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The training of mental handicap nurses—an FE College experience of joint training
NURSE EDUCATION TODAY
The training of mental handicap nurses an FE College experience of joint training D G Holloway and E F Cannon Lecturers, Norwich City College of Further and Higher Education IN RECENT YEARS the mental handicap hospitals and their staff have been subject to considerable criticism in official reports, the mass media, and in academic studies. During the same period knowledge concerning mental handicap has developed impressively. Such developments have been accompanied by : changes in social policy towards the care of mentally handicapped people. Although progress has been slow, policy has aimed at reducing the number of beds in the long-stay hospitals and expanding community services. Such developments have led to increased attention being paid to the RNMS training. The existing pattern has been criticised as being biased towards general nursing and inappropriate for mental handicap nursing, despite · syllabus modifications in 1957 and 1970. As reported briefly in this journal in August 1982, the Broadland School of Nursing (Mental Handicap Division) and Norwich City College of Further and Higher Education (the Department of Health and Community Studies) have, since 1976, been working in partnership to develop a nurse education programme which will prepare mental handicap nurses not only to work within the hospital setting, but also to serve in community residential or day care agencies, or to provide domiciliary nursing support. In addition, the course is designed to prepare nurses to take a responsible part, in due course, in shaping the new patterns of care for the mentally handicapped adumbrated in B ett er Services for the M entally Handicapped and in the Briggs, Warnock, and Jay Reports. This joint RNMS course remains based in the 'hospital. \Vard experience, clinical teaching, and blocks of study in the Nurse Education Centre still form the core of the three-year programme in preparation for the RNMS examination. In addition, an extensive programme of community studies and community practical experience is grafted on to this stem, allowing student nurses to gain knowledge of other models of care and education of the mentally handicapped, to establish relationships with workers in these other caring agencies, and to observe them at work and discuss with them their values, aims, objectives, and methods. During the six years this course has been running it has undergone continuous monitoring and curriculum development. A major evaluation of the 22
College component has recently been completed and action is now being taken to modify further aspects of it as a result. Attention is now being turned to the hospital component, and co-operation from nursing staff at all levels is being sought. However, since it is the College component which is The new and unusual aspect of the training, this seems to be a useful point at which to present our experiences in developing and mounting this joint training programme. THE CURRICULUM General aims and organisation In concept and implementation the principal aim has been to identify and reconcile the educational needs of a professional group whose role is being challenged by the professionals themselves and interested parties. The course leading to the RNMS qualification follows the usual three-year period for State Registration and offers three academic terms at the College. These terms are organised to occur in each of three respective years of training. Each of the terms has a similar structure, arranged as follows:
• two days per week full-time College-based study; • three days per week in a community placement. The remainder of the training period is spent in the clinical areas of Little Plumstead Hospital. The College modules are supplemented by an eight-week introductory course and a series of study blocks. Community studies modules Each module lasts one academic term, approximately twelve weeks . Module 1: The educational theme is the growth, development, care, and education of the mentally handicapped child. Theoretical inputs, from sociology, psychology, human growth and development, and language development, and practical placements have been devised to enable the student nurses to integrate the College-based learning with their practical experiences, and to apply both within the hospital situation. This integration is facilitated by close contact between College staff and nurse tutors. The student nurses are placed in local education authority special schools throughout the module, during which time they have the opportunity
NURSE EDUCATION TODAY to experience the organisation and application of teaching techniques and group management, and to evaluate techniques and approaches to child care with direct application to the hospital situation. Module 2: The educational theme is the education of the mentally handicapped adult within community and hospital settings. Students are provided with opportunities to develop teaching and remedial skills which have direct application within the hospital setting through courses on social skills, behaviour modification, and educational psychology. The students are placed in Social Services Department Adult Training Centres, where they are able to observe and participate in the care and education of the mentally handicapped adults in a community setting. This enables students to contrast and compare the training and remedial practices of an ATC with those of the hospital, and exposes them to the attitudes and values of other professional groups working with mentally handicapped adults. Module 3: · This aims at consolidating and extending the students' learning in modules 1 and 2. The educational theme examines the concepts of community and community care. This is achieved through courses on sociology, social administration, psychology, normalisation, and counselling. Classroom inputs are supplemented by a series of observational visits to community agencies offering residential accommodation, day care, and work for the mentally and physically handicapped, and by placements with social workers, health visitors, and in community residential establishments. The visits and placements enable the student to develop an understanding of the relationship between social services and health services in the provision of resources for mentally handicapped people.
