fournal of Advanced Nursing, 1977, 2, 383-391

Some structural considerations in moduiareducation for basic nursing students

Janet HarrisonS.R.N. B.A. Dip. Soc. Admin.

Research Officer

Margaret E. SaundersS.R.N. R.N.T. B.A.

Research Officer

Alan SimsB.A. M.Phil.

Acting Director

The General Nursing Council for England and Wales Research Unit,

32 Great Portland Street, London WiN sAD

Accepted for publication 26 November 1976

HARRISON JANET, SAUNDBRS MARGARET E. & SIMS ALAN {i^ji) Journal of Advanced Nursing 2,

383-391Some structural considerations in modutar education for basic nursing studentsThe report is concerned with some of the structural factors influencing modular schemes ofnurse education. Based on interviews with students, teachers and ward staff, in addition toexamination of ward staffing levels and structures, the report describes streaming of students,the possible effects of modular education on staffing and some changes introduced or proposedby four hospitals running such schemes.

For the most part streaming was seen as being feasible but without any real advantages.Small drawbacks associated with streaming were, however, evident. The research suggestedthat many of the staffing difficulties associated with modular education were not created by thescheme of training but perhaps highlighted by it. Improvements which would both increase theeffectiveness of the schemes and reduce some of these difficulties included movement towardsmore frequent intakes, a reduction in the length of classroom based element of the introductorycourse and abandonment of streaming and changes in the length/location of certain modules.

I N T R O D U C T I O N

The modular system of nursing education is already documented elsewhere

(Parnell 1975, Warcaba 1976) but it may be useful to reiterate briefly the aims of

such schemes and the means and structure adopted to meet those aims. The

383

384 J- Harrison, M. E. Saunders and A. Sims

suggested structure (Department of Health and Social Security 1970) involvedtwo major deviations from the normal pattern of nursing education in the UK. Inorder that theory and practice might be better integrated the programme was to bedivided into 'modules'. A modular structure is aptly defined, albeit in anothersetting by Schinkel (1974) as 'A more or less voluminous and complex whole,consisting of a number of unambiguous, rounded-off, usually simply replaceableand interchangeable component parts'. These modules would comprise a week'sspecific preparation in the school of nursing, ten weeks in a related ward, orsimilar practical experience, and a further week consolidating the informationgained through instruction and experience. Previous studies had shown thatcarefully selected students could be expected to succeed in the state final examina-tions after less than the statutory three year training (Pomeranz 1973, ScottWright 1963) hence streaming was included as part of the innovation. A thirdstructural change was the suggestion that students should have a broad introduc-tion to nursing and its context. This introductory course was to involve eightweeks covering broad contextual material, in what might be described as 'manin society', and four weeks dealing with an introduction to basic nursing proce-dures.

A further suggestion, aimed at improving integration, was for continuingpractical instruction during the ward-based part of the module. In fact it wasrecommended that the schools should aim to provide at least ten hours of suchinstruction per week. Regrettably practical instruction can legitimately be definedvery widely to include anything from a formal lecture/demonstration by atrained teacher to the student learning in a fairly unstructured situation by talkingto patients or following the good (or bad) examples of more senior nurses. Asdefinition must come before measurement (Pearson 1975) it was necessary toexamine this recommendation in spirit rather than substance. A final recommenda-tion was for a two week school-based management block coming towards the endof training.

Throughout the programme students were to remain in the wards to whichthey were allocated for each module (i.e. they should not be moved to otherwards to 'help out'). This was referred to as 'fixed allocation', again aimed atimproving integration by providing the student with a relevant and stable settingfor the practical experience. Finally all new students within the selected schoolswere to undertake modular training with a gradual phasing out of the existingschemes.

