- Email: [email protected]
Neonatal nursing education provision in the United Kingdom
Journal of Neonatal Nursing (2013) 19, 224e232
www.elsevier.com/jneo
EDUCATION ISSUES
Neonatal nursing education provision in the United Kingdom Katie Gallagher Department of Child & Adolescent Nursing, King’s College London, 57 Waterloo Road, London SE1 8WA, United Kingdom Available online 4 June 2013
Introduction Infants admitted to the neonatal unit are high risk due to the multitude of adverse events which may occur during their stay. Due to medical and technological advances, the number of infants admitted to neonatal units continues to rise and in the UK in 2011 the National Neonatal Audit Programme downloaded 78,934 episodes of care from 68,192 infants discharged from 163/171 neonatal units participating in the annual data collection period (RCPCH, 2012). Longitudinal research exploring the outcomes of neonatal care has shown that whilst we can effectively provide life sustaining treatment to the most premature of infants, the risk of adverse outcomes (including developmental delay and cognitive impairment) remains a challenge for this group of patients (Costeloe et al., 2012; Beck et al., 2010). These adverse outcomes have serious consequences for the infants and their families (Lake et al., 2012), and so interventions such as developmental care and NIDCAP have evolved to provide holistic care to infants and families. The ability to manage and understand these complex interventions, along with the high technology
E-mail address: [email protected].
therapies and complex treatment regimes, are skills required by the neonatal nurse to effectively care for these patients. This ability is reflected in current research which is starting to explore the relationship between the nurses caring for the infants and adverse events. Evidence from the UK which explored the relationship between nursing staffing and risk adjusted mortality in 54 neonatal intensive care units found that survival in very low birth weight infants was directly related to the proportion of nurses with specialist neonatal nursing qualifications (Hamilton et al., 2007). Similar evidence from the USA found a direct relationship between Recognised Nursing Excellence (RNE) status of the hospital (accredited by the American Nurses Credentialing Centre and encompassing 5 elements of transformational leadership, structural empowerment, exemplary professional practice, new knowledge and innovations and improvements, and empirical outcomes) and reduced risk of 7 day mortality, nosocomial infection and severe intraventricular haemorrhage in very low birth weight infants (Lake et al., 2012). To become effective neonatal practitioners, levels of competence must be achieved before the nurse can work independently in special care, high dependency and intensive care areas. The knowledge underpinning this competence is of vital
1355-1841/$ - see front matter ª 2013 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jnn.2013.04.013
Neonatal nursing education provision in the United Kingdom importance to ensure that the neonatal nurse understands the rationale behind complex interventions and can advocate for the infant and family in their care. This combination of knowledge and competence is currently taught in a variety of formats throughout England. The majority of education is provided through Higher Education Institutions (HEIs), where a range of courses are offered at post registration level which are tailored to meet the needs of the surrounding neonatal units. As there is no governing body which monitors and regulates the content of these post registration courses, a lack of standardisation between courses may occur (BAPM, 2012). For the neonatal nurse, these different educational experiences may result in varying levels of knowledge and skills, and abilities to meet the demands of different neonatal units they may work in during their career. If neonatal nurses are not adequately prepared to meet the complex needs of the infants and families, the risk of adverse outcomes of infants due to lack of qualification (Hamilton et al., 2007) and nursing excellence (Lake et al., 2012) may increase. The recent document ‘matching knowledge and skills for qualified in speciality’ (BAPM, 2012) was developed to address this concern in clinical practice. An expert group of practitioners and academics highlighted the main areas a neonatal nurse would need competence and underpinning knowledge to meet the requirement of ‘Qualified In Speciality’ (QIS), a title provided in the UK for nurses who have taken extra training to work in this area of care. In order for the implementation of this document to be effective, an exploration of current education provision throughout the United Kingdom is required.
Aim The aim of this survey is to explore what education is being provided within HEIs and neonatal units and at what academic level. An understanding of the input of neonatal education into pre registration nursing programmes will also give an insight into the level of exposure of future neonatal nurses to neonatal education.
Methods To explore neonatal nursing education provision in the UK, a survey was developed using an internet based package, Survey Monkey. Questions explored access to education within HEIs, credits
225
awarded to individual courses and the range of assessments used within courses. Two versions of the survey were created, tailored to nurses working in either the hospital or university settings. Version 1, for neonatal nurses working in university settings, included questions exploring assessment formats and credit ratings for neonatal modules. Version 2, for neonatal nurses working in hospital settings, included questions exploring ward based educational provision. Both versions of the questionnaire explored pre registration neonatal nursing education, exploring the educational content of pre registration programmes and the opportunity for placement on the neonatal unit. It was hoped that this would provide an insight into the exposure of the neonatal nurses of the future into neonatal care. The aim of providing two versions of the Survey was to capture all educational provision of offer to neonatal nurses within the universities and units sampled. There were 10 questions in each survey, using a range of responses including space for comments in each. The survey was piloted on a colleague to ensure the questions were clear and that no further questions were required, and adjustments were made accordingly. The links to the surveys (hospital and university versions) were placed in an email which was then sent to all neonatal colleagues on the Special Interest Education Group and the Network of Neonatal Nurse Researchers emailing lists.
Results There were a total of 46 respondents to the survey, including 25 from hospital settings and 16 from the University sector. Removing duplicates of reported Institutions, this represented 28 different universities. Provision of education and access to education will be explored from both the post and pre registration perspective. For the purposes of analysis, only the core neonatal modules will be compared.