PLACEMENTS The programme of placements has been devised to complement the themes of each module. Firstly, students spend the whole term's placement in special schools, usually, but designedly not exclusively, in schools for mentally handicapped children. Schools for the physically handicapped, for emotionally deprived and/or disturbed children, and for the deaf are or have been used, allowing student nurses the opportunity to explore under guidance the interface between these conditions and 'mental handicap'. In the second module the whole term's practical experience is gained in Adult Training Centres where students can begin to gain a knowledge and understanding of social services provision for the mentally handicapped, and, in the more progressive centres, participate in training groups and see how trainees can be helped towards greater independence and the ability to manage. their lives with the minimum of supervision necessary. The third module placement programme is of necessity more varied and therefore more fragmentary. One half-term's experience in a community residential setting is provided, as well as
short periods of attachment to field social workers and to health visitors. Certain difficulties have been encountered in gaining a sufficient number of good placements within the areas accessible to students without subjecting them to an unreasonable amount of travelling, and the hospital to unreasonable levels of expense. These difficulties arise firstly in securing enough placements in social services agencies and with their field workers, and also with health visitors. These services are under great pressure from any number of social services and health service training programmes to take more and more students in placement, and some agencies have latterly also been a target for MSC work experience placements for the young unemployed. The second source of difficulty is the quality of the placement: in all types of agency used, some examples are excellent, some leave much to be desired, either in the quality of service they provide to clients or in their approach to the management of the students' experience. As with all other aspects of the course, the placements are continuously under observation and negotiations continue with all agencies concerned. The aims are always to provide a sufficient number of good placements and adequate support for each student in his/her individual situation, and to maintain close contact with the agency supervisors in order to monitor the students' progress and make a detailed assessment of their performance. It is hoped that this process can be refined and formalised so that placement assessments can eventually be included in the RNMS assessment profile in the manner in which ward reports are at present.
ADJUSTMENT Nurse training has long been recognised as demanding in physical, intellectual, and emotional terms. This course is more demanding in all those ways than most. Students experience considerable stress in adjusting initially to the College environment, and in making successive adjustments as they move between College, nurse training school, ward experience, and community placements. Much travelling is involved as the hospital, where many students live, is eight miles from the College in a village with a minimal bus service, while placements are scattered around the city and its environs. Perhaps the major difficulty students experience is in adjusting to the College. This is hardly surprising. Until their arrival in College the ir training has taken place within a ward team or in the Nurse Education Centre-both small-scale, even intimate, settings. By contrast, the College is vast, confusing, and apparently impersonal. The well-worn fabric of a functional and overcrowded college of further education comes as a nasty shock to students from a well-appointed Nurse Education Centre situated in a graciously designed country mansion. Likewise, it is not easy to move from being the only group of 23
NURSE EDUCATION TODAY students in block to being ,one group among hundreds. Stimulating and exciting it can be, but undeniably it takes some getting used to . Finally, intangible though it might seem at first sight, it is worth considering that when they are in the hospital environment these young people are on the staff side, with all the advantages of status and accommodation that brings. In College they become students, and although the distinction between staff and students is not so sharply drawn as that between staff and patients in the hospital, the loss of status is felt. Many of these strains are ultimately unavoidable, but we have found that they can be alleviated to some exten t. Firstly, by long and careful preparation for th e College experience, beginning in the initial interview before an applicant is accepted for nurse training, and continuing during' the introductory block in the Nurse Education Centre. Secondly, by assigning to each group a College tutor, again at a very early stage; a tutor who will remain the key link person between: College and hospital for that group for as long as they have contact with the College. \X'here this key person and the group's own tutor within the Nurse Education Centre maintain close contact, constant exchange of information and a high level of mutual trust and respect, students' emotional discomforts are considerably reduced, and physical ones consequently made more tolerable.
