Journal of Nursing Management, 2009, 17, 523531

The times they are a changin

MIKE THOMAS

PhD, MA, BSc, RMN, RNT, Cert Ed

and CELIA HYNES

MA, RGN, RSCN, RNT, RCNT

Dean (and Professor of Mental Health), Faculty of Health and Social Care, University of Chester, Chester and
Associate Head for Teaching and Learning, School of Nursing, University of Salford, Salford, UK

Correspondence
Celia Hynes
School of Nursing
University of Salford
Greater Manchester M66 PU
UK
E-mail: c.hynes@salford.ac.uk

T H O M A S M . & H Y N E S C . (2009) Journal of Nursing Management 17, 523531

The times they are a changin

Aim A discussion paper outlining the potential for a multi-qualified health practitioner who has undertaken a programme of study incorporating the strengths of the
specialist nurse with other professional routes.
Background and rationale The concept and the context of nursing is wide and
generalized across the healthcare spectrum with a huge number of practitioners in
separate branches, specialities and sub-specialities. As a profession, nursing consists of different groups in alliance with each other. How different is the work of
the mental health forensic expert from an acute interventionalist, or a nurse
therapist, from a clinical expert in neurological deterioration? The alliance holds
because of the way nurses are educated and culturalized into the profession, and
the influence of the statutory bodies and the context of a historical nationalized
health system. This paper discusses the potential for a new type of healthcare
professional, one which pushes the intra- and inter-professional agenda towards
multi-qualified staff who would be able to work across current care boundaries
and be more flexible regarding future care delivery. In September 2003, the
Nursing and Midwifery Council stated that there were more than 656 000
practitioners on its register and proposed that from April 2004, there were new
entry descriptors. Identifying such large numbers of practitioners across a wide
range of specialities brings several areas of the profession into question. Above all
else, it highlights how nursing has fought and gained recognition for specialisms
and that through this, it may be argued client groups receive the best possible
fit for their needs, wants and demands. However, it also highlights deficits in
certain disciplines of care, for example, in mental health and learning disabilities.
We argue that a practitioner holding different professional qualifications would be
in a position to provide a more holistic service to the client. Is there then a gap
for a new breed of practitioner; a hybrid that can achieve a balanced care
provision to reduce the stress of multiple visits and multiple explanations?
Methods Review of the literature but essentially informed by the authors personal
vision relating to the future of health practitioner education.
Implications for nursing management This article is of significance for nurse managers as the future workforce and skill mix of both acute and community settings
will be strongly influenced by the initial preregistration nurse education.
Keywords: hybrid, inter-professional, nurse education, Professional regulation, working
Accepted for publication: 5 June 2008

DOI: 10.1111/j.1365-2834.2008.00924.x
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd

523

M. Thomas and C. Hynes

Introduction
The concept and the context of nursing is wide and
generalized across the healthcare spectrum with a huge
number of practitioners in separate branches, specialities
and sub-specialities. As a profession, nursing consists of
different groups in alliance with each other. For example, how different is the work of the nurse intensivist
from a district nurse or a mental health forensic expert
from a cardiac rehab specialist. The alliance holds
because of the way nurses are educated and culturalized
into the profession; the influence of the statutory bodies
and the context of a historical nationalized health system. The profession is now about to participate in a
consultation process regarding its preparation of new
nurses for the future UK healthcare needs. This paper
discusses the potential for a new type of healthcare
professional, one which pushes the intra- and interprofessional agenda towards multi-qualified staff who
would be able to work across current care boundaries
and be more flexible regarding future care delivery.
In September 2003, the Nursing and Midwifery
Council (NMC) stated that there were more than
656 000 practitioners on its register and proposed that
from April 2004, there were new entry descriptors.
Identifying such large numbers of practitioners across a
wide range of specialities brings several areas of the
profession into question. Above all else, it highlights
how nursing has fought and gained recognition for
specialisms and that through this, it may be argued
client groups receive the best possible fit for their
needs, wants and demands. However, it also highlights
deficits in certain disciplines of care, for example, in
mental health and learning disabilities. At the same
time, there is a growing view that a vast quantity of
other health disciplines have also sub divided within
their own speciality while still others continue to adapt
to the health and social care environment (for example,
the recent designation of specialist mental health social
workers and the advanced pharmacy qualification). We
argue that a practitioner holding different professional
qualifications would be in a position to provide a more
holistic service to the client. Is there then a gap for a
new breed of practitioner; a hybrid that can achieve a
balanced care provision to reduce the stress of multiple
visits and multiple explanations?
How can this be achieved? In the first instance, there
is much talk around inter-professional and multi-professional learning that needs to be considered (Barr
2007, Centre for Advancement of Interprofessional
Education 2005) (CAIPE). What does sharing learning
mean? Is it learning across branches (which is not really
524