Post registration neonatal nursing education provision Respondents within the University sector were asked to report whether they provided post registration education for neonatal nurses. Of the 12 participants who responded, 11 reported that they did. Respondents within the hospital sector were also asked whether they had access to post registration neonatal nursing education in a university setting. Of the 25 respondents, 23 reported that
226
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did have access to university based education. For those reporting no access to university based education, participants were asked what training they provided to neonatal nurses in their units through free text responses: “CPD (continuing professional development) for the SW Region has been contracted to Capita Consulting Ltd to provide all nonaccredited education. Accreditation is not within the contract and Trusts may choose not to fund this education. This is a cause for concern re the future of the neonatal course due to a required minimum number of students per course” “We provide a Foundations in Neonatal Nursing programme which is no longer University accredited but is competency based” Clinical participants were asked to discuss what, if any, neonatal network training was provided for staff as an alternative to university based education. Free text comments provide an insight into this provision: “I provide a neonatal special care, high dependency (introduction to critical care), and enhanced neonatal critical care course” “The neonatal QIS is run in collaboration between a local university and one of the tertiary units e hospital providing education and university providing academic credits. Any other units are able to send staff on course and placement given on L3 unit if required” “We support 2 clinical QIS modules currently accredited.and delivered by Network Educator and other key clinicians.” All respondents were asked to identify which modules or courses were available to the neonatal nurses in their units. The neonatal intensive care
Table 1
module was the most widely reported module available, with 25 clinical and 12 university respondents reporting access to or provision of this course. Separate special care and high dependency modules were more commonly reported than a combined foundation of neonatal nursing module. Enhanced practice and advanced nurse practitioner modules or courses was less widely available with only 48% and 40% respectively reporting availability within the partner Universities (Table 1). Respondents were asked whether nurses had a competency assessment document (CAD) as part of their specialist training. There were only 2 respondents who reported that a CAD was not part of the specialist training, and whose responses reflected a special care and enhanced practice module. All other respondents indicated a CAD was part of the module. Respondents were asked to report at which academic level the above courses were provided. For the entry level courses (foundations and special care), there was a marked distinction between courses being run at diploma and degree level. Very few courses were available at MSc level. This distinction continued through to ANNP level where the course was only available at MSc level (Table 2). Respondents within the university setting were asked to provide information around the methods of assessment for each module, including credits awarded for successful completion (Table 3): Participants from the University setting were asked whether individual modules were linked to specific neonatal qualifications. A range of responses were reported: “Neonatal Critical Care Award is a 60 credit programme.this runs at level 6 or 7 depending upon previous experience and qualifications” “We run a Short Course in Neonatal Studies.the students can use these towards their BSc(Hons) Neonatal Studies”
Number of participants reporting access to different neonatal courses.
Neonatal nursing education provision in the United Kingdom
227
Table 2 Educational level at which neonatal modules are available (NB: responses will equate to more than reported in Q3 due to simultaneous occurrence of modules at different levels taught in same class). 40 35 30 25 20 15 10 5 0 Foundation Neonatal s in Nursing: Neonatal Special Nursing Care Diploma Level Degree Level Masters Level
Table 3 Module FNN NN:SC NN:HD NN:IC NN:EP
1 6 0
7 21 5
Neonatal Nursing: High Dependen cy 6 22 6
Neonatal Advanced Nursing: Neonatal Enhanced Nurse Practice Practitioner
6 23 7
1 9 5
0 1 9
Assessment & credit ratings for completion of neonatal modules. Assessment
Credits awarded (number reported)
Portfolio with reflection, Essay, Short exam question, CAD Case history, Reflection, CAD, Exam Portfolio, Viva, Presentation, MCQ exam, OSCE, Essay, CAD Viva, Assignments, Essay, CAD
“Students can use (neonatal modules) towards a BSc(Hons) Enhanced Neonatal Studies” “(programs available)Diploma in Neonatal Nursing, PG Cert Intensive Care newborn, PG Diploma in Enhancing Neonatal Practice” “On completion of their degree or diploma (students receive) Diploma in Healthcare Practice (Neonatal Critical Care), Degree in Healthcare Practice (Neonatal Critical Care)” “Students can exit with a BSc in neonatal nursing”
Table 4
Neonatal Nursing: Intensive Care
15 (2) 15 (4), 20 (2), 30 (1) 15 (4), 20 (2), 30 (1) 15 (3), 20 (4), 30 (2) 15 (2), 20 (1), 30 (1)
Pre registration neonatal education Of the 16 respondents from within the University Sector, 81% (13) included neonatal education as part of their pre registration nursing curriculum. Respondents were asked during which branch and year of pre registration nursing this education occurred. Education was most common in the child branch programme, with the majority of teaching occurring in year 3. Neonatal content in adult or mental health curriculum was only reported once per branch.