SOME I M P O R T A N T VARIATIONS

In practice the four hospitals, three general and one psychiatric, examined by theresearch team adopted structures and strategies which differed among themselvesand from the initial recommendations. These differences included:I In one hospital the introduction of short modules (ten instead of twelve weeksto fit round the pattern of 'internal rotation' for night duty), truncation of the

Some structural considerations in modular education for basic nursing students 385

introductory course to concentrate largely on the nursing procedures and havingan intake of students every eight weeks.2 In one hospital the introduction of a study day each week during the practicalpart of the module.3 In two hospitals the splitting of sets (e.g. half the students being prepared for andgoing to a medical ward), whilst the other half had a surgical preparation andexperience with the allocation being reversed for the next module.4 In one hospital students were streamed in the first year and then followeddifferent sequences of modules whilst in three the streaming decision was made inthe first year but the streams were not educationally separated until towards theend of the second year.

We mention these differences because all of them influence the overridingconstraint of nurse education, that the system adopted should not adversely affectthe staffing of the wards and departments, to the point where patient care suffers,nor render the teacher's job unmanageable. The effects of radical changes ineducational structure are many and complex and we shall limit ourselves here tothree main issues and outcomes:1 The feasibility and desirability of streaming.2 Possible effects on ward staffing levels and ways of measuring these effects.3 Some actual and proposed structural changes.

The feasibility and desirability of streamingStreaming in the modular scheme meant dividing a set into one group whichfollowed an 'accelerated' programme and another which followed a 'normal'programme. Those on the accelerated stream registered after approximately 2^years, those on the normal after three years.

In effect the term 'streaming' was rather inappropriate. The course was notaiming at two different end products but at one—a registered nurse. Nor in theproduction of this common end were two different educational programmesactually used. The two groups tended to stay together receiving the same edu-cational treatment until well into their second year.

By and large the streaming decision in each of the hospitals was made on similarbases (i.e. a theoretical and practical assessment of each student at the end of thesecond module). In addition, tutors spoke of trying to identify students who couldlearn for themselves, e.g. those who might put in extra study, those who could uselibrary facilities efficiently and those who were capable of abstracting informationin the practical situation. The students had a varying amount of influence on thestreaming decision. On the whole they were 'offered' a stream and could then putforward arguments as to why they would prefer the alternative. Approximatelyone-third of the students were placed on the accelerated programme in eacbhospital. Tutors emphasized that there was no 'slow' stream and, on the whole,students accepted the concept of streaming.

In the questionnaire given to students at the end of their second year we askedthem to indicate their agreement or disagreement with ten statements about

386 J. Harrison, M. E. Saunders and A. Sints

streaming. These statements were taken from the responses resulting from inter-views with a small number of students in each hospital in which we asked for theirviews about streaming. The total figures for the three general hospitals are set outin Table i.

TABLE I Students' views on streaming

Streaming is a good idea

The streaming decision is carried outtoo early

Streaming itself is carried out too early

Students do not have enough say inthe streaming decision

Streaming helps you to go at yourown pace

Students should be allowed to changestreams at least once

Streaming divides up friendships

There is no illfeeling between fast andnormal streams

When the fast stream leaves the set theother students suffer academically

Streaming is necessary in nurse training

Strongly

agree

25

5616

33

16

20

25

34

6

7

Agree

151

147

74

126

181

132

I I I

150

23

51

Undecided

63

26

35

41

32

50

27

41

5780

Disagree

60

83176

104

75

94

131

75

185

138

Strongly

disagree

13

412

12

I I

13

20

14

52

41

Noresponse

I I

710

7

8

14

9

9

0

6

Differences between normal and accelerated students. Accelerated studentswere more likely to think that streaming was a good idea (P < o*oi). The normalstream students were more critical of streaming. They were more likely to feelthat the streaming decision was made too early (P < 0"00i) and that streamingitself was carried out too early (P < o-ooi). They were also more likely to feelthey had too little say in the streaming decision (P < o-oi), that it broke upfriendships (P < o-oi) and that it created illfeeling between streams (P < o-ooi).

