As university lecturers in acute adult care, the authors were involved in the development of a medicines management module for trainee nursing associates, as part of the pilot curriculum at their university. With limited guidance from professional organisations, the authors considered the needs and concerns of service users and providers, drew on educational philosophies and the feedback of the students. This article describes the development process.
A literature review provided background information. This included details about the emergence of the nursing associate role from the Shape of Caring review (Higher Education England (HEE), 2015), which called for higher-level training and apprenticeships (Department for Business, Innovation and Skills (BIS), 2016). The literature also revealed:
Additionally, the literature demonstrated that the design of a curriculum directly affects the acquisition of knowledge, therefore this multidimensional and complex process required understanding. Embedded educational philosophies provide the rationale for the chosen content and the strategies used to deliver it. Nurse education has been influenced by humanistic psychology, a philosophical and ethical stance concerned with human welfare, nature and values, with an emphasis on the importance of self, with motivation, empowerment and autonomy being key.
Knowle's theory of androgogy, the method and practice of teaching adult learners, described the importance of process, with the emphasis on the means rather than outcomes of programme delivery (Smith, 2017). This suggests education should not be separated from the learner's experiences and interests (Hughes and Quinn, 2013). Ideas result from action, with the belief that knowledge is socially constructed in interaction with others as an experiential learning approach. Kolb's (1984) experiential learning cycle is a useful tool within work-based learning, enabling students to reflect on their practice and relate it to knowledge acquired through reading and the taught curriculum.
There is a requirement for educators' values to be articulated at the start of curriculum development so that influences are understood and an amalgamation of the philosophies can then provide structure and a shared purpose (QAA, 2013). These educational philosophies underpinning the curriculum design are strongly influenced by external drivers and benchmarks for the programme; therefore a needs assessment helps to identify these at a local, national and international level (HEE, 2017a; NMC, 2017a; 2017b; 2017c).
Drivers and benchmarks
There is emphasis on the nursing associate role promoting self-care and preventing ill health, particularly in the ageing population, fostering collaborative, flexible working in a variety of settings, enabling them to work across the four domains of nursing: adult, mental health, learning disability and child, and across the lifespan (HEE, 2017a). These political requirements underpinning the nursing associate programme have stemmed from the Francis report recommendation that the role should be designed to bridge gaps between nurses and healthcare assistants and integrate health and social care services (Francis, 2013; NHS England, 2014; HEE, 2015; 2017a). In addition, the introduction of the nursing associate role addresses the requirement for a flexible workforce that can meet the current demands on the NHS, where patients' needs are becoming increasingly complex and multifaceted, exacerbated by an ageing population (HEE, 2015; NHS England, 2017).
As trainee nursing associates are employed by local trusts, who are key stakeholders in the development of the curriculum, students need to meet their outcomes for employment (HEE, 2017a), thus communication and person-centred care have a strong focus within the NMC's ‘skills annexe’ for trainee nursing associates (NMC, 2017b). Person-centred care is defined by HEE (2017b) as focusing care on the needs of the individual, ensuring that people's preferences, needs and values guide clinical decisions, and providing care that is respectful and responsive to patients.
Most significant legally is that the role is now regulated by the NMC, with eligible trainee nursing associates able to join the NMC register (NMC, 2017a; RCN, 2018). As part of this commitment, the NMC has produced standards of proficiency and adapted its code of conduct to ensure benchmarking standards are met (HEE, 2017a; NMC, 2018a). The NMC skills annexe also outlines tasks trainee nursing associates are allowed to perform as level 5, skilled professionals (NMC, 2017c). In addition, they are expected to follow standards within the Care Certificate (HEE, 2017a). Legislation to protect the public, including, but not exclusively, the Health and Social Care Act (2008), the Medicines Act (1968) and the Human Medicines Regulations (2012) must also be considered when developing a medicine management module to ensure safe and effective practice.