Branch and year of pre registration nursing programme in which neonatal education takes place. 25 20 15 10 5 0 1st year 2nd year 3rd year
Child 3 9 10
Adult 1 0 0
Mental Health 1 0 0
228 Table 5
K. Gallagher Branch & year of pre registration students who undertake placements in the neonatal unit. 50 45 40 35 1 2 3 Do not have these students
30 25 20 15 10 5 0 Child branch Adult branch Mental Health
Through free text comments, four respondents reported the delivery of neonatal educational within the midwifery curriculum and one participant reported that neonatal education was provided through special arrangement (Table 4). Respondents who include neonatal education within their curriculum were asked to estimate the number of teaching hours dedicated to this purpose in the pre registration curriculum. Half of institutions (50%) provided 3e4 h of education, with 10% respectively providing 1e2 or 5e6 h. In 30% of institutions, 7e8 h of curriculum time were dedicated to neonatal teaching. Free text responses also reported 10e12, 20 and 30 h of dedicated teaching time. When asked whether formal placements within the neonatal unit formed part of the pre registration nursing programme, 92% of respondents answered yes. All positive responses reflected the children’s nursing curriculum where respondents reported placements in all three years of the pre
Midwifery
registration nursing curriculum. The availability of placements increased in line with the progression of the student, with only 27% of respondents reporting a neonatal placement in year 1, 82% in year 2 at 82% and 100% in year 3. Respondents within the hospital sector were also asked to report whether pre registration students were accepted for placements in the neonatal units in which they worked, and if so, as part of which branch of nursing and during which years. Only students in the mental health branch were not currently accepted for placement within the neonatal unit, with all other branches of pre registration nursing and midwifery being accepted during various points of their training (Table 5). Finally, all participants were asked to report which University provided post registration neonatal nursing education. Responses from both university and hospital settings have been amalgamated:
University
Course provided
Academic level
Anglia Ruskin University Bedfordshire University Birmingham City University Canterbury Christ Church University City University London
NNSC, HD, ITU, EP NNSC, HD, ITU, EP FONC, HD, ITU, ANNP NNSC, HD, ITU NNSC & HD combined, ITU, EP FONC, ITU FONC, NNSC, HD, ITU, ANNP in progress HHSC, HD, ITU FONC, NNITU NNSC, HD, ITU, EP
Diploma, Degree Diploma, Degree Degree, Masters Degree Degree
Coventry University De Montfort University Hull university Keele University King’s College London
Degree Degree Degree Degree Diploma, Degree
Neonatal nursing education provision in the United Kingdom
229
(continued ) University
Course provided
Academic level
Kingston University
NNSC, HD, ITU, neonatal pathophysiology HHSC, ITU NNSC, HD, ITU, ANNP FONC, ITU, EP, ANNP NNSC, HD, ITU, EP, ANNP NNSC, HD, ITU, EP, ANNP NNSC, HD, ITU, EP, ANNP NNSC, HD, ITU, EP NNSC, HD, ITU
Diploma, Degree
Leeds University Liverpool John Moores London South Bank University Manchester University Napier University, Edinburgh Northumbria University Salford University Sheffield University Southampton University Stafford University Teesside University University of Brighton University of Central Lancashire University of East Anglia University of Plymouth (in partnership with Derriford Hospital) University of West of Scotland Wolverhampton University
ANNP In collaboration with Heart of England NNSC, HD, EP, ANNP NNSC, ITU NNSC, HD, ITU NNSC, HD, ITU, EP,(ANNP) under consideration NNSC, HD, ITU, EP NNSC, HD, ITU, ANNP FONC, NNSC, HD, ITU, ANNP FONC, ITU
Discussion Limitations The aim of this exploratory survey was to determine the provision and academic level of neonatal nursing education within the UK. The survey is limited by its small response rate, and potentially missing some HEI provision around the same institutions. Of the 46 institutions reported, removing duplicates revealed 28 individual universities. As an exploratory study, what this does provide is an insight into the current status of educational provision within England that can be built upon in future research. The findings will briefly be explored from the post and pre registration perspectives.
Post registration The results indicate that there is an increasing demand for neonatal nursing education at the higher academic level of degree and masters. This may be reflective of the move to degree level entry only to the nursing profession, resulting in graduates who require either BSc or MSc post qualification courses to meet or exceed their current academic level of learning. This shift towards a minimum of degree level education may bring
Degree Degree, Masters Degree, Masters Degree, Masters Degree, Masters Degree, Masters Degree, Masters Diploma, Degree, Masters Masters Degree, Masters Degree Degree Diploma, Degree Diploma, Degree Degree, Masters Diploma, Degree, Masters Degree
challenges in the continuing requirement for education at diploma level for staff recruited from overseas to meet workforce demands of the neonatal unit, and whose previous qualifications do not meet BSc requirements of the UK. Exploration of the size of this demand is required to determine how best to meet the needs of these neonatal nurses; potential collaboration between different HEI’s to ensure all levels are provided at different institutions may be one step towards a resolution. The results also indicate a move towards e-learning in neonatal education, with Trusts in the South West of England currently moving towards a complete provision of CPD through e-learning packages (Health Education South West, 2013). From a Trust perspective, the benefits of elearning can be seen in minimising issues around flexibility of granting study leave and the associated requirement to release staff from clinical areas (Hewitt-Taylor, 2003). However research into the utilisation of e-learning in post registration nursing students has identified that numerous factors may inhibit interaction with e-learning, including inequalities in functional computer abilities (particularly in mature students) and a lack of confidence in perceived e-learning capability (McVeigh, 2009). Some of these issues may reduce over time due to the changing nature of the post registration student, however education providers
230 need to be aware of the need for additional support when moving towards this form of education. Moving towards e-learning will also require research to explore the impact of e-learning as opposed to classroom teaching upon nursing knowledge, and any associated adverse infant outcomes, to determine the effectiveness of this method as a learning tool. Individuals assimilate new knowledge in different ways (Nelson Laird et al., 2008), and it has been found that content along with environment contribute to the development of interest, attention and learning (Hidi and Renninger, 2006). Current research has evaluated the effectiveness of e-learning versus tradition lectures in a variety of pre and post registration nursing settings with mixed results indicating both improved knowledge retention (Bloomfield et al., 2010) and lower knowledge scores on resulting questionnaires (Reime et al., 2008). An interesting finding from Reime et al. (2008) indicated that students using e-learning saw this resource as the whole syllabus and did not access further information, compared to the lecture group who saw the lecture as an additional source to their individual study. This reinforces the need for clear information regarding the purpose of e-learning, and support to be available when utilising this is curriculum design. The results also identify a wide range of assessment methods and credits awarded for similar courses. This raises questions around the course content itself and the variability between HEIs, as assessment should be reflective of the course objectives as a method of directing and enhancing students learning (Zou, 2008). Such variety in method of assessment would indicate variation between course content and opportunities for student feedback to help students improve throughout their entire course of study. Whilst differing course content may not be an entirely negative finding e research has found that creativity in the classroom can help foster critical thinking skills in students (Anderson, 2010) e this has implications for nurses moving between different units, whose education has been provided through different institutions. With the development of the ‘matching knowledge and skills for qualified in speciality’ document (BAPM, 2012), it would be interesting to explore whether HEIs who use this method to develop curriculum content also amend their assessment methods. This variation between assessment methods also suggests that there may be inequalities in the amount of summative work expected from the student in relation to the credits on offer. Adding to the complexity is the
K. Gallagher variation in cost of course provision between HEI; whilst a core curriculum content may not be the most appropriate solution to address such variation (course costs are driven by individual HEIs and not module providers), increased collaboration between course providers may provide more strategic approach to curriculum content for neonatal nurses. What was not mentioned throughout the survey was the availability of specialist neonatal outreach or community courses or modules, although some respondents did report specialist surgical or pathophysiology modules. The Neonatal Toolkit (2009) suggests that qualified in speciality may take the form of either an intensivist nurse or a community nurse, however as of yet it appears that the HEI’s are not meeting the requirements to fulfil this role. More discussion and exploration between Trusts and HEI’s is required to explore the potential demand for such a course, and what the basic outline of this course or module would be.
