Education and debate
Education and staffing in the ICU: past, present and future Carol Ball, St Bartholomew’s College of Nursing and Midwifery, London This article discusses the history of intensive care education in the UK and the impact of recent developments and their effect on the education of nurses in intensive care units.
Miss Hall is Intensive Care Unit Tutor at St Bartholomew’s College of Nursing and Midwifery, London
T J L he Joint Board of Clinical Nursing
Studies (BJCNS) was established in 1972 to provide postregistration education in specialist areas. The main reason for its gen esis was to standardize the type of clinical experience and theoretical input available. The JBCNS also sought to: 1. Outline theoretical content and the amount of time spent in the classroom 2. Approve clinical areas, ensuring that they provided appropriate experience and learning opportunities 3. Provide specialist education that would prepare nurses to work in areas for which their basic State Registered Nurse education had not qualified them. In 1979, the Nurses, Health Visitors and Midwives Act established the four national boards of England, Scotland, Wales and Northern Ireland. The English National Board (ENB) replaced the JBCNS for postregistration education, establishing the ENB 100 General Intensive Care Nursing Course. The specialist courses, as well as incorporating specific knowledge, skills and attitudes, included study days related to management, research appreciation and basic teaching skills. That is to say, if three specialist courses, e.g. intensive care unit (ICU), oncology and renal, were establish ed in one institution, then all three would run separate management, research and teaching study days. This was seen to be a waste of available resources. There then arose the prospect of a core curriculum, whereby all professional issues and shared clinical skills would be taught in all specialist courses together. Not only was shared learning to occur, but assess ment and evaluation were also to be stan dardized across courses, and these were to be based on the same nursing model. Two problems are associated with this innova tion. First, the large numbers of students restrict the type of teaching method that can be employed. Second, the nursing model chosen to structure the curriculum
BritishJournalolNursing. l992,Vol I, N o 8
content does not generate enough theory to be tested and deemed appropriate for use in particular clinical areas. However, the core curriculum does allow different clini cal groups to gain a wider perspective of professional issues. It may also be more ef ficient in terms of resources, e.g. teacher time and classroom usage. Increasing efficiency is a very important factor in the reorganization of the NHS un der the 1990 National Health Service and Community Care Act. This introduces the concept of provider/purchaser units to gether with the separation of nursing col leges from the health authorities, to which they have historically belonged, and their amalgamation with universities and poly technics. The nursing college will now be a provider of specialist education and the clinical areas will be the purchasers, or it may be that the individual nurse will be come the purchaser of his/her own educa tion.
Project 2000 Education of preregistration students has also been revised in the UK and upgraded to diploma level. The aim of Project 2000 is to prepare the nurse to work in any area where the health requirements of people need to be met. This may include intensive care. At present, Project 2000 students arc not being allocated to ICUs in any great num ber. Therefore, their ability to function in this area may be limited. This indicates that future specialist education in intensive care will be a requirement, but does not necess arily guarantee the continuation of the cur rent ENB 100.
Post-Registration Education and Practice Project In 1990 the UK Central Council — the nurses’ governing body in the UK — introduced the Post-Registration Education and Practice Project. The main recommen-
399 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 16, 2019.
Education and staffing in the ICU: past, present and future
(It is clear that both education and staffing in the IC U are in a state of flux. Intensive care nurses have the responsibility to ensure that the standard o f care delivered to our patients is the highest achievable. 5
dations of this initiative which have specific implications for intensive care are that: 1. There should be a period of support for registered practitioners to consolidate their competence 2. A preceptor should provide support for each newly registered practitioner 3. All nurses must demonstrate profes sional knowledge and competence 4. Professional development should be re corded in a personal professional profile 5. Each practitioner should have a mini mum of 5 days study leave every 3 years 6. To function at the level of advanced practitioner, skills of effective leadership and sophisticated analytical ability should be demonstrated. With reference to the first two, a 6month orientation period to intensive care could replace the ENB 100. This orienta tion period could be facilitated by the ad vanced practitioner. Two questions arise, however: first, how would the educational value of clinical experience and skills be identified and, second, to what level would the advanced practitioner be educated?