The environment must promote learning and development, using inclusive teaching methods to enable students to meet the learning outcomes, as well as a broad spectrum of assessment strategies (HEA, 2011; HEE, 2017a). The HEE (2017a) advocates learning activities including action learning sets, simulation and shadowing in practice in order to meet the required outcomes (HEE, 2017a). This is in keeping with the work-based learning ethos to ensure students are adequately prepared to meet their employers’ needs on completion of their training (HEE, 2017a). The consultation period additionally identified the need for better access and sharing of information within health services through the use of new technologies and innovations to enhance service provision (HEE, 2015; NHS England, 2017).
A wide range of stakeholders were involved in the consultations to gain clarity of what was needed to boost the workforce (HEE, 2017a); with this wide mix encouraging a more collaborative approach (HEE, 2017a). However, there are challenges in combining academia with practice as outcomes for employers and higher education institutions (HEIs) need to be congruent.
Designing the medicines management module
The starting point for the taught content and assessment on medicines management was a review of the anticipated role of the nursing associate, within the apprenticeship document (HEE, 2017a). Additional documents reviewed included the NMC consultation paper, aligned with the standards of proficiency (NMC, 2017c; 2017d), advisory guidance on administration of medicines by nursing associates (HEE, 2017c; NMC, 2018b), National Institute for Health and Care Excellence medicines management guidelines (https://tinyurl.com/y4kwcgxt) and module learning outcomes. Alignment between the module, the wider curriculum and the HEI teaching and learning strategy was also deemed important to enable students to build their knowledge by following the connected structure.
A medicines management competency recording log was written, consisting of two parts:
The commentary was designed to ensure demonstration of knowledge and articulation at level 5; the OSCE reflected the practical nature of the skill of medicine management to produce competent practitioners. An unintentional benefit of the OSCE has been legitimising the importance of trainee nursing associates practising medicine administration, particularly in light of some of the concerns raised around whether they should have this responsibility (Lintern, 2016; Philips, 2017; Merrifield, 2018).
Module session philosophy and content
Module session content was adaptive and student-centred, to promote autonomy and independence. Based on constructivist learning theory, a philosophical viewpoint suggesting acquisition of knowledge is an active, constructive process whereby learners build their own understanding. This was achieved by emphasising the learner's role in constructing meaning from new information and prior experience, requiring examples demonstrating numeracy, case studies and action learning sets to be linked to the student's experience and knowledge gaps. Also considered were the six outcomes identified by the HEA (2016) to enable students to achieve, including innovations in assessment, ensuring employability, promoting student engagement and progression, encouraging inclusivity and using a flexible learning approach.
The module content included sessions with information on pharmacodynamics and pharmacokinetics, drug calculations, current discourse, legal and policy requirements including escalating concerns, and medicine management across the lifespan. A key theme throughout the module was the importance of safety, of following the HEE (2017c) standards for medicines administration for trainee nursing associates and the more detailed standards described by the NMC (2017c). As a pilot programme the key benchmarking standards have been subject to ongoing consultation, which led to challenges in delivery of content. Council meeting deliberations (NMC, 2018b) clarified certain inconsistencies within the original documentation, requiring some adaptations to the taught content.
The content and associated learning outcomes aligned closely with the needs analysis that had identified the requirements for nursing associates to be adaptable to different working environments and have an awareness of how care differs across the lifespan and within different fields of nursing (HEE, 2015; NHS England, 2017). The learning activities included case studies, reflections, action-learning sets, and technological strategies including the utilisation of a virtual learning environment and SN@P (an online numeracy assessment and education resource commissioned for use within higher education healthcare faculties and service providers across the UK). Its primary objective is to standardise assessments for healthcare students to achieve an excellent level of confidence and understanding in general and clinical numeracy.
