A GLIMPSE AT THE NURSING EDUCATION SYSTEM IN THE UNITED KINGDOM With Special Reference to the Sheffield School of Nursing T

Die Sheffield-verpleegskool is een van die grootste in Engeland met meer as ’n 1 000 studente op 25 verskillende basiese en naregistrasie kursusse. Die klem val op die kliniese aspek en verbeterde, totale en geindividualiseerde pasiëntsorg. Onderrig in die kliniese situasie is dan ook ’n belangrike deel van die opleiding. ’n Geintegreerde benadering tot kurrikulumontwikkeling en -implementering word ook gevolg. Die algemene ontwikkeling van die leerder is ’n verdere belangrike aspek. Strategieë soos die dra van gewone klere vir lesings, aktiewe raadgewing en dat stu­ dente verantwoordelikheid vir hulle eie leer moet aanvaar word gebruik. Die akademiese personeel is fisies en administratief onafhanklik van dienspersoneel. Samewerking in die aanbieding van verpleegopleiding word egter op verskeie wyses verseker. Suid-Afrikaanse verpleegkundiges kan hier baie leer. Anomalië in verpleegonderwys in Engeland is egter verdeelde beheer oor verpleegonderwys, ’n tekort aan dosente en verswakte solidariteit in die beroep deurdat studenten opgeleide verpleegkundiges aan verskillende vakbonde behoort.


INTRODUCTION
T he au th o r wishes to share her ex periences and im pressions about the system of nurses' education and training in E ngland with those nurses who m ay not have had the opportunity to see how nurse p re p aration is conducted in th at coun try.
T he au th o r had the privilege of visiting the U n ited K ingdom to o b serve th e nursing education and training system .Since th ere was a tim e constraint on h er visit and she could not visit as m any schools of nursing as she w ould have liked, the British C ouncil d irected the author to the Sheffield School of Nursing in the T ren t region.It was later learnt th at the Sheffield School of Nursing was not only the show piece of th e English schools of nurs ing, b u t also th at it was one of the largest.
T he inform ation p resen ted here was collected in the following m anner: the au th o r held discussions with senior and junior m em bers of the adm inistrative, academ ic and clinical staff.She had the o p p o rtu nity of interview ing them using a tape recorder and also observed them as they w ent about their duties.C onsultation of records, es pecially those of the School of N urs ing, helped to substantiate the in form ation.

C ourse M em b ers
The nam e used for all stu dents doing post-registration GNC, JBCNS and JEB courses.

The set o f lectures given to learners at the beginning of the first year o f training. In South Africa this is called the Preliminary Training School (PTS).
Training C om m ittee (R N T C ).This com m ittee is actually p art of the G N C at regional level.T he R N TC then distributes the m oney to area sc h o o ls .A p p r o x im a te ly £ 6 ,5m illion is allocated to the Sheffield A rea School o f N ursing annually.This m oney is not used to pay learn ers' allow ances, but it goes tow ards paying the salaries o f the teaching staff and purchasing and m aintain ing teaching equipm ent.
The G N C prescribes curricula in broad outline; approves of and in spects nurse training centres; con ducts exam inations and keeps re gisters and rolls for learners, course m em bers and for qualified nursing staff.
The JBCN S is a non-statutory body which functions in respect of p o s t-r e g is tr a tio n n o n -s ta tu to r y courses on sim ilar lines as the G N C. The JBCN S has instituted 76 post registration nursing courses.It con trols these courses but it neither fi nances them nor conducts exam in ations.It inspects schools, super vises the teaching and evaluates the courses in o rd er to m aintain desir able standards.The JEB is another non-statutory body which functions like the JBCN S. The JE B controls the basic and post-registration o r thopaedic courses only.This com plexity and diversity of control of nursing education is a result of peculiar historical developm ents.
T he national nursing adm inis trative structure of the U nited Kingdom is in the process of being re-organised on the lines prescribed by the N urses, Midwives and H ealth V isitor's Act of 1980.The G N C for E ngland and W ales as well as the G N C for each of the other countries in the U nited Kingdom are being absorbed by the new C en tral Council for N urses, Midwives and H ealth Visitors (C C N M H V ) for the U nited Kingdom.

Policy for educating and training nurses
E ducation and training is d eter m ined by the educational policy docum ent of the G N C ; an analysis of the health needs of society as well as by the E u ropean Econom ic C om m unity (E E C ) requirem ents.
The educational policy docum ent of the G N C seeks to discourage, am ong o th er things, procedure-orientated nursing and poor prep aration for m anagem ent.It aims at encouraging the attitude of regard ing m an in his environm ent and the nursing process approach to activ ity.