Pre registration Respondents have indicated that the majority of neonatal education occurs in the children’s nursing pathways at pre registration level. This input is limited however to <6 h input across the years in most programmes, with the reported exception being midwifery where students may undertake a short course in neonatal care. Despite this, placements within the neonatal unit are available to students throughout their training meaning that students are potentially going into the environment with little educational preparation. The importance of strong mentors in these situations is required to ensure that the students experience is a positive one, in order to attract students into a potential career in neonatal nursing in the future. Whilst little research exists to correlate positive experience with entering neonatal nursing as a career choice, experience at post registration does highlight the importance of strong preceptors in helping new graduates to transition into their new role (Hom, 2003), and aid with retention of these members of staff (Faron and Poeltler, 2007). An aspect which has not been explored is the role of educational input into other branches of pre registration nursing curriculum, and related potential short placements in neonatal units or mother & baby units. The results indicate the majority of academic learning and clinical placements occur in the pre registration children’s nursing branch, however nursing students from all
Neonatal nursing education provision in the United Kingdom branches have the potential to gain an insight into family functioning as part of a placement on the neonatal unit. Recent research has shown the psychological impact that preterm birth and admission to the neonatal unit can have upon parents and families. Studies reported an increased risk of Post Traumatic Stress Disorder (PTSD) in mothers following their infants admission to the neonatal unit, with symptoms found amongst mothers whose infants were in the neonatal unit for 6 months (Vanderbilt et al., 2009; Feeley et al., 2011). This increasing awareness of the impact of neonatal admissions has led authors to explore the role of the nurse in identifying maternal perinatal depression in the neonatal unit (Bicking and Moore, 2012), as the benefits of recognition of symptoms for parents could lead to more positive feelings of control, coping and ability to ‘parent’ and bond with their infant in the neonatal unit (Bicking and Moore, 2012). Expanding the role of the nurse into one of treating both the infant and the parents highlights the potential for collaboration between all branches of nursing. In these settings, nursing students would gain an insight into the difficult and unpredictable scenarios parents find themselves in, and how multidisciplinary teams can work together to care for these potentially vulnerable families. In combination with a crossover of educational input between the different branches in the HEI setting, this could also help to increase awareness and promote collaborative working between all nursing students. As more neonatal infants are discharged to a community setting which is currently undergoing a recruitment drive to increase the numbers of health visitor’s available (Department of Health, 2011), the nurses caring for families could be from a variety of branches. An understanding of experiences in the neonatal unit is arguably crucial to providing effective care for these families. Taking this into consideration for future pre registration nursing placements may become increasingly important as this trend develops.
Summary The aim of this survey was to determine the neonatal nursing educational provision at both pre and post registration level throughout England. A small number of responses were received which provided a good level of insight into current practices. What is now required is further exploration of these findings to determine how HEI’s and Trusts can work together to provide the
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educational content required for neonatal nurses to be qualified in speciality, using the knowledge and skills framework.
References Anderson, K., 2010. The whole learner: the role of imagination in developing disciplinary understanding. Arts and Humanities in Higher Education 9 (2), 205e221. Beck, S., Wojdyla, D., Say, L., Betran, A.P., Merialdi, M., Harris Requejo, J., Rubens, C., Menon, R., Van Look, P., 2010. The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bulletin of the World Health Organization 88, 31e38. http://dx.doi.org/10.2471/ BLT.08.062554. Bicking, C., Moore, G.A., 2012. Maternal perinatal depression in the neonatal intensive care unit: the role of the neonatal nurse. Neonatal Network 31 (5), 295e304. Bloomfield, J., Roberts, J., et al., 2010. The effect of computer-assisted learning versus conventional teaching methods on the acquisition and retention of handwashing theory and skills in pre-qualification nursing students: a randomised controlled trial. International Journal of Nursing Studies 47 (3), 287e294. British Association of Perinatal Medicine, 2012. Matching Knowledge and Skills for Qualified in Speciality. www.bapm.org. Costeloe, K.L., Hennessy, E.M., Haider, S., Stacey, F., Marlow, N., Draper, E.D., 2012. Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies). BMJ 345, e7976. Department of Health, 2011. Health Visiting Implementation Plan: a Call to Action. www.dh.gov.uk. Department of Health, 2009. Toolkit for High Quality Neonatal Services. www.dh.gov.uk. Faron, S., Poeltler, D., 2007. Growing our own: inspiring growth and increasing retention through mentoring. Nursing for Women’s Health 11 (2), 139e143. Feeley, N., Zelkowitz, P., Cormier, C., et al., 2011. Posttraumatic stress among mothers of very low birthweight infants at 6 months after discharge from the neonatal intensive care unit. Applied Nursing Research 24 (2), 114e117. Hamilton, K., Redshaw, M., Tarnow-Mordi, W., 2007. Nurse staffing in relation to risk-adjusted mortality in neonatal care. Archives Diseases in Children: Fetal and Neonatal Edition 92, F99eF103. Health Education South West, 2013. http://workforce. southwest.nhs.uk. Hewitt-Taylor, J., 2003. Facilitating distance learning in nurse education. Nurse Education in Practice 3 (1), 23e29. Hidi, S., Renninger, K.A., 2006. The four-phase model of interest development. Educational Psychologist 41 (2), 111e127. Hom, E., 2003. Coaching and mentoring new graduates entering perinatal nursing practice. Journal of Perinatal and Neonatal Nursing 17 (1), 35e49. Lake, E.T., Staiger, D., Horbar, J., et al., 2012. Association between hospital recognition for nursing excellence and outcomes of very low-birth-weight infants. JAMA: The Journal of the American Medical Association 307 (16), 1709e1716. McVeigh, H., 2009. Factors influencing the utilisation of e-learning in post-registration nursing students. Nurse Education Today 29 (1), 91e99. Nelson Laird, T.F., Shoup, R., Kuh, G.D., Schwarz, M.J., 2008. The effects of discipline on deep approaches to student
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learning and college outcomes. Research in Higher Education 49, 469e494. Reime, M.H., Harris, A., et al., 2008. The most successful method in teaching nursing students infection control e E-learning or lecture? Nurse Education Today 28 (7), 798e806. Royal College of Paediatrics and Child Health, 2012. Annual Report 2011: National Neonatal Audit Programme. www. rcpch.ac.uk.