CO-ORDINATION The management of the jomt scheme has posed particular problems exacerbated not least by the geographical separation of the College and . the hospital. More important, particularly in the early days, was the difference in philosophies between the School of Nursing and the College. This is well illustrated by developments since 1976 when College staff devised the initial curriculum. Substantial modification was necessary for a number of reasons. Firstly, due to difficulties in liaison between the College and the School of Nursing, College staff were insufficiently familiar with student nurses and their experiences. Secondly, nurse tutors had little experience and expertise in curriculum development since, we would suggest, schools of nursing lack the autonomy for curriculum innovation and dcyclopmcnt that colleges have. Thirdly, the College staff designed a curriculum which did not meet expressed student needs; consequently the credibility of College staff was repeatedly questioned. The modified curriculum was developed with considerable co-operation between nurse tutors and College staff. Philosophical and educational differences between the two parties were explored, and, in most cases, reconciled. This increased liaison has continued and has been developed further, with College staff visiting student nurses while they are on the wards, and teaching on the hospital-based introductory blocks. The 'credibility' issue still persists, albeit to a lesser degree. It is likely to continue, since it is reflected in what is probably the 24
greatest difficulty encountered by the students, namely their return to the hospital after each College module. Often their reception on the wards has been characterised by an indifference, and occasionally a resistance, to new modes of training on the part of long-serving ward staff and hospital administrators. This reflects, as does the 'credibility' issue, the social isolation and professional malaise affecting staff in the mental handicap hospitals. There is some evidence that within the context of limited resources the course is expensive. The placements, as mentioned earlier, involve substantial travelling costs. Although student nurses are theoretically supernumerary to ward staff their absence while at College does present the hospital administration with staffing difficulties. In the short term it is difficult to overcome such problems. Both College staff and nurse tutors have sought to explain the course, its aims, content, and differences, to ward staff. In the long .term, 'graduates' from the course will be promoted to positions of responsibility on th e wards.
CONCLUSION This joint RNMS trairung course has taken some years to develop. Some mistakes . have been made; much effort has been expended in devising and modifying it. This was only to be expectedcurriculum development is always a long and arduous process. However, those who are involved believe that the effort is worth while. The course is thoroughly in tune with modern thinking concerning the 'management of mental handicap, and new training proposals and guidelines can be easily incorporated into it. All in all, a picture emerges of a course which none of the participants yet finds wholly satisfactory, but one to which a very large majority of all participants, in whatever capacity, are deeply and firmly committed. A course still with imperfections, but one which is widely believed to be worth whatever effort is necessary to perfect it, and which could provide a more attractive model for the mental handicap nurse training of the future than either an entirely hospitalbased course, or the training proposed by Jay.
REFERENCES Cannon E F 1982 Little Plurnstead nurses community studies course-an evaluation, unpublished thesis , Huddersfield Polytechnic, DHSS 1971 Better services for the m entally handicapped, Cmnd. 4683, HMSO, London. DHSS 1972 Report of the Committee on Nursing (Briggs Report) Cmnd. 5115, HMSO, London. DHSS 1978 Special educational needs: Report of the Committee of En qu iry into the education of handicapped children and young people (Warnock Report) Cmnd. 7212, HMSO, London. DllSS 1979 Report of the Committ ee of Enquiry into mental handicap nursing and care (Jay Report) Cmnd. 7468 HMSO, London. GNC for England and \Vales 1981 A new syllabus for nurses for the mentally subnormal. GNC/CCETSW 1982 Co-operation in training (Part 1): report of the joint working group on training for staff working with mentally handicapped people (Sidebottom Report). Holloway D G and Cannon E F 1982 A joint approach to training mental handicap nurses, Nurse Education Today, 2:4.