DECEMBER 1983
The E E C requires th at the basic education and training of nurses should include any two of the fol lowing: obstetrics psychiatry com m unity nursing geriatrics.
The nurse whose basic training does not m eet these requirem ents cannot be allowed to practice nurs ing in o th er countries of the E u ro pean Econom ic Com m unity.

Degree education for nurses in England and Wales
Only about one percent of the total num ber of nurses in England have been prepared through degree courses.The G N C believes five percent of the country's nursing com plem ent should be prepared at degree level.The Briggs Com m is sion on nursing recom m ended that only 10 persent of the nurses need to be graduates.O n the whole, there are not m any advanced nurs ing degrees.
It is uncom m on in this country for a nurse to go up to a doctorate in nursing studies.T he D irector of the School of Nursing has a Mas te r's degree in E ducation.His assis tants are also pursuing M aster's d e grees in E ducation.

Basic nursing degrees
In the U nited Kingdom the basic nursing degree is offered at U niver sities and Polytechnics in various ways.T here are about eighteen dif ferent types of degrees.Each insti tution structures and develops its own degree and sets its limits of clinical practice depending on the circum stances in the particular com munity.In the final analysis, each institution m ust receive G N C ap proval for the degree course.On com pletion of m ost degree courses the nurse registers with the G N C as a state registered nurse.O thers re gister with o ther official bodies, for instance, midwives register with the C entral M idwives' B oard.
Universities' basic nursing degree.A lthough the degrees vary slightly in length the average d u ra tion is four years.These degrees in clude a large academ ic com ponent.

CURATIONIS
They are eith er Science, A rts, Social Sciences o r H um an Biology orientated depending on w hether they are offered in the A rts, Science, Social Sciences or Medical faculties.As autonom ous institu tions, U niversities give titles to their degrees.All lecturing staff possess University degrees.
The clinical placem ent pattern is referred to as non-integrated.This m eans that the student spends all her time at the University during the sem ester.D uring the vacation she seeks em ploym ent with health authorities and she practices in the hospital wards and clinical areas as a m em ber of the health care team , for which she is rem unerated.This non-integrated approach is being phased out.

Polytechnics'
basic nursing degree.T uition is undertaken by a staff of which 50 percent do not hold degrees.The nursing degrees are usually of three years' duration and are offered in the D epartm ent of H ealth Studies.The titles for the degrees are decided by the Council for N ational A cadem ic Awards.
A lthough there is no standardis ation of the Polytechnics' degrees, the G N C has to approve of the structure of the course.Clinical placem ent is mostly through the in tegrated approach.A ccording to the integrated approach, the stu dent spends one day per week in the hospital and four days in the Poly technic in the first year of training.In the second year she spends two days of the week in the hospital.The num ber of days in the clinical area is increased until tow ards com pletion of the course, she spends a block of tim e in the w ards as part of the ward team .These students are not paid for w orking in the wards.It is felt th at if they w ere to be paid it would tie them down to service d e mands.

The Sheffield School of Nursing
The setting Sheffield city is in the T ren t region of E ngland, N orth of L ondon, and has a population of 540 000.The Sheffield School of Nursing is a large "area" school which caters for

The teaching personnel
Param edicals and o th er hospital personnel, such as th e hospital chaplain, th e fire en gineer, the hos pital security officer, the social w orker, the w ard sisters and the nursing officers all m ake a contribu tion to th e teaching of the learners and course m em bers.In this con text how ever, teaching personnel refers only to qualified tutors and clinical teachers who constitute the lecture room staff.
As of 31 D esem ber 1981 the Sheffield School o f N ursing had nine senior tu to rs, nin eteen tutors and eighteen clinical teachers.The approved establishm ent is twelve senior tu to rs, 78 tu to rs and clinical teachers.T he tu to r staff position, at the tim e of reporting, w orked out to a ratio of one tu to r to 35 learners.This fell short of the G N C recom m endation which is one tu to r to 15 learners.D ue to the acute shortage of tutors the clinical teachers are to a large extent used as tu to rs, along side th eir clinical teaching duties.The shortage of staff does not seem to dam pen the spirit o f the teaching personnel.T heir creative ideas are given free rein.T hey are enthusias tic and devoted to their w ork and their m orale is high.

Teaching methods
T he nursing school authorities b e lieve th at 80 percent of teaching should take place in the w ards and clinical areas.It is m ostly th e trad i tional m ethods th at are used.M ost teachers em ploy these m ethods with creativity.T he criterion for se lection of a m eth o d and a strategy is its effectiveness in th at particular instance.E ven strategies suggested by learners are explored and ex ploited w henever possible.Speci fied objectives invariably precede and direct all teaching.A m ong others the following m ethods are em ployed: lecture m ethod lecture/dem onstration team teaching presenting of patient care studies by students exposure to clinical experience followed by discussions group discussion.