Vanderbilt, D., Bushley, T., Young, R., Frank, D., 2009. Acute posttraumatic stress symptoms among urban mothers with newborns in the neonatal intensive care unit: a preliminary study. Journal of Developmental & Behavioral Pediatrics 30 (1), 50e56. Zou, P.X.W., 2008. Designing effective assessment in postgraduate construction project management studies. Journal for Education in the Built Environment 4 (2), 80e94.
Available online at www.sciencedirect.com
www.elsevier.com/jneo
EDUCATION ISSUES
Neonatal nursing education provision in the United Kingdom Katie Gallagher Department of Child & Adolescent Nursing, King’s College London, 57 Waterloo Road, London SE1 8WA, United Kingdom Available online 4 June 2013
Introduction Infants admitted to the neonatal unit are high risk due to the multitude of adverse events which may occur during their stay. Due to medical and technological advances, the number of infants admitted to neonatal units continues to rise and in the UK in 2011 the National Neonatal Audit Programme downloaded 78,934 episodes of care from 68,192 infants discharged from 163/171 neonatal units participating in the annual data collection period (RCPCH, 2012). Longitudinal research exploring the outcomes of neonatal care has shown that whilst we can effectively provide life sustaining treatment to the most premature of infants, the risk of adverse outcomes (including developmental delay and cognitive impairment) remains a challenge for this group of patients (Costeloe et al., 2012; Beck et al., 2010). These adverse outcomes have serious consequences for the infants and their families (Lake et al., 2012), and so interventions such as developmental care and NIDCAP have evolved to provide holistic care to infants and families. The ability to manage and understand these complex interventions, along with the high technology
E-mail address: [email protected].
therapies and complex treatment regimes, are skills required by the neonatal nurse to effectively care for these patients. This ability is reflected in current research which is starting to explore the relationship between the nurses caring for the infants and adverse events. Evidence from the UK which explored the relationship between nursing staffing and risk adjusted mortality in 54 neonatal intensive care units found that survival in very low birth weight infants was directly related to the proportion of nurses with specialist neonatal nursing qualifications (Hamilton et al., 2007). Similar evidence from the USA found a direct relationship between Recognised Nursing Excellence (RNE) status of the hospital (accredited by the American Nurses Credentialing Centre and encompassing 5 elements of transformational leadership, structural empowerment, exemplary professional practice, new knowledge and innovations and improvements, and empirical outcomes) and reduced risk of 7 day mortality, nosocomial infection and severe intraventricular haemorrhage in very low birth weight infants (Lake et al., 2012). To become effective neonatal practitioners, levels of competence must be achieved before the nurse can work independently in special care, high dependency and intensive care areas. The knowledge underpinning this competence is of vital
1355-1841/$ - see front matter ª 2013 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jnn.2013.04.013
Neonatal nursing education provision in the United Kingdom importance to ensure that the neonatal nurse understands the rationale behind complex interventions and can advocate for the infant and family in their care. This combination of knowledge and competence is currently taught in a variety of formats throughout England. The majority of education is provided through Higher Education Institutions (HEIs), where a range of courses are offered at post registration level which are tailored to meet the needs of the surrounding neonatal units. As there is no governing body which monitors and regulates the content of these post registration courses, a lack of standardisation between courses may occur (BAPM, 2012). For the neonatal nurse, these different educational experiences may result in varying levels of knowledge and skills, and abilities to meet the demands of different neonatal units they may work in during their career. If neonatal nurses are not adequately prepared to meet the complex needs of the infants and families, the risk of adverse outcomes of infants due to lack of qualification (Hamilton et al., 2007) and nursing excellence (Lake et al., 2012) may increase. The recent document ‘matching knowledge and skills for qualified in speciality’ (BAPM, 2012) was developed to address this concern in clinical practice. An expert group of practitioners and academics highlighted the main areas a neonatal nurse would need competence and underpinning knowledge to meet the requirement of ‘Qualified In Speciality’ (QIS), a title provided in the UK for nurses who have taken extra training to work in this area of care. In order for the implementation of this document to be effective, an exploration of current education provision throughout the United Kingdom is required.
Aim The aim of this survey is to explore what education is being provided within HEIs and neonatal units and at what academic level. An understanding of the input of neonatal education into pre registration nursing programmes will also give an insight into the level of exposure of future neonatal nurses to neonatal education.