inter professional), or does it mean sharing learning

across disciplines both in theory and in practice. At
best, most programmes boast inter-professional learning in practice, arguing that in the practice placements,
all professions are exposed to each others expertise and
offered the opportunity for crossing over boundaries
and roles. However, unless these exposures are planned,
how can there be an assessment of what learning has
taken place and more than anything how do these
exposures affect client care in the long term (Thomas &
Hynes 2002).
There is also the argument regarding the difference
between inter-professional learning and multi-professional learning. Is this simply defined as either learning
between or learning with professions? The whole aspect
of the definition is in fact quite a woolly one. Ten years
ago, Centre for Advancement of Interprofessional
Education (1997) suggested that inter-professional
education is occasions when two or more profession
learn from and about each other to improve collaboration and the quality of care, and differentiated this
from multi-professional education which they suggested
was occasions when two or more professions learn side
by side for whatever reason. While this may seem very
clear, it is not. Who evaluates (when professionals learn
side by side) that they are not learning something that
will directly improve collaboration and quality of care?
Conversely, what guarantees are there that professionals who learn from and about each other will improve
collaboration and quality of care. How will the outcomes impact on the clinical area, the service user, the
client and their carer? The key aspect missing is
understanding that it is not about the process but about
the outcome. It is not about educational theory but
about evidence-based care.
The recognition of an ever changing climate within
the National Health Service (NHS) which is primarily
driven by policy means it is essential that we capitalize
on the wider opportunities available for inter-professional education (Barr 2002). Centre for Advancement
of Interprofessional Education suggest that this can be
carried out by taking an approach to education which
maps out cumulative learning, integrated learning,
experiential learning and relating all three to the context in which they would be applied. While this is seen
as good practice and likely to be delivered in the context
of profession-specific curricula, there is more needed to
meet the demands of the user/carer. What the public
want is a focus on outcome. Hence, the strong emphasis
on evidence-based care and the growth in government
funding for what is measured as efficient and effective
care interventions.

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

The times they are a changin

Choosing Health (Department of Health 2004b)

explores this issue in some detail and we conclude that
the core skills of all the health professions are essentially
the same and that the key to all successful professional
working is good communication skills. In fact, the NHS
Plan stated that by 2002, it will be a precondition of
qualification to deliver patient care in the NHS that an
individual has demonstrated competence in communication with patients. In other words, this is a generic
competence. And this is surely supported by the far too
many failures in the system (for example, Department
of Health 2003). As a core skill communication was
also highlighted in the Agenda for Change and Choosing Health papers and significantly affects personal
development (Department of Health 2004a) (DH). This
skill (communication) is furthermore just one example
of the six major components which were part of the
Agenda for Change. In addition to acquiring core skills,
there is a need to develop practitioners who can be
flexible and quickly alter patterns of care to deal with
issues such as the winter rush and seasonal outbreaks of
certain illnesses as well as working with the European
Time directive. A multi-skilled hybrid would assist in
areas such as reducing waiting lists (already seen in day
units) and would have a knock-on effect to junior
doctors hours. With the increased emphasis on care in
the community, a multi-skilled professional would help
in delivering a more seamless service to the client and
family and they would be able to work with technology
in such a way that care is enhanced.
But we are not advocating a jack of all trades. The
client wants many skills in one package. To achieve
this, higher education, practice and the professional
bodies need to work towards a core curriculum that is
client focused and not, as at present, a professionfocused curriculum. This is a real barrier to developing a professional able to practice across current
boundaries. As curriculums focus on a specific profession, there is an inevitable cultural induction to the
rules and regulations of that profession and a narrowing of focus regarding what it (and only it) can do
for the end user.
Each profession has developed a curriculum with the
required profession-specific proficiencies that require
achievement (HPC 2004). In nursing, students are
required to progress successfully through the common
foundation programme before entering the branch and
then once in the branch remain focused on that area of
practice. Despite this, some practitioners have dual
qualifications anyway. The profession-focused curriculum appears to be the problem but some barriers are
creaking. We already have postgraduate mental health