Credit Accum ulation Transfer System To answer the former questions we need to explore another innovation, namely the Cred it Accumulation Transfer System (CATS). This was established to provide educational rec ognition of all the learning that the individ ual has undertaken. Points are allocated by the Council for National Academic Awards to certain levels of learning, e.g. certificate level carries 120 points, diploma level carr ies 240 points, degree level carries 360 points and masters level carries 480 points, At pre sent the ENB 100 is accorded 70 points at certificate level. In some colleges, nurses who register after 1987 are already accredited 240 points, equating to diploma level and so the further accumulation of points at certificate level is obviously futile. For this reason many colleges of nursing are attempting to integrate intensive care education into di ploma or degree modular programmes. Cli nical experience will also be accorded credit accumulation points, but these have yet to be identified by the Council for National Academic Awards. It is postulated that a masters degree will be necessary to ensure the appropriate level of analytical ability for the advanced practitioner. Another issue related to CATS is the as sessment of diploma or degree level prac tice. This is important both for newly regis tered practitioners and for those who have
400
been registered for several years. For the former it may mean that they will be unable to undertake degree level studies in nursing until they are able to practise at the required level. Criteria for assessing diploma/degree level practice have yet to be identified. For the latter a system of accreditation of prior experiential learning (APEL) will be used to assess the clinician’s level of practice (Hill, 1992). The aim of the process is to value the clinical experience of the nurse and credit this towards her professional education. This therefore highlights the im portance of clinical experience in the pro fessional education of the nurse.
ENB Higher Award The recording of professional development in a personal professional profile is covered by another innovation, this time generated by the ENB, entitled the ENB Higher Award. The scheme will commence in April 1992 and practitioners will have to demonstrate increasing expertise in 10 key characteristics. 1. Professional accountability and respon sibility 2. Clinical expertise with a specific client group 3. Using research to plan, implement and evaluate strategies to improve care 4. Team working and building (multidis ciplinary team leadership) 5. Flexible and innovative approaches to care 6. Use of health promotion strategies 7. Facilitating and assessing development in others 8. Handling information and making in formed clinical decisions 9. Setting standards and evaluating quality of care 10. Instigating, managing and evaluating clinical change. This award will be equivalent to an honour’s degree. The Higher Award will comprise 12-week modules each accorded a certain number of CATS points. Utilizing the outcomes of Characteristic 2, the current ENB 100 Gen eral Intensive Care Course may be taught in two or three modules. Associated with this is a reduction in the amount of hours spent by students in the classroom. In order for the ENB Higher Award to be validated as diploma/degree level, the amount of self-di rected study performed by the student will be increased. Individuals requiring specific information related to this should approach their local college of nursing. British Journal of Nursing, 1992, Vol l,N o 8
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 16, 2019.
Education and staffing in the ICU: past, present and future
Staffing levels The impact of 5 study days over 3 years for each member of the ICU staff will have to be considered. Obviously, those inten sive care nurses who want to work towards a degree will require more study leave than this. However, if we take the example of an ICU which has an establishment figure of 80 nurses, then 400 study days will need to be attended over 3 years in order for those nurses to register. That means 400 shifts when the number of nurses will be reduced by at least one. No extra funding is being provided to cover this loss of man power. Therefore, it is unlikely, given the limited financial resources available, that these nurses will be replaced by agency or bank nurses. Another factor that will affect staffing levels relates to the current market place philosophy in the NHS. MacSweeney (1991) stated that both Project 2000 and the Post-Registration Education and Practice Project are an attempt to prepare the pro fession for a rapidly changing work envi ronment, or what Davies (1990) called the collapse of the conventional career. Davies proposed four areas in which the nursing profession and education should respond to the changes in employment arrangements. First, part-time work is expected to increase and part-time nurses should have equal status and the same access to continuing education and opportunities as their full time colleagues. This will obviously have an effect on staffing levels, e.g. if two people sharing a job are entitled to the same
KEY POINTS • The Joint Board of Clinical Nursing Studies (JBCNS), established in 1972, sought to standardize the type of clinical experience and theoretical input required for postregistration nurses in specialist areas. • The English National Board (ENB) superseded the JBCNS as a result of the Nurses, Health Visitors and Midwives Act of 1979. • Colleges of nursing will become the providers of specialist intensive care education and the clinical areas or individual nurses will become the purchasers. • The implementation of Project 2000 may alter the educational needs of nurses wishing to specialize in intensive care. • The introduction of the Credit Accumulation Transfer System will lead to diploma or degree level modules being developed in intensive care. • Increasing clinical expertise could be engendered through the ENB Higher Award. • More flexible use of the workforce Is envisaged, promoting the use of part-time and episodic employment, to meet the demands of the NHS as a contract-based organization.