The Teaching Facilities
All the hospitals at which clinical teaching is undertaken have basic teaching facilities.
These facilities include m odern le c tu re ro o m s , d e m o n s tra tio n room s, the library (only at the Royal H allem shire H ospital), plus a wide range of audio-visual teaching m aterial.
T here is an audio-visual aid tech nician based at C larke H ouse who controls and m onitors the use of audio-visual aids by all the hospitals attached to the School of Nursing.He helps tutors to use, handle and m aintain the com m only used teach ing aids for maxim um benefit; to produce video-tapes and to design good quality professional tran sp a rencies.T he teaching aids used are the overhead p ro jecto r, slide p ro jector, video, flannel graphs, m ag netic boards and others.

The approach to education and training
The curricula for the various nurs ing courses are prescribed in broad outline by the controlling bodies.The Sheffield School of Nursing d e velops and im plem ents its curricula to m eet the institutional objectives, in line with its philosophy of nursing and nursing education.Learners doing the basic G N C courses sit for the external G N C exam inations.Those studying for the post-basic courses sit for an internal exam in ation.
The Sheffield School of Nursing follows an integrated approach to curriculum developm ent and im ple m entation.Instead of breaking the c u rric u lu m in to A n a to m y an d Physiology, Surgery and M edicine, the curriculum is organised around the p atien t's activities of life, the organs or the systems of the body DECEMBER 1983 and related surgical, m edical, p h ar macological, social as well as psy chological intervention, and the patient in his environm ent.
A t basic level, the curriculum is im plem ented by the use of the block system of training.The daily lecture system is m ore popular for th e s h o r te r p o s t-b a s ic n u rs in g courses.A lecture period is 60 m in utes.In the lecture room the day starts at 08h30 and ends at 16h00.The training period is estim ated in weeks.For exam ple, the course for pupil nurses' training is 112 weeks, the one for basic general nurses' training is 173 weeks.Pupil nurses have seven blocks of one w eek's d u ration for the whole period of train ing.Student nurses have a total of thirteen blocks, seven of two weeks and six of one week.(See table 2 for a sam ple of the standard plan of training).Some of the principles underlying the developm ent of the curriculum and the im plem entation of the plan of education and training are: -total and individualised patient care -involvem ent of the student in such a way th at she/he takes the responsibility for her/his learn ing -each block constitutes a m odule, to prepare the student for the clinical area to which she/he will be allocated thereafter -lecture room teaching is guided by objectives of nursing practice as designed and stipulated by the w ard sisters for their special clinical areas.

Enrolment and selection
Students com e from all over E ng land but m ainly from Sheffield and the surrounding area.The recruit m ent clerk at C larke H ouse p ro cesses all applications and short lists those applicants which are suit able for a selection interview .The selection com m ittee is com posed of representatives from the lecture room staff as well as from the clini cal or service staff.Through an in terview this com m ittee selects those

CURATIONIS
candidates who seem to have the potential to be good nurses.T here is no waiting list of applicants.C an didates that have been short-listed have to re-apply in o rd er to be re considered for training.Several groups of about thirty to fourty learners are adm itted each year.

Employee Status
The students ren d er a service to the public through working in the wards and o th er clinical areas.They are, therefore, part of the clinical staff during their stay in the hospital wards and clinical departm ents.For this reason they are regarded as em ployees.They are subject to the provisions of the Industrial R ela tions A ct and have statutory rights.
O n appointm ent the learners are given a copy of the rules and p ro cedures of Industrial R elations.
Lectures on this topic are offered to learners during the introductory course.T he students are allocated to and placed in rotation in wards and clinical areas.
T here is a nursing officer, re ferred to as the Liaison Officer, whose sole function is to allocate learners to clinical areas and look after their academ ic interests while they are in these areas.

Students' health service
The O ccupational H ealth Service looks after the learners' and course m em bers' health in the sam e way as it looks after the health of all o th er hospital em ployees.T he health ser vice includes a medical exam ination on appointm ent, routine preventive and protective procedures, tre a t m ent of illness and injury and h e a l t h c o u n s e l l i n g to s t u d e n t nurses.
The health records of hospital em ployees are kept strictly under lock and key and are retained for five years.A dm inistratively, the O ccupational H ealth Service is in dependent of the hospital and of the School of Nursing.It falls directly under the district tier of national structure.As a neutral party the health service personnel can in ter cede on behalf of a nurse in training if her/his health is jeopardised in the working situation.The school has an internal organ isational arrangem ent to effect direct com m unication betw een the student body and the highest school officials.Each group of learners and course m em bers chooses a group representative from am ong its m em bers.

