Nurse Education in Practice (2008) 8, 299–301

Nurse

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Educationin Practice

EDITORIAL

Proposed changes for nurse education in England(UK) as a result of the Darzi report (DoH, 2008a)Health Quality Care for All – NHS next stage reviewfinal report: Some initial observations

As in other countries worldwide the United King-dom (UK) has experienced significant and unrelent-ing change in its health care service over the past20 years. The impact on the workforce requiredto deliver this service has also been significant, inparticular ensuring that staff have the necessaryskills and evidence – based knowledge to ensureeffective and high quality care for the patientsand clients who have health and social needs. Inaddition, the focus to health care has been on whatDarzi (DoH, 2008b) calls ‘the quantity of care’which has concentrated on reducing patient wait-ing lists and ensuring patient choices in their care.This year marks the 60th anniversary of theNational Health Service (NHS), which was foundednot on the ability of people to pay for care buton the basis of enabling everyone to have accessto care that was free at the point of delivery.The increasing demands for its use were howevernever envisaged; in particular, the needs of agrowing elderly population who may be livinglonger but may also have multiple health needs.

This latest report (DoH, 2008a) begins to re-focus the NHS on the improvement of the qualityof care. Central to this is ensuring that the work-force is enabled and empowered to deliver the bestcare possible. For the purpose of this editorial thefocus is on the nursing profession and in particularthe implications of the main report and anotherpublished at the same time: a high qualityworkforce – NHS next stage review (DoH, 2008c).

One of the key messages of this latter report isthe commitment to ‘reaffirming the role of the

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nurse’ in care delivery, which is significant fortwo reasons. First the implication that the role ofthe nurse has somehow got lost and needs to bereaffirmed and second that there is a clear under-standing of what the nurse does and by implicationthe question what is nursing? It is noted that a teamof researchers at a London University is undertak-ing work with partners and employers to ‘reaffirmthe role of the nurse’ and that this work ‘will setout a compelling and inspiring portrait of the mod-ern nurse, rooted in the values of the nursing pro-fession and the NHS’ (DoH, 2008c, p. 18). It willbe interesting to see the outcome, as attemptingto define what nursing is and by implication whatis the role of the nurse, has long been an issuefor debate by nurse theorists, although one has toadmit that in the literature today this does not ap-pear to be the same ‘burning issue’ as it was in1980’s. I am not sure whether this means that thereis an inherent acceptance that we now know whatnursing is or for another reason it is no longer con-sidered a valid area for intellectual debate?

For some of us who are often accused of remi-niscing too much about what nursing and the roleof the nurse used to mean in terms of valuing peo-ple and having caring as an essential core of ourpractice, this report is welcomed. Nursing and careare synonymous with quality, and as Smith (1987)noted, there is also a close relationship betweenthe quality of care and the quality of the learningenvironment.

The implication for nurse education in England(the other three UK countries having different

300 K. Holland

health care policies as they affect specific regionalneeds and priorities) appears to focus on both preand post-registration. It is clear that ‘recruitingthe best candidates into nursing’ initially, and thenbeing able to retain them, will be critical to thesuccessful implementation of the Darzi (DoH,2008a) recommendations for nursing. However, itcould be argued that if the outcomes of the longawaited review report from the UK Nursing andMidwifery Council (due in summer 2008) on thefuture of pre-registration nursing do not appeal tothose who currently choose it as a profession anda career, then this could be hard to achieve.

This is particularly important for those whochoose to enter specific ‘branches’ of nursing, suchas mental health, where there is a significant num-ber of mature students who have considered all op-tions available to them and often given up variedother careers in order to choose that ‘branch’ astheir preferred option. A possible outcome of thereview is not to specialise in specific areas of prac-tice prior to registration. The consultation processon the future of pre-registration nursing stimulatedmuch debate on this particular issue. It also reso-nates with debates in other countries such asAustralia.

Another key issue, and one very much linked torecruitment of the best candidates, is the shift toa graduate nursing workforce. In the UK, unlikemany other countries, not all nurses are graduateson registration. This has had an impact on manyeducational developments such as inter-profes-sional education, where all the other health careand social work professions are graduates or evenpost-graduates. It is also unclear whether the cur-rent system of bursaries paid to diploma but notdegree students in England would be paid to allof them, as is currently the situation in Scotland.This would have significant implications forrecruitment.

A positive recommendation of the Darzi report(DoH, 2008d) is the acknowledgement of the needfor a ‘foundation period of preceptorship for nursesat the start of their careers to help them make thejourney from novice to expert’ (p. 3). This is aclear message that despite the need to be ‘fit forpractice’ at the point of registration as a studentnurse, that taking on the role of staff nurse is an-other transition role, where the newly qualifiednurse who may well have the set of skills andknowledge at that point in time requires additionalsupport to take on the new responsibility of theregistered nurse. This is where, in employment,they begin to develop their ‘fitness for purpose’in the clinical area of their choice and, much insame way as their medical and allied health care

colleagues, begin their continuing journey as aqualified health care professional.