British Journal of Nursing, 1992,Vol l,N o 8
amount of study leave, then double the per iod will be required for one whole-time equivalent. Second, episodic participation in paid work will become more common. People will move in and out of the paid labour market and come forward for train ing at different ages and with different life experience. Third, contract-based organiz ation is already in place in the NHS and nurse education programmes will be deter mined by this. Finally, flexible use of the workforce will increase.
Conclusion What then is the future of education and staffing in the ICU? In education, advanced practitioners could facilitate skill acquisition in newcomers to intensive care and be re sponsible for maintaining standards of practice. Colleges of nursing will become self-governing trusts or faculties within a university. They will provide study days re lated to issues in intensive care which have been contracted for by specific hospitals. Degree level intensive care modules may also be provided for individuals who wish to increase their credit accumulation points to degree level. Clinical masters pro grammes could be developed to prepare the advanced practitioner. This would have the added benefit of improving the level of nursing research in intensive care in the UK. With reference to staffing levels, there will be a great deal more flexibility in em ployment in the future. It is usual in the UK to have a 1:1 nurse:patient ratio in the ICU. This practice may be in jeopardy as nurses will be increasingly absent from the clinical environment while they fulfil their professional obligations. Advanced practi tioners will be employed, improving career opportunities for clinical nurses. It is clear that both education and staffing in the ICU are in a state of flux. Intensive care nurses have the responsibility to ensure that the standard of care delivered to our patients is the highest achievable. To this end, theoretical and clinical education must be geared to providing an appropriate skill mix, with the provision of high quality care as our ultimate goal.
Davits C (1990) The Collapse o f the Conventional Ca reer: The Future of Work and its Relevance for Postregistration Education in Nursing, Midwifery and Health Visiting. ENB, London Hull C (1992) Experience counts. Nurs Times 88 (23): 36-7 MacSweeney P (1991) The collapse of the conventional career, Nurs Times 87 (31): 26-8
401 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 16, 2019.
Education and staffing in the ICU: past, present and future Carol Ball, St Bartholomew’s College of Nursing and Midwifery, London This article discusses the history of intensive care education in the UK and the impact of recent developments and their effect on the education of nurses in intensive care units.
Miss Hall is Intensive Care Unit Tutor at St Bartholomew’s College of Nursing and Midwifery, London
T J L he Joint Board of Clinical Nursing
Studies (BJCNS) was established in 1972 to provide postregistration education in specialist areas. The main reason for its gen esis was to standardize the type of clinical experience and theoretical input available. The JBCNS also sought to: 1. Outline theoretical content and the amount of time spent in the classroom 2. Approve clinical areas, ensuring that they provided appropriate experience and learning opportunities 3. Provide specialist education that would prepare nurses to work in areas for which their basic State Registered Nurse education had not qualified them. In 1979, the Nurses, Health Visitors and Midwives Act established the four national boards of England, Scotland, Wales and Northern Ireland. The English National Board (ENB) replaced the JBCNS for postregistration education, establishing the ENB 100 General Intensive Care Nursing Course. The specialist courses, as well as incorporating specific knowledge, skills and attitudes, included study days related to management, research appreciation and basic teaching skills. That is to say, if three specialist courses, e.g. intensive care unit (ICU), oncology and renal, were establish ed in one institution, then all three would run separate management, research and teaching study days. This was seen to be a waste of available resources. There then arose the prospect of a core curriculum, whereby all professional issues and shared clinical skills would be taught in all specialist courses together. Not only was shared learning to occur, but assess ment and evaluation were also to be stan dardized across courses, and these were to be based on the same nursing model. Two problems are associated with this innova tion. First, the large numbers of students restrict the type of teaching method that can be employed. Second, the nursing model chosen to structure the curriculum
BritishJournalolNursing. l992,Vol I, N o 8
content does not generate enough theory to be tested and deemed appropriate for use in particular clinical areas. However, the core curriculum does allow different clini cal groups to gain a wider perspective of professional issues. It may also be more ef ficient in terms of resources, e.g. teacher time and classroom usage. Increasing efficiency is a very important factor in the reorganization of the NHS un der the 1990 National Health Service and Community Care Act. This introduces the concept of provider/purchaser units to gether with the separation of nursing col leges from the health authorities, to which they have historically belonged, and their amalgamation with universities and poly technics. The nursing college will now be a provider of specialist education and the clinical areas will be the purchasers, or it may be that the individual nurse will be come the purchaser of his/her own educa tion.