S T A T E F IN A L E X A M I N A T I O N
T he group represen tativ e takes the g roup's problem s, requests and com plaints to a special com m ittee m eeting.This com m ittee m eets re gularly and it consists of all group representatives and one of the A s sistant D irectors of the school.

Motivation of the student body
T utors and clinical teachers do not w ear a uniform except for white coats w hen they go to the clinical areas for clinical instruction.W hen learners are on block they w ear their private clothes instead of their nurses' uniform .This arises from the fact th at a nurses' uniform is protective clothing and there is nothing for the nurses to be p ro tected from in the lecture room .The practice is also seen as a stra tegy to enable both teachers and students to see them selves m ore as ordinary people working together, r a th e r th a n as te a c h e r /s tu d e n t camps.The intention of this prac tice is to prom ote ready mixing and relating to one an o ther informally for m ore effective teaching/learn ing.It is also m eant to bridge the social distance to allow m ore free com m unication for the students' be nefit.
Active guidance and counselling of learners is given throughout training by various personnel.This activity helps to develop the student and to m inimise adjustm ent p ro blems which tend to affect the stu d e n ts ' p e r fo rm a n c e a d v e rse ly .Counselling is done by social w ork ers, hospital chaplains, occupa tional health service personnel, tutors, clinical instructors and other people who may be in a position to contribute at any one time.
T he lecture room staff is divided into team s.Each team consists of one senior tu to r, tuto rs and clinical instructors.Every new group of learners is allocated to a particular team of lecturing staff.Each team is concerned with the interest and welfare of about three groups of learners.
A n o th er tool to encourage good perform ance and to tap the stu dents' potential is a yearly com pe tition.Once a year the school authorities select the best students.These students are asked to submit patient studies.T he student who subm its the best patient care study is aw arded a prize of £1 000 to be spent in pursuing fu rth er studies in any country she prefers.
T here is also an on-going in-service training program m e for practis ing nurses.The program m e for these lectures is placed on all notice boards in the different hospitals.Students may attend these in-service lectures on a voluntary basis to augm ent their lecture room and clinical instruction.

COMMENTS
The autho r wishes to highlight the CURATIONIS following points because they m ade either a favourable o r an unfavou rable im pression.

Remarks on the practices at the Sheffield School of Nurs ing Organisation of the School of Nursing
The academ ic staff is physically and a d m in is tr a tiv e ly in d e p e n d e n t o f and separate from the clinical or service staff and the academ ic sec tion has its own clerical and adm i nistrative staff.This section caters exclusively for the learning needs of the students.
T here are how ever, strategies to effect sm ooth and co-ordinated functioning in the offering of nurs ing courses.Some of these strate gies are the following: -both sections are represented on the selection com m ittee th at in terviews prospective students -joint conferences and m eetings are held regularly -there is a liaison officer em ployed by the service side who is responsible for placing and ro tating learners in clinical areas in consultation with the lecture room staff -there is m onitoring of the system of education and training through joint evaluation ses sions and on an individual basis by m em bers of staff.R ecom m endations for change are con sidered.
-there is organised inservice ed u cation that is adm inistratively separate from both the service and the teaching sections.Both sections are involved in offering lectures and dem onstrations on invitation.
-on an inform al basis, both sec tions have parties to which they invite each o th er on special oc casions.
A t a lower level there are proce dures to integrate theory and prac tice, such as: -ward sisters are either m ade to participate in classroom teaching and/or allow ed to sit in during th e in tro d u cto ry course.
-classroom teaching is guided by w ard objectives stipulated by w ard sisters -clinical instructors are effective links betw een clinical experi ence and classroom theory.
T he selection of prospective learners is com plex and rigorous.B etw een receiving th e first letter of application and the invitation to the selection interview , a num ber of ap plicants are disqualified.A ccording to statistics for the year 1980, the position regarding selection was as follows: th ere w ere 6 800 applications and of these, 2 926 re tu rn ed com pleted form s. O u t o f this num ber only 1 247 w ere short-listed for the selec tion interview and 513 of these w ere finally selected and com m enced training.

The nature of education and training
Em phasis is laid on the clinical as pects.T he focus is on im proved, holistic and individualistic patient care.Preparing

Anomalies
T here are som e aspects in the system of education in the U nited Kingdom and in the organisation of nurses which ap peared anom alous.