workers who can do public health and mental health

work and we have also seen the development of assistant practitioners, a potentially important new generic
type of worker who could meet many needs of the client. Recent consultations from the NMC aim to gather
the thoughts around the future of preregistration nursing and yet, one can predict that there will be no
appearance of any managed risk taking. It is not proposed that a hybrid is something that is for everyone,
healthcare may need professionals trained in their own
specialties, but would not be forward thinking to develop a preregistration programme that was inter professional and produced a unique practitioner at the end.
To think the unthinkable, there could even be room for
training medical students and other healthcare students
together, there could be exit points at the relevant levels
prequalification or access points for continuous
professional development joint qualifications. Each
would learn from the other and additionally, by
increasing the involvement of users and carers in curriculum planning and delivery help the services to be
more client focused rather than professions focused.
At the present time, whether it is liked or not, the
health and social care professions deliver a curriculum
that in essence is dictated by professional bodies and
higher education regulations. This is regardless of the
profession, be it social work, nursing, midwifery, health
care professions or medicine. And despite what
nomenclature is given, (multi professional or inter
professional, education or learning) what matters above
all else in todays health agenda is that the client group
remains the focus of the curriculum (Department of
Health 2005).
Achieving a client-driven curriculum essentially
means altering the mind set of academics and practitioners. It means, becoming less precious around single
disciplines. A client-focused curriculum means, taking
the client and placing them at the centre, and by asking
the simple question of how can the needs, wants and
demands of that person be met. The growing involvement of users and carers within curriculum development helps place the client at the core of training. This
should not be about one-off sessions on teaching by
expert patients, or about a paper exercise that slots
clients into certain boxes. A client-focused curriculum is
about a curriculum that maintains the core competences
across all professions, but is flexible enough and brave
enough to leave parts of a curriculum open so that
student and clients can specifically identify the areas
that are most needed (Horrocks 1998). The much needed move to higher education in the 1990s has been
excellent, recognizing and supporting the health and

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

525

M. Thomas and C. Hynes

social care professions in its drive from its historical

subservient beginnings to a vocational profession.
However, at the same time some aspects have been lost.
Some would argue this is not the case, that students
learn all the time, but most clinical placements are
overloaded with students, and those clinical placements
are so busy that learning frequently becomes a victim of
role modelling. This can mean that future practice is
based on what is seen in that particular area and not
necessarily on best evidence-based practice. The key to
a client-focused curriculum is application in the practice
setting, pertinent to the relevant learning outcomes and
to student supervision. By using assessment in practice
that links theory closely to client care and welfare, fitness for practice and competency can be achieved in a
curriculum which could emphasize the skills and
knowledge required for healthcare that continues to
develop and change. In the practice environment, it
would mean that the client should not have to provide
personal details and background to illness more than
once; no client should have to encounter many different
people when they or members of their family are ill. A
hybrid practitioner would have the knowledge, skills
and attitudes to apply better and more holistic care.
Healthcare workers are aware of the agenda which
currently prevails around the concepts of multi-professional and inter-professional working in an aim to
establish a more effective and seamless service for service users (see Department of Health 2004b, 2005).
However, the reality is that aiming for a multi-skilled
worker and dual qualification is hampered by professional regulations and boundaries. Having previously
established the benefits of a multi-skilled worker
(Thomas & Hynes 2004), the aim here is to provide not
only debate but guidance as to how these difficulties
may be overcome in order to achieve a unique hybrid.
By hybrid, we emphasize a type of profession which
shares the best out of existing healthcare qualifications
with the aim of developing a new and more adaptable
healthcare worker. The focus on wellbeing Department
of Health (2005) means health and social care is now
firmly aimed at public health, health education, prevention of diseases, health promotion, rehabilitation,
chronic disease management and leadership. We propose that a practitioner clinically carrying out care in
more than one narrow sphere has more to offer clients
and carers as well as supporting the patient-led philosophy being auctioned by the DH. For example, a public
health nurse with both an NMC and Social Work registration would be useful because the practitioner would
assist in the provision of care for a client with health
needs who may also be struggling with aspects of the
526