Differences between hospitals. Students from one hospital were much morelikely to feel that the streaming decision was made too early (P < o-ooi) but, andthere is no inconsistency here, they were more likely to feel that the timing ofstreaming itself was acceptable (P < 0-05). Students in the same hospital wereagain more likely to feel that they had too little say in the decision (P < 0"00i),that they should be able to change streams (P < o-oi), that it breaks up friendships(P < O'Oi) and that normal students can suffer academically when the streamsdivide (P < o*oi).

From other questions asked we know that students were also influenced inother ways by streaming. The accelerated students tended to feel more preparedfor being left in charge (P < 0-02) than did normal students. As might be predictedboth groups of students felt better prepared for being left in charge on nights than

Some structural considerations in modular education for basic nursing students 387

on days (P < o-ooi). Accelerated students were less likely to have felt like leavingduring their training (P < o-oi) and in fact proportionally fewer had left by theend of the second year. Significantly more of these students also reported that theywould choose nursing if they had to make the career decision again (P < 0-05).Presumably this difference would have been even larger had we been able toinclude those students who had already left. The accelerated group also felt betterprepared for taking their final state examination (P < o-oi). In fact the examina-tion results for these students were, at the time of writing, better (P < O'Oi).

However, bearing in mind the selection criteria for the accelerated stream,some of these results are not surprising. For research purposes a truer test of thevalue of streaming, in respect of state finals, would have been possible if studentshad been allocated at random to fast and normal streams in equal numbers. In factwe already knew from the '2 + 1' experimental scheme of student nurse trainingthat students who were given a training programme which integrated theory andpractice had rather better pass rates at state finals after two years than those studentswith the traditional nonintegrated training had after three years (Pomeranz 1973).

Some views and comments on the question of streaming were gathered viainterviews with one set of students from each hospital and, together with tutors'views, provide supplementary information to that set out above.

We asked all the students how happy they were about being in their particularstream. Interestingly, whatever their stream, students were, on the whole, happyabout this allocation. The following verbatim comments illustrate the reasons mostfrequently given by students as to why they were glad to be on their particularstream-

Accelerated:

'I will be glad to get finals over with.''After finals I can concentrate on things which interest me.''I feel happy about taking my finals early as there are many things I wish to do andI feel the training is very adequate.''I shall be qualified more quickly and able to move to another hospital if I want to.''If I fail and have to take it again I won't be behind everyone else.'

Normal:

'It is frightening to do finals before doing more basic medicine and surgery.''You need the experience before you take finals. It is more difficult to answerquestions on someone you haven't nursed.''Most people could take the exam, but experience is important.''I need the time to study the theory.''If you are rushed through training so fast that you are worried about the exam,nursing itself can take second place.'

The main feeling then, particularly of students on normal streams, but also bya number on the accelerated stream, was that the accelerated programme lackedbasic surgical and medical experience but that it was nice to get finals behind them

388 J . Harrison, M. E. Saunders and A. Sims

as quickly as possible. The general contentment with the streaming decision maywell result from a measure of rationalization on the students' part. Commentsmade by students in both streams mirrored those frequently made by teachers andward staff, particularly comments to the effect that three years was a minimum forgaining adequate practical experience. Despite the views set out in Table i some ofthe 'normal' length students interviewed, and many of the tutors, were consciousof a 'leadership gap' occurring when the streams separated. Some tutors felt thatthe accelerated students were more questioning and made for more participativesessions in the classroom. In fact there was evidence, with which we shall deal in alater paper, that the accelerated students were in fact better able to abstract relevantlearning material from practical situations and preferred a greater range of teachingmethods. Finally, all the students were greatly influenced in their views by theexperiences to which they had been allocated. This was particularly the case foraccelerated students, who felt that their allocation had to be carefully planned ifthey were to be confident when left in charge, having registered after 2^ years.Careful allocation in any case is vital. By and large scarce teaching resources wereconcentrated on more junior students so that seniors had increasingly to depend onthe ward for their 'learning experiences'.