However, an interesting outcome related to thiswas alluded to in a news report in the Nursing Stan-dard (June 25th–July 1st 2008), with reference tomodernising nursing careers (DoH, 2006). This wasthe possibility that following initial registrationand subsequent ‘salaried foundation year’ thatnewly qualified nurses would then have to revali-date their registration ‘with the nurse regulator’.A Royal College of Nursing (RCN) policy discussionpaper (Sines and Naish, 2008) had also noted the‘as yet unresolved issues about the assessmentand validation of practice at the end of the fourthyear’ (p. 14).

The implications of this for employers is signifi-cant, especially in terms of assessment of compe-tence, but it is also a recognition that althoughstudents at the point of initial registration are con-sidered ‘fit to practice’, that they have not been‘tested and tried’ in their new role as a qualifiednurse and all that entails.

The issue of costs associated with clinical place-ments for student nurses has long been a conten-tious one and it is hoped that the ground-breakingrecommendation that healthcare organisations willbe paid for all clinical placements in future will ad-dress some of the issues. There is certainly a needto increase clinical placements in community set-tings due to the changes in health care deliveryand this will now be a feasible developmentthrough ensuring payment not only to general prac-titioner (GP) practices but also to other new place-ments previously unattainable due to costimplications. However, there will be a need to en-sure that a robust and transparent system of qual-ity assurance is in place for clinical learningenvironments and the pressure that additional clin-ical placements will bring to universities already‘creaking at the seams’ with large numbers of edu-cational audits as per professional body require-ment will also need to be considered. In additionthere is a need for professional recognition of thoseexcellent practitioners involved in direct teachingand assessment of the students who are often tornbetween duty of care to patients and duty of careto the learner. In my view the experienced andhighly motivated mentor is central to the success-ful progress and retention of student nurses. Theyare however often constrained by lack of time forthe role to be pursued as they would wish and addi-tionally many are restricted by lack of finance andopportunity to pursue their skills and knowledgedevelopment, not only to be able to continue tosupport students but also their own professionalpractice. The recent news (Nursing Standard July

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23rd–29th) that ‘more than £100 million of fundingintended for training nurses and other health pro-fessionals was plundered’ last year to offset theNHS cash crisis (p. 8) does not however instil confi-dence in the Darzi (DoH, 2008a) recommendationthat continuing professional development will bevital to the successful implementation of the visionespoused in Health Quality Care for All (DoH,2008a). It is hoped that the results of the consulta-tion on a new post-registration career frameworkfor nurses will help both Universities and the NHSto ensure a successful outcome for future fundingin order to ensure achievement of the ambitiousand welcome recommendations outlined in theDarzi report (DoH, 2008a)

In conclusion therefore, the principle recom-mendations of the Darzi report (2008a) are to becommended, in particular reaffirming the impor-tance of the nurse, bringing improvement of thequality of care for patients back onto the agendaand along with it a refocus on the importance ofeducation and training for all the healthcare pro-fessions and healthcare support workers. It is nowup to both the education and healthcare serviceorganisations to begin working collaboratively andin partnership to ensure that this becomes a realityand that patients and their families can be assuredof a quality caring experience, delivered by a highquality and well prepared workforce.

Note: I have used the term patients to encom-pass all who may need health care and the services

of health care professions and services. I recognisethat varying terms such as clients, service usersand carers may also be applicable alongside thatof the patient.

References

Department of Health (DOH), 2006. Modernising NursingCareers. DoH, London.

Department of Health, 2008a. High Quality Care for All – NHSNext Stage Review Final Report. Department of Health,London, Review Chaired by Professor the Lord Darzi ofDenham KBE, Fmedsci.

Department of Health, 2008b. High Quality Care for All – NHSNext Stage Review Final Report – Summary. Department ofHealth, London, Review Chaired by Professor the Lord Darziof Denham KBE, Fmedsci.

Department of Health, 2008c. High Quality Workforce – NHSNext Stage Review. Department of Health, London.

Department of Health, 2008d. A High Quality Workforce – NHSNext Stage Review: Quality Workforce –Strategy ImpactAssessment. Department of Health, London.

Nursing Standard, 2008. Move to all-graduate profession likely inDarzi review 22 (42), 7.

Sines, D., Naish, J., 2008. Funding Nursing Education: A PolicyDiscussion Paper, RCN Policy Unit, Policy Briefing 10/2008.RCN. London

Smith, P., 1987. The relationship between quality of nursingcare and the ward as a learning environment: developing amethodology. Journal of Advanced Nursing 12, 413–420.

Karen HollandEditor, Nurse Education in Practice

E-mail: karen.holland3@ntlworld.com

Available online at www.sciencedirect.com