social care system that they do not fully understand. A

professional of this kind would provide more of the
skills required without subjecting the client to multiples
of different professionals and would meet both health
and social aspects of the patients care. Additionally, an
Occupational Therapist with a Mental Health Nursing
qualification would be useful in aspects of rehabilitation. Other examples could be a Health Visitor or
Childrens expert with family therapy qualifications, a
Physiotherapist with a child qualification or a Cognitive
Behavioural Therapy award. Other professions may
include Podiatrists, Dieticians and Midwives who
would have wider application of care if they also had
Social Work and family therapy qualifications. We
emphasis qualifications that are professionally regulated
and publicly recognized. We are not advocating that an
existing qualifying programme assimilates parts of
other programmes. We are discussing education which
gives an individual clinician more than one registration
or awards. To reinforce again, we are not discussing
dual qualification where a person has performed two
separate unitary programmes (and often practices in
just one of the areas anyway). We use existing professional titles to demonstrate inter-professional qualifications precisely because there is no other example out
there.
At the turn of this century, in a period of change in
healthcare delivery the United Kingdom Central
Council (2001) published their Fitness for Practice and
Purpose paper and suggested that multi-professional
education was the way forward. The present healthcare
climate remains as changeable as in 2001 and we must
question how change affects the professions. We need to
understand that if we continue to always educate, train
or learn in the same way then we will undoubtedly have
the same end result. The move towards multi-professional outcomes can only be achieved by reviewing how
nurses currently intervene with their client group
(Thomas & Hynes 2004). This can be approached via
three distinct concepts: what the client needs, what the
clients wants and what the client demands.
The first of these, need, is usually driven by obvious
physical and psychological requirement. The ill client
needs to return to wellness or maintained at the point
of optimal well-being for them. Their need therefore
becomes demand led and is responded to by the nurse
who deals with that aspect of the patients care that
best relates to their professional practice. The demand
around care is therefore influenced by several factors
(Percy-Smith 1996). Nevertheless, what the community needs for its healthcare drives the agenda for
service provision. Additionally, in the era of the

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

The times they are a changin

expert patient (Department of Health 2001b), those

in need often know the demands they are in a position to make. They are informed of their rights and
how these rights are influenced by the law and most
patients make informed choices around their care. For
many clients, particularly those with a chronic illness,
this can create a dependency and an expectation that
the nurse will continue to provide care for a long
time. Simultaneously, the nurse is aiming towards
empowering the client as a way of reducing need
(Miller et al. 2001). In such situations, demands may
paradoxically prevent or at least slow, needs reduction. The client also has wants. These wants fall
into both professional and personal categories, are
driven by desires and frequently conflict with need
when placed in an illnesswellness continuum. The
conflict between the two may lead to ambiguity and
place a strain on the expectations of the professional
and the client around issues of continuity of care,
contact time and interventions. A client will have, as
previously mentioned, the need for physical, psychological and social care. These needs cannot always be
met by one profession and therefore another health
care professional will provide the other aspects of
care. Conversely, clients can develop a desire for
dependency on their carer. Needs, demands and
wants then cause problems with planning and actually
delivering care programmes. This cycle of interdependency which encompasses need, demand and want
is difficult to break anyway but even harder when
several different professions provide input (Hartman
& Zimberoff 2004). The development of the care
team approach is just one example of how different
professions try to communicate with each other.
The question that must be asked here is whether we
currently develop the professionals in a way that deals
with all the needs, demands and wants of the client. We
argue that the answer is no because each carer is limited
by the unitary nature of their profession. A health and
social care worker gains knowledge and skills to be
proficient, they then acquire further knowledge, skills
and experiences in dealing with a specific client group.
But such workers cannot gain the majority of modern
skills requirements from current profession-focused
curricula, or in fact from a token of shared learning
from other professions. Health and social work education is currently limited in what it can achieve as it
grapples with newer and broader public health and
primary care agendas (Ovretveit et al. 1997). Education
needs to be free to develop a multi-qualified healthcare
professional curriculum rather than constrained by
unitary professional concerns.

There is a need to examine what kind of care skills we

want to create. To do this, it is necessary to consider the
influence of policy on practice. With the exception of a
few, most policy documents are professionally orientated (for example, Department of Health 2002a,
Department of Health 2002b, Department of Health
2004b, General Social Care Council 2005). Consequently, because of this, the professional is limited by
the practice policies of that profession. If we think
about what clients really require to meet their needs,
demands and wants then it makes sense to consider the
following which would cause a change to existing
demarcation lines which are supported by professional
rules and regulations and healthcare policies.