The training of mental handicap nurses an FE College experience of joint training D G Holloway and E F Cannon Lecturers, Norwich City College of Further and Higher Education IN RECENT YEARS the mental handicap hospitals and their staff have been subject to considerable criticism in official reports, the mass media, and in academic studies. During the same period knowledge concerning mental handicap has developed impressively. Such developments have been accompanied by : changes in social policy towards the care of mentally handicapped people. Although progress has been slow, policy has aimed at reducing the number of beds in the long-stay hospitals and expanding community services. Such developments have led to increased attention being paid to the RNMS training. The existing pattern has been criticised as being biased towards general nursing and inappropriate for mental handicap nursing, despite · syllabus modifications in 1957 and 1970. As reported briefly in this journal in August 1982, the Broadland School of Nursing (Mental Handicap Division) and Norwich City College of Further and Higher Education (the Department of Health and Community Studies) have, since 1976, been working in partnership to develop a nurse education programme which will prepare mental handicap nurses not only to work within the hospital setting, but also to serve in community residential or day care agencies, or to provide domiciliary nursing support. In addition, the course is designed to prepare nurses to take a responsible part, in due course, in shaping the new patterns of care for the mentally handicapped adumbrated in B ett er Services for the M entally Handicapped and in the Briggs, Warnock, and Jay Reports. This joint RNMS course remains based in the 'hospital. \Vard experience, clinical teaching, and blocks of study in the Nurse Education Centre still form the core of the three-year programme in preparation for the RNMS examination. In addition, an extensive programme of community studies and community practical experience is grafted on to this stem, allowing student nurses to gain knowledge of other models of care and education of the mentally handicapped, to establish relationships with workers in these other caring agencies, and to observe them at work and discuss with them their values, aims, objectives, and methods. During the six years this course has been running it has undergone continuous monitoring and curriculum development. A major evaluation of the 22
College component has recently been completed and action is now being taken to modify further aspects of it as a result. Attention is now being turned to the hospital component, and co-operation from nursing staff at all levels is being sought. However, since it is the College component which is The new and unusual aspect of the training, this seems to be a useful point at which to present our experiences in developing and mounting this joint training programme. THE CURRICULUM General aims and organisation In concept and implementation the principal aim has been to identify and reconcile the educational needs of a professional group whose role is being challenged by the professionals themselves and interested parties. The course leading to the RNMS qualification follows the usual three-year period for State Registration and offers three academic terms at the College. These terms are organised to occur in each of three respective years of training. Each of the terms has a similar structure, arranged as follows:
• two days per week full-time College-based study; • three days per week in a community placement. The remainder of the training period is spent in the clinical areas of Little Plumstead Hospital. The College modules are supplemented by an eight-week introductory course and a series of study blocks. Community studies modules Each module lasts one academic term, approximately twelve weeks . Module 1: The educational theme is the growth, development, care, and education of the mentally handicapped child. Theoretical inputs, from sociology, psychology, human growth and development, and language development, and practical placements have been devised to enable the student nurses to integrate the College-based learning with their practical experiences, and to apply both within the hospital situation. This integration is facilitated by close contact between College staff and nurse tutors. The student nurses are placed in local education authority special schools throughout the module, during which time they have the opportunity
NURSE EDUCATION TODAY to experience the organisation and application of teaching techniques and group management, and to evaluate techniques and approaches to child care with direct application to the hospital situation. Module 2: The educational theme is the education of the mentally handicapped adult within community and hospital settings. Students are provided with opportunities to develop teaching and remedial skills which have direct application within the hospital setting through courses on social skills, behaviour modification, and educational psychology. The students are placed in Social Services Department Adult Training Centres, where they are able to observe and participate in the care and education of the mentally handicapped adults in a community setting. This enables students to contrast and compare the training and remedial practices of an ATC with those of the hospital, and exposes them to the attitudes and values of other professional groups working with mentally handicapped adults. Module 3: · This aims at consolidating and extending the students' learning in modules 1 and 2. The educational theme examines the concepts of community and community care. This is achieved through courses on sociology, social administration, psychology, normalisation, and counselling. Classroom inputs are supplemented by a series of observational visits to community agencies offering residential accommodation, day care, and work for the mentally and physically handicapped, and by placements with social workers, health visitors, and in community residential establishments. The visits and placements enable the student to develop an understanding of the relationship between social services and health services in the provision of resources for mentally handicapped people.
