. 27. Winskill R 2000 Is competency based training/education useful for workplace training. Contemporary Nurse 9 (2): 115-119. Summary This paper addresses the training of health care specialists in the United Kingdom (UK), past present and future. In doing so, the examples of three groups of health care specialist are cited, namely nurses, operating department practitioners (ODPs) and physicians. Previously in the UK the training of nurses and ODPs was undertaken within the hospital-based 'apprenticeship' system whereby they were employed directly by a hospital and utilised as part of hospital workforce, learning mainly 'on the job'. Conversely, physicians were and still are, enrolled at a university and seconded to hospitals. However, there is now a degree of parity in nurses, ODPs and physicians preparation for practice and increasingly in their postgraduate education and their actual way of working in hospitals. To enhance this further, a working definition of competence, specific to health care practice in general, needs to be agreed upon by all interested parties and operationalised in order to underpin the research needed for the development of precise competency standards and the tools required for the measurement and assessment of such. 81