Multiple skills and knowledge

In preparing a new health and social care worker, the
curriculum should be required to have multi-professional outcomes to produce a new profession. This
hybrid should generate a practitioner with multiple
skills and knowledge. The learning and skills outcomes
would mean more consistency of care, greater confidence in the care relationship, a more seamless service
and more practitioners available to deal with the
growing client population in primary care and elsewhere, and holistic care as it is intended to be. This new
practitioner can be achieved by combining existing
different practitioner education.
This means letting go of current professional ownership. To some degree, there has been an attempt at this
through the introduction of Trainee Assistant Practitioner Education (Department of Health 2001a), a
generic level two worker and also with the Graduate
Mental Health Worker. To date, they have not been
widely established. An example of a programme model
would be a 3-year graduate programme of study which
in year two provides an option to study mental health,
social work or an aspect of health care practice together
with other content (such as nursing or physiotherapy).
This would be a way forward for multi-professional
outcomes without moving specifically towards a generic
worker. The end product could have several different
awards. There could be a Registered Child Health and
Adolescent Mental Health Practitioner, a Registered
Mental Health Nurse and an Adult or Social Work
Practitioner, or a registered Occupational Therapist and
an Adult or Mental Health Practitioner, or a registered
Occupational Therapist and Social Work and Public
Health Practitioners. Is this difficult? Just look at the
core skills of the different professions. They are interpersonal and communication skills, problem-solving

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

527

M. Thomas and C. Hynes

skills, numerical ability, literacy, working with others,

patience, acceptance, congruence, empathy, knowledge
of their role and evidence-based practice. Examine the
national benchmark in the curriculum, or the references
to the transferable skills. Only application within a
defined discipline creates a difference. Then, the professional knowledge and practical skills acquisition
create further separation within the professions. After
so many years of unitary education, the mere thought of
developing a new profession using what we have already in place can appear too daunting to contemplate.
But while multi-professional or dual qualifications
may appear out of reach, they are not if proper consideration is given to overcoming the barriers. First and
most obvious, there is likely to be strong objection by
professional and regulatory bodies. Then, there is the
question of who would employ the dual or multiqualified practitioner, including contractual issues
around how would the practitioner legally protect
themselves and also keep professionally updated.
Employers may get confused and human resources
would need to examine job specifications. The career
structure and promotions ladder would have to
encompass the health and social care sector and the
attitude of fellow health professions may initially be
negative towards this multi-skilled worker. Even at
commencement of education, there would be issues
around supervision and placement for the student. For
postqualifying development, the practitioner themselves
would have to find efficient ways of remaining multiskilled. Nevertheless, an analysis of the current climate
indicates that the difficulties remain professional
boundaries and demarcation (specialities). There is fear
of change. New leaders need to come forward. There
may be a need for new legislation to change professional bodies as they currently exist.
For educators, a more practical question would be
around managing a diverse curriculum and how this
hybrid would be classified under current monitoring
audits and benchmarks. All of these barriers are not
insurmountable. Now is the opportunity to do something different. There needs to be leadership which can
facilitate bringing different professions together. Yet, it
is not difficult to envisage a DH initiative which could
bring together groups of delegates who represent multiprofessions and service users to develop curriculum
designs which encompass both applied and core
knowledge. These could then be applied in piloted
practice settings with relevant learning outcomes and
relevant supervision. Learning outcomes could be
measured by appropriate multi-professional assessments preparing new practitioners with fitness for
528

purpose, practice, competency and proficiency. It would

be difficult at first. It is acknowledged that there would
be a range of obstacles to overcome and that these may
initially be focused on culturally long-lasting and wellmeaning professional identity. In order to progress and
move forward with inter-professional education which
culminates in multi-professional outcome, the current
system has to be challenged. There needs to be a challenge on the long held assumption that the quantity of
hours is important and instead move to a model where
intended learning outcomes for theory and standard of
proficiency are successfully met by the student. Reaching an agreement on joint professions with shared hours
and shared proficiencies would not lead to a dilution
but a strengthening of care for the client. There needs to
be a more contemporary interpretation of curriculum
hours which meets EU guidelines but reflects the UK
healthcare delivery. Lets face it straight on; the purpose
of the tribal protection of any health profession is
to protect the public. We would argue that if it is to
protect the public, then a hybrid may be even more
rigorous.
In addition, the challenge requires a need for a full
and clear appreciation of each others roles and where
relevant identifying regulations that can be shared in a
dual or even triple qualification. This would need a
single governing body. To reach that point may require
a general body of advocates as an Advisory Working
group possibly with representation from each of the
professions and with equal representation from users
and carers.
There also needs to be a growth in confidence about
taking a lead on change. For example, from the nursing
professions perspective, there is often a reputation for
being retroactive rather then proactive. Who remembers
the frequent request for a branch of nursing in the care
of older people or the long opposition in relation to who
was allowed to access the child and adolescent mental
health programme, or more recently, the reluctance for
a graduate nursing workforce?
There is a strong need for commitment. Employers
need to speak out and employ the multi-professional
and have the vision to see how this professional would
enhance and fit within the workforce. This requires
due recognition of skills by providing good reimbursement and a career structure. Such proposals need
the backing of the DH, the Strategic Health Authorities and local employers. If there were exciting
employment opportunities for new multi-professional
staff and employers commissioned this new type of
professional, then there would be requisite changes in
training and education.