Project 2000 Education of preregistration students has also been revised in the UK and upgraded to diploma level. The aim of Project 2000 is to prepare the nurse to work in any area where the health requirements of people need to be met. This may include intensive care. At present, Project 2000 students arc not being allocated to ICUs in any great num ber. Therefore, their ability to function in this area may be limited. This indicates that future specialist education in intensive care will be a requirement, but does not necess arily guarantee the continuation of the cur rent ENB 100.
Post-Registration Education and Practice Project In 1990 the UK Central Council — the nurses’ governing body in the UK — introduced the Post-Registration Education and Practice Project. The main recommen-
399 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 16, 2019.
Education and staffing in the ICU: past, present and future
(It is clear that both education and staffing in the IC U are in a state of flux. Intensive care nurses have the responsibility to ensure that the standard o f care delivered to our patients is the highest achievable. 5
dations of this initiative which have specific implications for intensive care are that: 1. There should be a period of support for registered practitioners to consolidate their competence 2. A preceptor should provide support for each newly registered practitioner 3. All nurses must demonstrate profes sional knowledge and competence 4. Professional development should be re corded in a personal professional profile 5. Each practitioner should have a mini mum of 5 days study leave every 3 years 6. To function at the level of advanced practitioner, skills of effective leadership and sophisticated analytical ability should be demonstrated. With reference to the first two, a 6month orientation period to intensive care could replace the ENB 100. This orienta tion period could be facilitated by the ad vanced practitioner. Two questions arise, however: first, how would the educational value of clinical experience and skills be identified and, second, to what level would the advanced practitioner be educated?
Credit Accum ulation Transfer System To answer the former questions we need to explore another innovation, namely the Cred it Accumulation Transfer System (CATS). This was established to provide educational rec ognition of all the learning that the individ ual has undertaken. Points are allocated by the Council for National Academic Awards to certain levels of learning, e.g. certificate level carries 120 points, diploma level carr ies 240 points, degree level carries 360 points and masters level carries 480 points, At pre sent the ENB 100 is accorded 70 points at certificate level. In some colleges, nurses who register after 1987 are already accredited 240 points, equating to diploma level and so the further accumulation of points at certificate level is obviously futile. For this reason many colleges of nursing are attempting to integrate intensive care education into di ploma or degree modular programmes. Cli nical experience will also be accorded credit accumulation points, but these have yet to be identified by the Council for National Academic Awards. It is postulated that a masters degree will be necessary to ensure the appropriate level of analytical ability for the advanced practitioner. Another issue related to CATS is the as sessment of diploma or degree level prac tice. This is important both for newly regis tered practitioners and for those who have
400
been registered for several years. For the former it may mean that they will be unable to undertake degree level studies in nursing until they are able to practise at the required level. Criteria for assessing diploma/degree level practice have yet to be identified. For the latter a system of accreditation of prior experiential learning (APEL) will be used to assess the clinician’s level of practice (Hill, 1992). The aim of the process is to value the clinical experience of the nurse and credit this towards her professional education. This therefore highlights the im portance of clinical experience in the pro fessional education of the nurse.
ENB Higher Award The recording of professional development in a personal professional profile is covered by another innovation, this time generated by the ENB, entitled the ENB Higher Award. The scheme will commence in April 1992 and practitioners will have to demonstrate increasing expertise in 10 key characteristics. 1. Professional accountability and respon sibility 2. Clinical expertise with a specific client group 3. Using research to plan, implement and evaluate strategies to improve care 4. Team working and building (multidis ciplinary team leadership) 5. Flexible and innovative approaches to care 6. Use of health promotion strategies 7. Facilitating and assessing development in others 8. Handling information and making in formed clinical decisions 9. Setting standards and evaluating quality of care 10. Instigating, managing and evaluating clinical change. This award will be equivalent to an honour’s degree. The Higher Award will comprise 12-week modules each accorded a certain number of CATS points. Utilizing the outcomes of Characteristic 2, the current ENB 100 Gen eral Intensive Care Course may be taught in two or three modules. Associated with this is a reduction in the amount of hours spent by students in the classroom. In order for the ENB Higher Award to be validated as diploma/degree level, the amount of self-di rected study performed by the student will be increased. Individuals requiring specific information related to this should approach their local college of nursing. British Journal of Nursing, 1992, Vol l,N o 8
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 16, 2019.