Methods To explore neonatal nursing education provision in the UK, a survey was developed using an internet based package, Survey Monkey. Questions explored access to education within HEIs, credits
225
awarded to individual courses and the range of assessments used within courses. Two versions of the survey were created, tailored to nurses working in either the hospital or university settings. Version 1, for neonatal nurses working in university settings, included questions exploring assessment formats and credit ratings for neonatal modules. Version 2, for neonatal nurses working in hospital settings, included questions exploring ward based educational provision. Both versions of the questionnaire explored pre registration neonatal nursing education, exploring the educational content of pre registration programmes and the opportunity for placement on the neonatal unit. It was hoped that this would provide an insight into the exposure of the neonatal nurses of the future into neonatal care. The aim of providing two versions of the Survey was to capture all educational provision of offer to neonatal nurses within the universities and units sampled. There were 10 questions in each survey, using a range of responses including space for comments in each. The survey was piloted on a colleague to ensure the questions were clear and that no further questions were required, and adjustments were made accordingly. The links to the surveys (hospital and university versions) were placed in an email which was then sent to all neonatal colleagues on the Special Interest Education Group and the Network of Neonatal Nurse Researchers emailing lists.
Results There were a total of 46 respondents to the survey, including 25 from hospital settings and 16 from the University sector. Removing duplicates of reported Institutions, this represented 28 different universities. Provision of education and access to education will be explored from both the post and pre registration perspective. For the purposes of analysis, only the core neonatal modules will be compared.
Post registration neonatal nursing education provision Respondents within the University sector were asked to report whether they provided post registration education for neonatal nurses. Of the 12 participants who responded, 11 reported that they did. Respondents within the hospital sector were also asked whether they had access to post registration neonatal nursing education in a university setting. Of the 25 respondents, 23 reported that
226
K. Gallagher
did have access to university based education. For those reporting no access to university based education, participants were asked what training they provided to neonatal nurses in their units through free text responses: “CPD (continuing professional development) for the SW Region has been contracted to Capita Consulting Ltd to provide all nonaccredited education. Accreditation is not within the contract and Trusts may choose not to fund this education. This is a cause for concern re the future of the neonatal course due to a required minimum number of students per course” “We provide a Foundations in Neonatal Nursing programme which is no longer University accredited but is competency based” Clinical participants were asked to discuss what, if any, neonatal network training was provided for staff as an alternative to university based education. Free text comments provide an insight into this provision: “I provide a neonatal special care, high dependency (introduction to critical care), and enhanced neonatal critical care course” “The neonatal QIS is run in collaboration between a local university and one of the tertiary units e hospital providing education and university providing academic credits. Any other units are able to send staff on course and placement given on L3 unit if required” “We support 2 clinical QIS modules currently accredited.and delivered by Network Educator and other key clinicians.” All respondents were asked to identify which modules or courses were available to the neonatal nurses in their units. The neonatal intensive care
Table 1
module was the most widely reported module available, with 25 clinical and 12 university respondents reporting access to or provision of this course. Separate special care and high dependency modules were more commonly reported than a combined foundation of neonatal nursing module. Enhanced practice and advanced nurse practitioner modules or courses was less widely available with only 48% and 40% respectively reporting availability within the partner Universities (Table 1). Respondents were asked whether nurses had a competency assessment document (CAD) as part of their specialist training. There were only 2 respondents who reported that a CAD was not part of the specialist training, and whose responses reflected a special care and enhanced practice module. All other respondents indicated a CAD was part of the module. Respondents were asked to report at which academic level the above courses were provided. For the entry level courses (foundations and special care), there was a marked distinction between courses being run at diploma and degree level. Very few courses were available at MSc level. This distinction continued through to ANNP level where the course was only available at MSc level (Table 2). Respondents within the university setting were asked to provide information around the methods of assessment for each module, including credits awarded for successful completion (Table 3): Participants from the University setting were asked whether individual modules were linked to specific neonatal qualifications. A range of responses were reported: “Neonatal Critical Care Award is a 60 credit programme.this runs at level 6 or 7 depending upon previous experience and qualifications” “We run a Short Course in Neonatal Studies.the students can use these towards their BSc(Hons) Neonatal Studies”
Number of participants reporting access to different neonatal courses.
Neonatal nursing education provision in the United Kingdom
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Table 2 Educational level at which neonatal modules are available (NB: responses will equate to more than reported in Q3 due to simultaneous occurrence of modules at different levels taught in same class). 40 35 30 25 20 15 10 5 0 Foundation Neonatal s in Nursing: Neonatal Special Nursing Care Diploma Level Degree Level Masters Level
Table 3 Module FNN NN:SC NN:HD NN:IC NN:EP
1 6 0
7 21 5
Neonatal Nursing: High Dependen cy 6 22 6
Neonatal Advanced Nursing: Neonatal Enhanced Nurse Practice Practitioner
6 23 7
1 9 5
0 1 9
Assessment & credit ratings for completion of neonatal modules. Assessment
Credits awarded (number reported)
Portfolio with reflection, Essay, Short exam question, CAD Case history, Reflection, CAD, Exam Portfolio, Viva, Presentation, MCQ exam, OSCE, Essay, CAD Viva, Assignments, Essay, CAD
“Students can use (neonatal modules) towards a BSc(Hons) Enhanced Neonatal Studies” “(programs available)Diploma in Neonatal Nursing, PG Cert Intensive Care newborn, PG Diploma in Enhancing Neonatal Practice” “On completion of their degree or diploma (students receive) Diploma in Healthcare Practice (Neonatal Critical Care), Degree in Healthcare Practice (Neonatal Critical Care)” “Students can exit with a BSc in neonatal nursing”
Table 4
Neonatal Nursing: Intensive Care
15 (2) 15 (4), 20 (2), 30 (1) 15 (4), 20 (2), 30 (1) 15 (3), 20 (4), 30 (2) 15 (2), 20 (1), 30 (1)
Pre registration neonatal education Of the 16 respondents from within the University Sector, 81% (13) included neonatal education as part of their pre registration nursing curriculum. Respondents were asked during which branch and year of pre registration nursing this education occurred. Education was most common in the child branch programme, with the majority of teaching occurring in year 3. Neonatal content in adult or mental health curriculum was only reported once per branch.
