Nurrc Educatwn T&y (1991) 11, 8%93 0 Longman Group UK Ltd 1991

Nurse Education Tomorrow Conference 1990

Reforming nurse education 2 - implications for teachers and students

Joan Chandler

The development of Project 2000 will lead to the reorganisation of nursing knowledge as nurse education enters higher education. This paper explores the implications of these changes for the future of role of nurse teachers and the new choices for professional development as teachers evolve into nursing theorists, lecturer practitioners and educational managers. The paper also explores changing pedagogic relationships with students, changing assessment strategies, their new supernumerary position in clinical environments, and reference groups likely to be selected by students. Finally it examines the ways in which links with higher education and the contributions of non-nurse academics may lead to the reorganisation of course management structures.

INTRODUCTION

As nursing enters higher education under the auspices of Project 2000, a series of questions are raised about the future role of nurse tutors, pedagogic relationships with students, modes of assessment and educational management. These questions are addressed in this second article on the implications of the changes in train in nurse education in Britain.

As nursing knowledge enters higher edu- cation, it is being cut up and partly hived off to other disciplines, a process which is bound to stir

fears and defensiveness among nurse tutors about what is left. The remaining core of nursing knowledge then has two parts, nursing theory and nursing practice, and both may present problems to the staff of colleges of healthjnur- sing. The development of a more self-conscious nursing theory will mean that this element of nursing knowledge will become more esoteric, more detached from everyday nursing know- ledge. Relatedly, it must be remembered that a profession whose knowledge is common place is a contradictory concept. Hence social and intell- ectual pressures unite as, if nursing theory is to be recognised in higher education and be able to converse and comDete with other discivlines. it

Joan Chandler BA (HonsJ Sot PhD is jointly Lecturer 1

in Sociology at South West College of Health Studies, must develop the accoutrements to knbwledge

North Friary House, Greenbank Terrace, Plymouth, of a conceptual framework and an epistemologi- Devon PL4 &3Q and the Department of Applied Social cal base. Studies, 15 Portland Villas, Polytechnic South West, Drake Circus, Plymouth, Devon PL4 8AA.

There are other forces for the abstraction of

(Requests for offprints to JC) nursing knowledge. As it draws upon social, Manuscript accepted 12 December 1990 behavioural and life sciences problems are

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encountered as each of these’ allied disciplines has its own epistemology and methodo!ogy, each its own route(s) to truth. As the search for intellectually common ground is made, so con- ceptual frameworks are elevated to higher levels of abstraction or exponents of nursing know- ledge ignore epistemological questions and con- centrate on the practical problems presented by the world of nursing work. Difficulties arise in identifying what is nursing research. Rather than argue at a conceptual level research is largely given an empirical grounding in the pursuit of the technical objectives of clinical practice. Consequently, nursing is developing an empirico-analytic tradition of research-based practice, an approach which may be viewed as technicist and with some disdain by many social and behavioural scientists.

NURSING KNOWLEDGE AND NURSE TUTORS

The changing nature of nursing knowledge impinges directly on the future educational role of nurse tutors. Tutors in the past have attempted to further their careers by pursuing courses in education. and this is evident in the differing educational profiles of tutors in higher education and colleges of health/nursing. Nurse

tutors who have in the past wanted career development have frequently pursued first and subsequent degrees in education for a number of reasons: the furthering of expertise in nurs- ing was both not available and not relevant; what was to be developed was their capacity to teach not what they were teaching; they were appointed for their administrative skills as much as their knowledge of clinical areas. They were essentially generalists and are now left, partiahy stranded, as the educational tide turns. Other qualities will be demanded in the future. Special- ists are likely to be sought in a nursing theory which is more tightly defined and, if it is to find a place in higher education, academically credible. Alternatively, nurse tutors may choose to develop more specific knowledge of particular clinical areas or become more effective edu- cational managers. But what is evident is that the status quo is no longer an option.

Aside from nursing theory, in the new courses nurse practice is redefined as education rather than employment and becomes a programme of study which runs alongside other programmes which are more classroom based. It is part of the modularisation of nursing, a structure which permits diverse themes to run concurrently, and one which is in keeping with courses throughout higher education. Practice appears as one strand of study and it is difficult both for those in higher education and colleges of nursing to understand or accept this. In colleges of nursing this is because it is so central to the course and in new structures it appears demoted; in higher edu- cation it is because practice is a marginal activity in academic courses which still prioritise academic study and formal examination.