Education and staffing in the ICU: past, present and future
Staffing levels The impact of 5 study days over 3 years for each member of the ICU staff will have to be considered. Obviously, those inten sive care nurses who want to work towards a degree will require more study leave than this. However, if we take the example of an ICU which has an establishment figure of 80 nurses, then 400 study days will need to be attended over 3 years in order for those nurses to register. That means 400 shifts when the number of nurses will be reduced by at least one. No extra funding is being provided to cover this loss of man power. Therefore, it is unlikely, given the limited financial resources available, that these nurses will be replaced by agency or bank nurses. Another factor that will affect staffing levels relates to the current market place philosophy in the NHS. MacSweeney (1991) stated that both Project 2000 and the Post-Registration Education and Practice Project are an attempt to prepare the pro fession for a rapidly changing work envi ronment, or what Davies (1990) called the collapse of the conventional career. Davies proposed four areas in which the nursing profession and education should respond to the changes in employment arrangements. First, part-time work is expected to increase and part-time nurses should have equal status and the same access to continuing education and opportunities as their full time colleagues. This will obviously have an effect on staffing levels, e.g. if two people sharing a job are entitled to the same
KEY POINTS • The Joint Board of Clinical Nursing Studies (JBCNS), established in 1972, sought to standardize the type of clinical experience and theoretical input required for postregistration nurses in specialist areas. • The English National Board (ENB) superseded the JBCNS as a result of the Nurses, Health Visitors and Midwives Act of 1979. • Colleges of nursing will become the providers of specialist intensive care education and the clinical areas or individual nurses will become the purchasers. • The implementation of Project 2000 may alter the educational needs of nurses wishing to specialize in intensive care. • The introduction of the Credit Accumulation Transfer System will lead to diploma or degree level modules being developed in intensive care. • Increasing clinical expertise could be engendered through the ENB Higher Award. • More flexible use of the workforce Is envisaged, promoting the use of part-time and episodic employment, to meet the demands of the NHS as a contract-based organization.
British Journal of Nursing, 1992,Vol l,N o 8
amount of study leave, then double the per iod will be required for one whole-time equivalent. Second, episodic participation in paid work will become more common. People will move in and out of the paid labour market and come forward for train ing at different ages and with different life experience. Third, contract-based organiz ation is already in place in the NHS and nurse education programmes will be deter mined by this. Finally, flexible use of the workforce will increase.
Conclusion What then is the future of education and staffing in the ICU? In education, advanced practitioners could facilitate skill acquisition in newcomers to intensive care and be re sponsible for maintaining standards of practice. Colleges of nursing will become self-governing trusts or faculties within a university. They will provide study days re lated to issues in intensive care which have been contracted for by specific hospitals. Degree level intensive care modules may also be provided for individuals who wish to increase their credit accumulation points to degree level. Clinical masters pro grammes could be developed to prepare the advanced practitioner. This would have the added benefit of improving the level of nursing research in intensive care in the UK. With reference to staffing levels, there will be a great deal more flexibility in em ployment in the future. It is usual in the UK to have a 1:1 nurse:patient ratio in the ICU. This practice may be in jeopardy as nurses will be increasingly absent from the clinical environment while they fulfil their professional obligations. Advanced practi tioners will be employed, improving career opportunities for clinical nurses. It is clear that both education and staffing in the ICU are in a state of flux. Intensive care nurses have the responsibility to ensure that the standard of care delivered to our patients is the highest achievable. To this end, theoretical and clinical education must be geared to providing an appropriate skill mix, with the provision of high quality care as our ultimate goal.
Davits C (1990) The Collapse o f the Conventional Ca reer: The Future of Work and its Relevance for Postregistration Education in Nursing, Midwifery and Health Visiting. ENB, London Hull C (1992) Experience counts. Nurs Times 88 (23): 36-7 MacSweeney P (1991) The collapse of the conventional career, Nurs Times 87 (31): 26-8
401 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 16, 2019.