Some effects on staffingClearly an unmodified modular scheme could have a marked impact on thepattern of staffing in hospital wards. A complete set of students, following thesame sequence of experiences of fixed allocation to one ward for ten weeks, fixedholidays and a twelve week introductory block, were all seen as potentiallydamaging to the immediate provision of nursing on the ward. Secondary effectswere also anticipated and in some cases did happen, e.g. parallel improvements inthe pupil nurses' programme which made pupils less available to fill gaps instaffing resulting from the students' programme. Additionally, increased allocationof students to 'special' wards, to the community and to psychiatric hospitals orunits (a trend independent of the modular scheme) influenced reactions of wardstaff, as did a reduction in working hours for nurses which was implementedduring the period of the research. In order to provide students with a similarsequence of experiences more wards were used for training, some in outlyingdistricts, which again appeared to dilute the service provided by students.

As we described briefly in the introduction, hospitals modified their schemesprior to their inception and during the first few years, but service staff still ex-pressed concern over a real or perceived reduction in the students' service commit-ment. In order to examine this we collected data on actual staffing levels in 50% ofwards used for training over a period of ten months. For each twenty-eight dayperiod a random selection of eight 24-hour periods was made and the name, gradeand actual hours worked were recorded for each ward and for each nurse, in-cluding nursing auxiliaries, working on that ward. The results of this study showedlittle evidence of lengthy 'peaks and troughs' in ward staffing levels. We identifiedwards receiving a steady flow of students and some receiving spasmodic alloca-

Some structural considerations in modular education for basic nursing students 389

tions, but in both types of ward the number of learners was relatively constant asthe numbers of students and pupils complemented each other. The followingexamples illustrate this: (i) For approximately half the time ward i had no studentsbut for 79% of the time had between four and six learners (for some shift) duringthe 24-hour period. (2) Similarly ward 2 had between nil and four students (withconsiderable fluctuation) but for 66yQ of the time had between three and fivelearners. (3) Wards 3 and 4 both had a fairly steady flow of students and had sevento eleven learners for 70% and 77% of the time respectively. Whilst there is somevariability in the number of students allocated to a ward over the period, 'troughs'are often met, rightly or wrongly, by increased numbers of pupils. Afternoonstudy periods cannot interfere too much with staffing as our figures for the level ofstaffing on the wards over a 24-hour period were typical (i.e. maximum numbers ofstaff between 12.00 and 17.00 hours). It is probable then that the peaks andtroughs are briefer than we initially expected, e.g. morning shifts where thestudents have a full study day. Longer 'troughs' might also be hidden by increasedmobility of pupils, but pupils have always been a flexible part of the work force.Again peaks and troughs may be emphasized by the movement of, say, fourstudents from the ward to be replaced by four completely new students, with allthe problems of reporting on those departing and integrating the newcomers intothe ward team.

A further problem for some ward staff was a perceived lack of senior students.This only partly resulted from the modular pattern. Some sisters, for example, hadto get used to having only junior students. Even some of those receiving third yearstudents felt that these students, having spent the best part of the second yearoutside of what might narrowly be described as general nursing, had to readjust toward routines and to some extent this feeling was also expressed by students,particularly those on the accelerated stream.

It would be wrong, however, to suggest that all the results on staffing werenegative. Over a period many of the sisters began to value the predictability of thescheme in terms of the type and flow of students. Similarly splitting of sets, asdescribed earlier, decreased the potential disruption. It would also be wrong tobelieve that teaching staff were immune from changes. Increasing the number ofintakes per year can offset problems in the ward but clearly can easily result in therebeing a number of different sets in the school at the same time. It also depends onthe ability of hospitals to recruit outside of normal school-leavingperiods. Whilstthe schemes may well have increased the pressure on teachers this was largelyoffset by advantages. Teachers felt that the schemes were more open to improve-ment than the previous block system and that this encouraged a willingness to tryout new ideas. Feedback to tutors was also valued. Students returned after eight orten weeks on the ward and were better able to appraise the value of their prepara-tory week.