Branch and year of pre registration nursing programme in which neonatal education takes place. 25 20 15 10 5 0 1st year 2nd year 3rd year
Child 3 9 10
Adult 1 0 0
Mental Health 1 0 0
228 Table 5
K. Gallagher Branch & year of pre registration students who undertake placements in the neonatal unit. 50 45 40 35 1 2 3 Do not have these students
30 25 20 15 10 5 0 Child branch Adult branch Mental Health
Through free text comments, four respondents reported the delivery of neonatal educational within the midwifery curriculum and one participant reported that neonatal education was provided through special arrangement (Table 4). Respondents who include neonatal education within their curriculum were asked to estimate the number of teaching hours dedicated to this purpose in the pre registration curriculum. Half of institutions (50%) provided 3e4 h of education, with 10% respectively providing 1e2 or 5e6 h. In 30% of institutions, 7e8 h of curriculum time were dedicated to neonatal teaching. Free text responses also reported 10e12, 20 and 30 h of dedicated teaching time. When asked whether formal placements within the neonatal unit formed part of the pre registration nursing programme, 92% of respondents answered yes. All positive responses reflected the children’s nursing curriculum where respondents reported placements in all three years of the pre
Midwifery
registration nursing curriculum. The availability of placements increased in line with the progression of the student, with only 27% of respondents reporting a neonatal placement in year 1, 82% in year 2 at 82% and 100% in year 3. Respondents within the hospital sector were also asked to report whether pre registration students were accepted for placements in the neonatal units in which they worked, and if so, as part of which branch of nursing and during which years. Only students in the mental health branch were not currently accepted for placement within the neonatal unit, with all other branches of pre registration nursing and midwifery being accepted during various points of their training (Table 5). Finally, all participants were asked to report which University provided post registration neonatal nursing education. Responses from both university and hospital settings have been amalgamated:
University
Course provided
Academic level
Anglia Ruskin University Bedfordshire University Birmingham City University Canterbury Christ Church University City University London
NNSC, HD, ITU, EP NNSC, HD, ITU, EP FONC, HD, ITU, ANNP NNSC, HD, ITU NNSC & HD combined, ITU, EP FONC, ITU FONC, NNSC, HD, ITU, ANNP in progress HHSC, HD, ITU FONC, NNITU NNSC, HD, ITU, EP
Diploma, Degree Diploma, Degree Degree, Masters Degree Degree
Coventry University De Montfort University Hull university Keele University King’s College London
Degree Degree Degree Degree Diploma, Degree
Neonatal nursing education provision in the United Kingdom
229
(continued ) University
Course provided
Academic level
Kingston University
NNSC, HD, ITU, neonatal pathophysiology HHSC, ITU NNSC, HD, ITU, ANNP FONC, ITU, EP, ANNP NNSC, HD, ITU, EP, ANNP NNSC, HD, ITU, EP, ANNP NNSC, HD, ITU, EP, ANNP NNSC, HD, ITU, EP NNSC, HD, ITU
Diploma, Degree
Leeds University Liverpool John Moores London South Bank University Manchester University Napier University, Edinburgh Northumbria University Salford University Sheffield University Southampton University Stafford University Teesside University University of Brighton University of Central Lancashire University of East Anglia University of Plymouth (in partnership with Derriford Hospital) University of West of Scotland Wolverhampton University
ANNP In collaboration with Heart of England NNSC, HD, EP, ANNP NNSC, ITU NNSC, HD, ITU NNSC, HD, ITU, EP,(ANNP) under consideration NNSC, HD, ITU, EP NNSC, HD, ITU, ANNP FONC, NNSC, HD, ITU, ANNP FONC, ITU
Discussion Limitations The aim of this exploratory survey was to determine the provision and academic level of neonatal nursing education within the UK. The survey is limited by its small response rate, and potentially missing some HEI provision around the same institutions. Of the 46 institutions reported, removing duplicates revealed 28 individual universities. As an exploratory study, what this does provide is an insight into the current status of educational provision within England that can be built upon in future research. The findings will briefly be explored from the post and pre registration perspectives.