PLACEMENTS The programme of placements has been devised to complement the themes of each module. Firstly, students spend the whole term's placement in special schools, usually, but designedly not exclusively, in schools for mentally handicapped children. Schools for the physically handicapped, for emotionally deprived and/or disturbed children, and for the deaf are or have been used, allowing student nurses the opportunity to explore under guidance the interface between these conditions and 'mental handicap'. In the second module the whole term's practical experience is gained in Adult Training Centres where students can begin to gain a knowledge and understanding of social services provision for the mentally handicapped, and, in the more progressive centres, participate in training groups and see how trainees can be helped towards greater independence and the ability to manage. their lives with the minimum of supervision necessary. The third module placement programme is of necessity more varied and therefore more fragmentary. One half-term's experience in a community residential setting is provided, as well as
short periods of attachment to field social workers and to health visitors. Certain difficulties have been encountered in gaining a sufficient number of good placements within the areas accessible to students without subjecting them to an unreasonable amount of travelling, and the hospital to unreasonable levels of expense. These difficulties arise firstly in securing enough placements in social services agencies and with their field workers, and also with health visitors. These services are under great pressure from any number of social services and health service training programmes to take more and more students in placement, and some agencies have latterly also been a target for MSC work experience placements for the young unemployed. The second source of difficulty is the quality of the placement: in all types of agency used, some examples are excellent, some leave much to be desired, either in the quality of service they provide to clients or in their approach to the management of the students' experience. As with all other aspects of the course, the placements are continuously under observation and negotiations continue with all agencies concerned. The aims are always to provide a sufficient number of good placements and adequate support for each student in his/her individual situation, and to maintain close contact with the agency supervisors in order to monitor the students' progress and make a detailed assessment of their performance. It is hoped that this process can be refined and formalised so that placement assessments can eventually be included in the RNMS assessment profile in the manner in which ward reports are at present.
ADJUSTMENT Nurse training has long been recognised as demanding in physical, intellectual, and emotional terms. This course is more demanding in all those ways than most. Students experience considerable stress in adjusting initially to the College environment, and in making successive adjustments as they move between College, nurse training school, ward experience, and community placements. Much travelling is involved as the hospital, where many students live, is eight miles from the College in a village with a minimal bus service, while placements are scattered around the city and its environs. Perhaps the major difficulty students experience is in adjusting to the College. This is hardly surprising. Until their arrival in College the ir training has taken place within a ward team or in the Nurse Education Centre-both small-scale, even intimate, settings. By contrast, the College is vast, confusing, and apparently impersonal. The well-worn fabric of a functional and overcrowded college of further education comes as a nasty shock to students from a well-appointed Nurse Education Centre situated in a graciously designed country mansion. Likewise, it is not easy to move from being the only group of 23
NURSE EDUCATION TODAY students in block to being ,one group among hundreds. Stimulating and exciting it can be, but undeniably it takes some getting used to . Finally, intangible though it might seem at first sight, it is worth considering that when they are in the hospital environment these young people are on the staff side, with all the advantages of status and accommodation that brings. In College they become students, and although the distinction between staff and students is not so sharply drawn as that between staff and patients in the hospital, the loss of status is felt. Many of these strains are ultimately unavoidable, but we have found that they can be alleviated to some exten t. Firstly, by long and careful preparation for th e College experience, beginning in the initial interview before an applicant is accepted for nurse training, and continuing during' the introductory block in the Nurse Education Centre. Secondly, by assigning to each group a College tutor, again at a very early stage; a tutor who will remain the key link person between: College and hospital for that group for as long as they have contact with the College. \X'here this key person and the group's own tutor within the Nurse Education Centre maintain close contact, constant exchange of information and a high level of mutual trust and respect, students' emotional discomforts are considerably reduced, and physical ones consequently made more tolerable.