The reformulation of practice also raises different problems for nurse tutors in terms of their educational role within clinical settings and their professional relationship with service per- sonnel. When students were employed they could be despatched to wards where, in their apprentice-like training, their supervision by clinical staff would merge imperceptibly with the management of their labour. In 1986 the Royal College of Nursing estimated that about three- quarters of nursing care in hospitals was given by student nurses, On the wards the role of tutors was essentially administrative and pastoral. The supernumerary status of students in the future and their more limited presence on the wards (especially in the Common Foundation Pro- gramme) calls for the closer involvement and educational monitoring of students in clinical settings. If classroom time is allocated to related disciplines and nursing theory and clinical staff become more reluctant to supervise students, a different remit for nurse tutors will emerge, generating challenges which they may or may not be willing to accept.

ASSESSMENT

As knowledge is reorganised so is its valid realisation, as there are changes in what counts as important and relevant knowledge for assess- ment. Assessment of any course is always a guide

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to what is deemed really worth knowing and Project 2000 brings a number of changes. There will be more formal written examinations and new ways of assessing practice at diploma level. Part of being taken seriously is an approximation to the principals of formal assessment and this has fuelled the search for objective. validated tools of practice assessment. It may lead to a greater emphasis on numeric marks, so that divisions between pass and fail are transformed into grades of achievement as is the form in higher education. For practice to be validated at a diploma level there is also pressure for the assessment tools to be more complex and sensi- tive. If service personnel are to administer these assessments, they must have both greater know- ledge of and greater commitment towards assessment strategies and objectives. To be effective assessors service personnel may need both greater training, which will make greater demands on colleges of heahhinursing, and some occupational reward for their efforts, which is beyond the gift of an educational

establishment.

Project 2000 brings potential contradiction. As the assessment demands on service personnel increase so their links with now supernumerary students become more tenuous. It remains unclear what the new links between trained staff and students will be during different parts of the

course, although progression is more con- sciously built into the new nurse training. The worse scenario could be that: in the Common Foundation Programme, where students have a limited involvement with wards, that they would be only seen as having a nuisance value; in the Branch Programmes, after more extensive study and where students emerge with a level of qualification higher than that of their assessor, they would be viewed with trepidation.

Furthermore, any proposal for health service personnel to assess the extent to which students apply knowledge gained in classroom to the delivery of care in practice is setting an imp- ossible task. Trained staff are being asked to assess the application of knowledge when they have not been privy to its acquisition. Who can assess in practice areas may in the future present problems. but also who can assess theoretical

work may cause some consternation. To assess in subject specialism is a traditional solution, but this of course does little to help integration or applicability. However, any integrative assess- ments between nursing and its subject- specialisms raises the spectre of who can legitimately mark what, of alternative perspec- tives and standards that blend uneasily.

As students become supernumerary and hos- pitals opt out, who is responsible for assessment becomes a more pressing problem. To continue with an assessment system built entirely around service personnel, which educational estab- lishments do not control has its difhculties. Also as colleges of health/nursing become the vessel in which knowledge of theory and practice are mixed, institutional boundaries blur. This raises questions not only about the relationship of colleges of health/nursing to higher educational establishments and service settings, and also between higher education and health providers.

Here colleges of health may act as go-betweens, a position which has its organisational discomforts.

PEDAGOGY

The reorganisation of nursing knowledge also alters pedagogy, what counts as the valid trans- mission of knowledge and appropriate relation- ships with students. As nursing knowledge is to be validated at diploma level and the number of nursing degrees proliferate, students will have to reach an agreed standard. This means students will have less power over the pace and content of what is taught. However, they may gain more privacy. Academic subject specialists may feel uncomfortable about commenting on student behaviour and attitude other than as it affects them personally or influences student perform- ance in the assessments for which they are responsible. This may lead to the re-drawing of the boundaries in nursing between the personal and the professional, giving reduced scope for nursing socialisation. Also the pastoral care given in academic institutions may be substan- tially different from the mentorship offered by nurse tutors and clinical personnel.

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The changing curriculum means that the representations of the workplace will be different to new students. As nursing knowledge is removed from its close connection with ward organisation, it will alter the identities and the experiences of student nurses. MacKay’s account of nurses in training (1989) details the not unfamiliar gap between nurse education and the wards, about learning to nurse in ‘the proper way’ and learning to nurse in a ‘realistic way’. The vocationalism that is learned on the wards is hostile to the clever nurse and values personal qualities, giving status to those who can accept hard work and human tragedy unflinchingly. In the accounts of learners there is the strong theme of fear of exclusion by the ward staff and the experience of being scapegoated as the occupant of the lowest tier within a rigid nursing hierarchy. As students move with each allo- cation, the experience is repeated until they learn to fit it, in a system of training that is designed to make student nurses eager to please. This is reinforced by systems of assessment which is based on the judgements of ward staff. The strong hierarchies within nursing discour- age empathy from experienced staff and staff shortages may bring early responsibility, where those who can swallow hard and buckle down survive.