Post registration The results indicate that there is an increasing demand for neonatal nursing education at the higher academic level of degree and masters. This may be reflective of the move to degree level entry only to the nursing profession, resulting in graduates who require either BSc or MSc post qualification courses to meet or exceed their current academic level of learning. This shift towards a minimum of degree level education may bring
Degree Degree, Masters Degree, Masters Degree, Masters Degree, Masters Degree, Masters Degree, Masters Diploma, Degree, Masters Masters Degree, Masters Degree Degree Diploma, Degree Diploma, Degree Degree, Masters Diploma, Degree, Masters Degree
challenges in the continuing requirement for education at diploma level for staff recruited from overseas to meet workforce demands of the neonatal unit, and whose previous qualifications do not meet BSc requirements of the UK. Exploration of the size of this demand is required to determine how best to meet the needs of these neonatal nurses; potential collaboration between different HEI’s to ensure all levels are provided at different institutions may be one step towards a resolution. The results also indicate a move towards e-learning in neonatal education, with Trusts in the South West of England currently moving towards a complete provision of CPD through e-learning packages (Health Education South West, 2013). From a Trust perspective, the benefits of elearning can be seen in minimising issues around flexibility of granting study leave and the associated requirement to release staff from clinical areas (Hewitt-Taylor, 2003). However research into the utilisation of e-learning in post registration nursing students has identified that numerous factors may inhibit interaction with e-learning, including inequalities in functional computer abilities (particularly in mature students) and a lack of confidence in perceived e-learning capability (McVeigh, 2009). Some of these issues may reduce over time due to the changing nature of the post registration student, however education providers
230 need to be aware of the need for additional support when moving towards this form of education. Moving towards e-learning will also require research to explore the impact of e-learning as opposed to classroom teaching upon nursing knowledge, and any associated adverse infant outcomes, to determine the effectiveness of this method as a learning tool. Individuals assimilate new knowledge in different ways (Nelson Laird et al., 2008), and it has been found that content along with environment contribute to the development of interest, attention and learning (Hidi and Renninger, 2006). Current research has evaluated the effectiveness of e-learning versus tradition lectures in a variety of pre and post registration nursing settings with mixed results indicating both improved knowledge retention (Bloomfield et al., 2010) and lower knowledge scores on resulting questionnaires (Reime et al., 2008). An interesting finding from Reime et al. (2008) indicated that students using e-learning saw this resource as the whole syllabus and did not access further information, compared to the lecture group who saw the lecture as an additional source to their individual study. This reinforces the need for clear information regarding the purpose of e-learning, and support to be available when utilising this is curriculum design. The results also identify a wide range of assessment methods and credits awarded for similar courses. This raises questions around the course content itself and the variability between HEIs, as assessment should be reflective of the course objectives as a method of directing and enhancing students learning (Zou, 2008). Such variety in method of assessment would indicate variation between course content and opportunities for student feedback to help students improve throughout their entire course of study. Whilst differing course content may not be an entirely negative finding e research has found that creativity in the classroom can help foster critical thinking skills in students (Anderson, 2010) e this has implications for nurses moving between different units, whose education has been provided through different institutions. With the development of the ‘matching knowledge and skills for qualified in speciality’ document (BAPM, 2012), it would be interesting to explore whether HEIs who use this method to develop curriculum content also amend their assessment methods. This variation between assessment methods also suggests that there may be inequalities in the amount of summative work expected from the student in relation to the credits on offer. Adding to the complexity is the
K. Gallagher variation in cost of course provision between HEI; whilst a core curriculum content may not be the most appropriate solution to address such variation (course costs are driven by individual HEIs and not module providers), increased collaboration between course providers may provide more strategic approach to curriculum content for neonatal nurses. What was not mentioned throughout the survey was the availability of specialist neonatal outreach or community courses or modules, although some respondents did report specialist surgical or pathophysiology modules. The Neonatal Toolkit (2009) suggests that qualified in speciality may take the form of either an intensivist nurse or a community nurse, however as of yet it appears that the HEI’s are not meeting the requirements to fulfil this role. More discussion and exploration between Trusts and HEI’s is required to explore the potential demand for such a course, and what the basic outline of this course or module would be.
Pre registration Respondents have indicated that the majority of neonatal education occurs in the children’s nursing pathways at pre registration level. This input is limited however to <6 h input across the years in most programmes, with the reported exception being midwifery where students may undertake a short course in neonatal care. Despite this, placements within the neonatal unit are available to students throughout their training meaning that students are potentially going into the environment with little educational preparation. The importance of strong mentors in these situations is required to ensure that the students experience is a positive one, in order to attract students into a potential career in neonatal nursing in the future. Whilst little research exists to correlate positive experience with entering neonatal nursing as a career choice, experience at post registration does highlight the importance of strong preceptors in helping new graduates to transition into their new role (Hom, 2003), and aid with retention of these members of staff (Faron and Poeltler, 2007). An aspect which has not been explored is the role of educational input into other branches of pre registration nursing curriculum, and related potential short placements in neonatal units or mother & baby units. The results indicate the majority of academic learning and clinical placements occur in the pre registration children’s nursing branch, however nursing students from all
Neonatal nursing education provision in the United Kingdom branches have the potential to gain an insight into family functioning as part of a placement on the neonatal unit. Recent research has shown the psychological impact that preterm birth and admission to the neonatal unit can have upon parents and families. Studies reported an increased risk of Post Traumatic Stress Disorder (PTSD) in mothers following their infants admission to the neonatal unit, with symptoms found amongst mothers whose infants were in the neonatal unit for 6 months (Vanderbilt et al., 2009; Feeley et al., 2011). This increasing awareness of the impact of neonatal admissions has led authors to explore the role of the nurse in identifying maternal perinatal depression in the neonatal unit (Bicking and Moore, 2012), as the benefits of recognition of symptoms for parents could lead to more positive feelings of control, coping and ability to ‘parent’ and bond with their infant in the neonatal unit (Bicking and Moore, 2012). Expanding the role of the nurse into one of treating both the infant and the parents highlights the potential for collaboration between all branches of nursing. In these settings, nursing students would gain an insight into the difficult and unpredictable scenarios parents find themselves in, and how multidisciplinary teams can work together to care for these potentially vulnerable families. In combination with a crossover of educational input between the different branches in the HEI setting, this could also help to increase awareness and promote collaborative working between all nursing students. As more neonatal infants are discharged to a community setting which is currently undergoing a recruitment drive to increase the numbers of health visitor’s available (Department of Health, 2011), the nurses caring for families could be from a variety of branches. An understanding of experiences in the neonatal unit is arguably crucial to providing effective care for these families. Taking this into consideration for future pre registration nursing placements may become increasingly important as this trend develops.
Summary The aim of this survey was to determine the neonatal nursing educational provision at both pre and post registration level throughout England. A small number of responses were received which provided a good level of insight into current practices. What is now required is further exploration of these findings to determine how HEI’s and Trusts can work together to provide the
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educational content required for neonatal nurses to be qualified in speciality, using the knowledge and skills framework.
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