Control of nursing education
C ontrary to the holistic approach to patient care, the control of nursing education is fragm ented and irregu lar.T he G N C controls and finances m ost of th e basic nursing courses and a few post-registration courses.M idwifery education falls u n d er the C entral M idwives' B oard.The JBCN S controls m ost of the post registration nursing courses but does not finance them .T he JEB controls the basic and post-registra tion orthopaedic courses.

Shortage of tutors
In spite of the alarm ing shortage of tutors, conditions m itigate against qualified nurses becom ing tutors.A qualified nurse has to go through two courses of training before she can be registered as a tutor.T he b e nefits to w ard sisters are such th at in the final analysis the w ard sistertakes hom e a m uch higher salary than the tu tor.T hose who becom e tutors do so at a considerable perso nal and financial sacrifice, and they do it for the real love of teaching.

Stunted growth of higher nurs ing education
T here is a dearth of advanced nurs ing courses.N urses who attem p t advanced university degrees follow non-nursing degrees.This seem s in consistent with a profession that is approxim ately 200 years old and in a country which spearheaded world civilisation.It appears a w aste of nursing m aterial, for B ritish nurses are seasoned nurses who know and love their w ork.T heir feet are very much on the ground, yet they are ima ginative and innovative in their w ork situation.

Weakened solidarity of the nurs ing profession
The fact th at qualified nurses and learners belong to different trade unions underm ines the strength of the profession.N urses as a distinc tive group of w orkers whose prac tice is based on a code of ethics all have a pace to set and the same battles to fight.Joining trad e unions o ther than the professional associa tions m itigates against solidarity and unity.

CONCLUSION
T he visit to Sheffield School of Nursing was a stim ulating experi ence.T he nurses' education and training at this school not only centres around the p atien t and his surroundings but is also com m unity orien tated and internationally ac ceptable.
N urse educators in South A frica have a few things to learn from the British approach to nursing educa tion described above.A m ong the things to learn are m ethods to e d u cate and train student nurses for re sponsible in dependent thinking and functioning.This w ould open up possibilities for p atien t care th at are realistic and relevant to con tem p o rary conditions.N urse educators can pursue this ideal only to the extent to which they them selves are allowed responsible ind ep en d en t thinking and functioning by th eir authorities and adm inistrators.

T
he G eneral N ursing C ouncil of England and W ales (G N C ) is the statutory body responsible for con trolling and financing a larger p o r tion of basic and a sm aller portion of post-registration courses offered by schools of nursing in these coun tries.T he G N C receives the m oney for education and training of nurses from the governm ent vote to the D ep artm en t of H ealth and Social Security.T he G N C then allocates the m oney to the R egional N urses' Also stem m ing from the fact that the learners and course m em bers are em ployees is the right to elect to join any w o rk ers' organisation they prefer.D uring the introductory course representatives of the var ious trad e unions are invited by the school officials to address the new group of learners about the trade union they rep resent.T he aim is to offer guidance to learners about the conditions and im plications of join ing any one of the trade unions.L earners m ay choose to join the R oyal College of N ursing (R C N ).A lthough this is regarded as a trade union, it is exclusively for nurses and is m ore professionally o rien tated th an the rest.T he learners are also at liberty to join eith er the C onfederation of H ealth Service E m ployees (C O H S E ), the N ational U n i o n o f P u b l i c E m p l o y e e s (N U P E ) or the N ational E m ployees' O rganisation (N E L G O ).
This degree is offered in the D e partm ent of H ealth Studies in con junction with the Sheffield School of Nursing.The philosophy of this D epartm ent focuses on support to patients on an individual basis.It places . . .strong emphasis on hum an aspects in health care, especi ally where this involves developing . . .professional sensitivity to the needs and fears o f individuals as they face potentially threatening changes in their personal lives . . .(B rochure on B .A .N ursing, Shef field City Polytechnic.)This is a full-time degree of four years duration.O n com pletion the nurses are eligible for registration with the G N C for E ngland and W ales as state registered nurses.In this degree the following subjects are offerededucational qualifica tions as adm ission requirem ents the applicants have to subm it an essay.This essay and the selection inter view help to select suitable candi dates for training.T he students receive theoretical instruction at the Polytechnic.Clinical instruction is undertaken in the clinical areas falling under the Sheffield School of Nursing.The clinical teachers of the School of Nursing, in collaboration with the nurse teaching staff of the Polytech nic, guide and supervise the clinical experience of the degree students.The authorities of the School of Nursing are m orally and legally o b liged to help im plem ent this degree because its establishm ent was a joint endeavour by the School of Nursing personnel, the lecturers of the Polytechnic and others.