These teaching activities aligned with the authors' values, empowering students to develop their own learning, drawing on humanistic theories and promoting a process model of learning, where value is given to the way of learning, building necessary social relationships in a sustainable manner to engender a deeper approach to learning. These learning activities additionally align with external influences, including the drive for enhanced technology within pedagogy, or method of teaching and a work-based learning approach (HEA, 2011; HEE, 2017a). In the authors' experience work-based learning was enhanced significantly by liaison and engagement with the lecturer in a practice learning role.
Problem-based learning
An exploration of and reflection upon medicine administration was achieved using a problem-based learning approach, creating scenarios across different fields, with clients of differing ages and pharmacological needs. This approach enabled students to reflect on their own practice, encouraged self-development and promoted critical thinking skills by drawing on real-life situations. In addition, problem-based learning draws on social efficacy and learner-centred ideologies in a process curricular model, which acknowledges the learning journey as opposed to focusing on set learning objectives (Stenhouse, 1975).
This approach can also increase student engagement, which correlated with the authors' experience of a motivated trainee nursing associate cohort who were able to synthesise concepts due to their background knowledge from practice. This addresses external drivers and aligns with the trainee nursing associate curriculum philosophy by increasing adaptability, drawing on the work-based learning model and encouraging students to link theory to practice as well as promotion of level 5 analysis skills (HEE, 2017a). It is acknowledged that problem-based learning is resource intensive, requiring small groups to facilitate student interaction and debate (Paslawski et al, 2013). As student cohorts are set to increase, problem-based learning as well as other interactive teaching strategies will have to adapt (Council of Deans of Health, 2017). Drawing on technological resources, such as the inclusion of online forums to broaden scenario discussions and enable group reflection, is one way to address this (Young and Papinczak, 2013).
Findings and future considerations
The experience of producing this module has revealed some interesting findings and considerations for the future. Listening to the experiences of the first cohort of trainee nursing associates has exposed a ‘hidden curriculum’ which must be acknowledged as it will impact on the explicit curriculum. This includes the inter-professional tensions in practice, identified by the trainee nursing associates as well as in research for similar roles. This highlights the need for a greater focus on collaborative working within the curriculum, particularly with nursing students, to ensure an optimal learning environment and to meet the needs of key stakeholders.
Personal reflection from teaching this cohort of trainee nursing associates has been their regular comparison to preregistration nursing students and an element of competitiveness has been noted.
There can be negative connotations for students who are the first to use a new curriculum. This cohort described having to prove their worth, highlighting the importance of listening to the student voice and ensuring the curriculum meets their needs and is focused on their learning. Drawing on trainee nursing associates' previous experiential learning will help them reach their full potential and by drawing on the application of prior experiential learning, could engender more humanistic and constructivist learning approaches.
Revising and updating of key benchmarking standards by government and professional bodies has caused frustration among the students. Trainee nursing associates must work within the confines of their local trust policies (HEE, 2017c). The authors identified, within classroom discussions, that the medication administration learners were able to perform varied according to the ward on which they worked. This student feedback highlights the importance of continuous liaison with employers to ensure alignment of shared outcomes. These challenges could contribute to the perception that the trainee nursing associates feel disadvantaged because they are on a pilot programme. Although these issues cannot be eradicated completely, if educators are aware of these challenges the curriculum can be better adapted to meet the students' needs.
Conclusion
There is a lack of agreement on intent and meaning of the term curriculum and educational philosophy and curriculum ideology can be influenced by the values of individuals and organisations designing the programme. This has been exacerbated, within the trainee nursing associate curriculum, by having numerous stakeholders and the challenge of designing a curriculum in the midst of many unknown variables as a pilot programme for a new clinical role. Transparency in articulating values is required so that influences are understood and application of ideologies are justified. The curriculum framework needed to identify ways in which teaching can support the transition of this role into practice, encouraging collaborative working and optimising the learning environment, equipping students to meet the demands of their role in practice. The authors needed to understand and incorporate external drivers and benchmarks when creating this medicines management module for this unique student cohort. Listening to the students helped to make delivering this programme a dynamic process that responded to their needs.