The real enigma concerning the effect on staffing lies in costing nursingeducation. It is commonly held that student nurses constitute a net cost after thevalue of their service has been taken into consideration. However, streaming was

390 f. Harrison, M. E. Saunders and A. Sims

seen as adding to costs since it reduced the number of senior students at any pointin time, some having registered after 2-̂ years, and these could not automatically bereplaced by trained staff. In fact with more nurses wishing to remain in theservice on registration, influenced by the economic climate, the more rapidproduction of trained staff is not always seen as a benefit. Perhaps students can onlybe said to be expensive when there is a ready supply of trained staff.

Some further changesAs can be seen some of the potentially deleterious effects of the modular schemewere anticipated and modifications were made from the outset. Changes were alsomade during the first four years of the schemes and suggested changes were madewhen the schemes came up for renewal—all 'experimental' schemes have to bereapproved by the GNC after five years. The following changes were made orsuggested by at least one of the hospitals.

The abandonment of streaming. Whilst the evidence strongly suggests that ineducational terms streaming can be made to work, and students and teachers inthese terms were in favour of the idea, the case has been made for removing itfrom the revised schemes. Forecasting the numbers of students registering at anypoint in time becomes more difficult unless students are allocated to a stream earlyand then forced to remain in that stream. A more flexible system of streamingwould have been incompatible with forecasting. Additionally new EEC regula-tions may result in three years being the accepted minimum time for training forthe register.

Modular length. There is no evidence that all modules need to be the samelength and it has been suggested that length can be flexible if it is felt that the aimsof a module can be met in less or more than the normal modular length.

The introductory module. It is probable that this twelve week course will begreatly shortened with more time being spent in the wards and on preparation forpractical procedures. It was difficult to justify this part of the course which wasseen very much as a luxury.

Number of intakes. Of the three hospitals currently having two intakes per year,two of them are proposing an increase in the number of intakes. This will evenout the flow of students and seems particularly feasible where teaching staff can bedivided into teams.

Management course. Towards the end of training, students had undertaken a twoweek school based management course. A management module, following thepattern of other modules, is seen as potentially more beneficial. Where practicablestudents will be able to choose to which type of ward they return for the ten weekpart of the module. Not only might this improve the integration of the manage-ment experience but might also assist ward staffing by the allocation of seniorstudents to wards which presently receive predominantly juniors.

Some structural considerations in modular education for basic nursing students 391

C O N C L U S I O N

Perhaps by its very nature research tends to identify more negative than positiveresults. People are better able to identify problems than advantages, possiblybecause problems are immediate whilst advantages may be potential or longterm.Similarly an advantage may be the nonoccurrence of a problem and hence goesunnoticed. Thus, whilst we have tended to concentrate on things which might gowrong with a modular scheme, we must stress that the majority of students,teachers and service staff supported the decision to continue with the schemes,albeit with the modifications described. The research evidence similarly wouldsupport the continuation of the schemes. As with any other scheme it should betailored to fit the hospital, including the school. It should be remembered that'integration' was the main aim of these schemes, the modular structure was themeans and, in trying to improve integration, no part of this structure should beheld sacrosanct. Finally, as with any other system, discussion with staff at all levels,prior to its introduction and during its formative years, would appear essential.

ReferencesDEPARTMENT OF HEALTH & SOCIAL SECURITY (1970) Report of the Nurse Tutor Working Party.

PARNELL J.E. (1975) Modular systems and allocation. In A Guide for Teachers of Nursing. Ed. RaybouldE. Blackwell Scientific Publications, Oxford.

PEARSON J . (1975) Learning Opportunities in Hospital Wards. Unpublished paper, Conference onNursing, University of Liverpool.

POMERANZ R. (1973) The Lady Apprentices. Occasional papers on social administration. No. 51.G. Bell & Sons, London.

ScHiNKBL A. (1974) Certificate in Informatics. Education yearbook 1973-74, 117-125. British Com-puter Society, London.

Scorr WRIGHT M . (1963) Experimental Nurse Training at Glasgoii' Royal Infirmary. H.M.S.O.,Edinburgh.

WARCABA B . (1976) An experimental scheme in nurse education. JoHrna/ of Advanced Nursing i ,243-252.