The reorganisation of student knowledge in Project 2000 may alter this system. Where student nurses are taught in institutions of higher education and mingle with other students, their reference group may not be ward staff but other students. More limited time on wards means that there will be fess social pressure on them to fit in. However, in their discussion of undergraduate nurse training, Ashworth and Morrison (1989) give some indi- cation of the likely practice experiences of the Project 2000 nurse. They note that aside from the inevitable tensions between education and work, short-lived placements continue to generate anomaly and tension for the student nurse. Under Project 2000 tension may be greater as clinical staff voice anxieties about the student nurse of the future. Part of the anxiety is that students will not be so easily or effectively controlled, which they may well not be. It could

be argued that the knowledgeable nurse in herself is not a problem, as a growing number of trained staff have diplomas and degrees, but

these staff tend to be in superior positions. Hence, some of the fears are about the unk- nown, but many others are about the knowledge- able underling and the threats they pose to the status hierarchy of nurses and medical prac- titioners.

COURSE MANAGEMENT

The reorganisation of knowledge also has impli- cations for the management of courses and the allegiances of tutors. Nurse tutors with mana- gerial responsibility for courses may find specialist tutors less controllable as their prime loyalty is to subject areas and they remain final arbiters of knowledge in their specialist area. Collection codes mean that there are strong allegiances vertically and, at classroom level, a tolerance and privacy which limits and contains the potential for inter-disciplinary conflict and rivalry.

Colleges of health/nursing are monotechnic institutions in contrast with polytechnic estab- lishments of higher education and this has a number of organisational implications. Compe- tition for resources is keener within polytechnic establishments and here departmental politics is a well-practised pursuit. There are questions about whose model of management should apply and how responsibility for new course will be distributed. The concept of conjoint planning may be naive but the strategies of organisational encirclement are unhelpful and unproductive. Also any merging of education and service in the context of rising educational standards creates other ambiguities and role strains uoachim 1988), other contradictions about appropriate course managment and ultimate control.

An emergent issue is the future home of schools of nursing which, as they are margin- alised in the health service, may be forced to move closer to institutions of higher education, to find allies in their navigation of organisational and institutional change. Otherwise they may be forced to occupy isolated and vulnerable

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positions, vulnerable because of changes in nurse education and health care provision. Where hospitals opt out their directorates may become more akin to private employers rather than public authorities and as they become more like employers they are likely to adopt the same attitudes towards employment training. Employers in Britain have traditionally had small regard for training (Sheldrake & Vicker- staff 1987; Chandler & Wallace 1990). preferring to poach rather than to train and, where training is carried out, to tie this to immediate needs. However, any commitment to training demands a long-term perspective rather than immediate cost-consciousness.

The reorganisation of nursing knowledge reflects institutional change, part of the con- tinuing debate between issues of education and training. Nurse education is inevitably moving more towards the education end of the conti- nuum, where knowledge is taught more discur- sively and more critically and greater onus is placed upon the student to integrate and apply this knowledge. But from the perspective of higher education it is a movement towards vocational training in courses whose recruitment is driven by local manpower strategies, whose students hold bursaries not grants, where edu- cation is tempered by service-giving, whose assessments are more integrative and practice- based and where the relevance of specialist input may be judged by those outside that field of

expertise.

CONCLUSION

The changing curricula and the new connections with higher education raise a series of edu- cational problems to be solved by colleges of health/nursing. These range from the relation- ship between nursing and non/nursing special- ists, through the future role of nurse tutors and the links between higher education and clinical staff and on to the implications these changes have for pedagogic relationships, forms of assessment and course administration. These seem to be one set of related issues to be debated if not resolved by nurse educators of both today and tomorrow.

References

Ashworth P, Morrison P 1989 Some ambiguites of the student’s role in undergraduate nurse training. Journal of Advanced Nursing 14: 1009-1015

Chandler J, Wallace C 1990 Some alternatives in youth training: franchise and corporatist models. In: Training and Its Alternatives D Gleeson (ed). Open UniversTty Press, Milton Keynes

loachim G 1988 Faculty practice: dilemmas and 0 solutions. Journal of’A’dvanced Nursing 13: 410-415 Mackay 1989 Nursing a Problem. Open University

Press, Milton Keynes Royal College of Nursing 1986 A Manifesto for Nursing

and Health. RCN, London Sheldrake J, Vickerstaff S A 1987 The History of

Industrial Training in Britain. Gower, Aldershot