CO-ORDINATION The management of the jomt scheme has posed particular problems exacerbated not least by the geographical separation of the College and . the hospital. More important, particularly in the early days, was the difference in philosophies between the School of Nursing and the College. This is well illustrated by developments since 1976 when College staff devised the initial curriculum. Substantial modification was necessary for a number of reasons. Firstly, due to difficulties in liaison between the College and the School of Nursing, College staff were insufficiently familiar with student nurses and their experiences. Secondly, nurse tutors had little experience and expertise in curriculum development since, we would suggest, schools of nursing lack the autonomy for curriculum innovation and dcyclopmcnt that colleges have. Thirdly, the College staff designed a curriculum which did not meet expressed student needs; consequently the credibility of College staff was repeatedly questioned. The modified curriculum was developed with considerable co-operation between nurse tutors and College staff. Philosophical and educational differences between the two parties were explored, and, in most cases, reconciled. This increased liaison has continued and has been developed further, with College staff visiting student nurses while they are on the wards, and teaching on the hospital-based introductory blocks. The 'credibility' issue still persists, albeit to a lesser degree. It is likely to continue, since it is reflected in what is probably the 24
greatest difficulty encountered by the students, namely their return to the hospital after each College module. Often their reception on the wards has been characterised by an indifference, and occasionally a resistance, to new modes of training on the part of long-serving ward staff and hospital administrators. This reflects, as does the 'credibility' issue, the social isolation and professional malaise affecting staff in the mental handicap hospitals. There is some evidence that within the context of limited resources the course is expensive. The placements, as mentioned earlier, involve substantial travelling costs. Although student nurses are theoretically supernumerary to ward staff their absence while at College does present the hospital administration with staffing difficulties. In the short term it is difficult to overcome such problems. Both College staff and nurse tutors have sought to explain the course, its aims, content, and differences, to ward staff. In the long .term, 'graduates' from the course will be promoted to positions of responsibility on th e wards.
CONCLUSION This joint RNMS trairung course has taken some years to develop. Some mistakes . have been made; much effort has been expended in devising and modifying it. This was only to be expectedcurriculum development is always a long and arduous process. However, those who are involved believe that the effort is worth while. The course is thoroughly in tune with modern thinking concerning the 'management of mental handicap, and new training proposals and guidelines can be easily incorporated into it. All in all, a picture emerges of a course which none of the participants yet finds wholly satisfactory, but one to which a very large majority of all participants, in whatever capacity, are deeply and firmly committed. A course still with imperfections, but one which is widely believed to be worth whatever effort is necessary to perfect it, and which could provide a more attractive model for the mental handicap nurse training of the future than either an entirely hospitalbased course, or the training proposed by Jay.
REFERENCES Cannon E F 1982 Little Plurnstead nurses community studies course-an evaluation, unpublished thesis , Huddersfield Polytechnic, DHSS 1971 Better services for the m entally handicapped, Cmnd. 4683, HMSO, London. DHSS 1972 Report of the Committee on Nursing (Briggs Report) Cmnd. 5115, HMSO, London. DHSS 1978 Special educational needs: Report of the Committee of En qu iry into the education of handicapped children and young people (Warnock Report) Cmnd. 7212, HMSO, London. DllSS 1979 Report of the Committ ee of Enquiry into mental handicap nursing and care (Jay Report) Cmnd. 7468 HMSO, London. GNC for England and \Vales 1981 A new syllabus for nurses for the mentally subnormal. GNC/CCETSW 1982 Co-operation in training (Part 1): report of the joint working group on training for staff working with mentally handicapped people (Sidebottom Report). Holloway D G and Cannon E F 1982 A joint approach to training mental handicap nurses, Nurse Education Today, 2:4.