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

The times they are a changin

How long would it take from commencement of

training to completion is an interesting issue. We would
propose that students to do a 3-year undergraduate
programme which has the proficiencies and learning
outcomes achieved through exposure to theory and
practice using a variety of different media, such as
simulation, and on-line learning. Core proficiencies
could also have continuous professional development
mapped against then to enable existing practitioners to
step on and off in order to update skills and knowledge.
A 2-year postgraduate Masters programme could be
offered for graduate entry. At postqualifying, the
advanced practice programmes should be based on
professional courses at Masters level while consultants
should complete professional examinations involving
practice at taught doctorate levels. To achieve this, there
needs to be new legislation to prepare and implement a
new professional statutory regulatory body. This is not a
criticism of existing statutory bodies. They operate
within a legislative framework designed primarily to
protect the public with regard to specific professions.
The fact that the UK has the Social Work Council,
the NMC, the Health Professions Council (HPC), the
General Medical Council and General Osteopathic
Council is the point. Add the number of psychologists,
complementary therapists, counsellors, therapists and
health coaches who operate in the health and social
environment with membership of quasi-professional
but not statutory status and you have a long list.
Nurses are currently required to complete a European
directive of 4600 hours in order to be deemed proficient/competent to register with the NMC. These hours
are required to be split equally between theory and
practice. At present, practice hours cannot be assimilated in a virtual learning environment setting and
clinical competence must be verified by a qualified
mentor (Department of Health 2001c); at the time of
writing the NMC are considering how simulation may
be recognised as a part of the clinical hours. This is a
mandatory requirement put in place to protect the
public, and is considered a necessary and understandable regulation for nurses. However, other professions
also work with the public but are not required to
complete the same number of hours. The health professions council regulates 13 professions none of which
are required to undertake this quantity of hours, but all
of which work closely with the public. For example,
physiotherapists and occupational therapists undertake
1000 hours of clinical practice. Social workers undertake 910 hours in field instruction or 200 days of field
work. Why should such a disparity exist across
professions that all work with the public? It is difficult

to even begin thinking of inter-professional learning and

multi-professional outcome while the regulatory bodies
have not yet begun discussions on how they could
compromise on what constitutes competence. It is
unclear, on what basis the decision around the quantity
of hours for each profession was made. It does seem
arbitrary. Despite the EU directive (which concentrates
on medical and surgical experience), the logic appears
to be that for nursing the more hours undertaken the
more competent the student. This original idea appears
to be based on a simple equal split of an existing 3-year
programme to accommodate the theory/practice debate
raging at the time. The current requirement also gives
the anomaly of most nursing students studying over a
46-week year; a programme of study in excess of the
requirements for fellow healthcare students. The crucial
point is that regardless of the quantity of hours, or the
length of time to the exit point, any programme of study
produces a newly qualified practitioner who is fit for
practice, purpose and award. Essentially, Fitness to
Practice is a registrants suitability to be on the register
without restrictions, in other words to be an autonomous practitioner providing the best fit for the care
and guidance for clients.
It is self-evident that professionals need to understand
other professionals. The same can also be said for professional bodies. This may now be a time when only one
governing body is required and this could be by statutory order. For example, in the past 20 years look at
how in Nursing, the United Kingdom Central Council
(UKCC) replaced the General Nursing Council and
thereafter how the National Boards and the UKCC were
disbanded and statutes absorbed into the existing NMC.
Professions could follow the line of shared Quality Assurance Agency benchmarks and value statements and
by using the five principles outlined below as a starting
point. We recognize that what is suggested here is difficult but look at the Health Professions Council umbrella, 13 generic standards of proficiency already exist
in the professions regulated by the HPC. These generic
standards of proficiency fall into three domains: expectations of a health professional; the skills required for
application of practice; and finally knowledge, understanding and skills. It would seem that these broad
headings which provide specifics for each are also generic to other professional groups.
To facilitate inter-professional working on a new
curriculum, we would suggest five guiding principles to
provide a basis for early discussions and the commencement of an inter-professional programme leading
to multi-professional qualifications. These principles are
based on the following:

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

529

M. Thomas and C. Hynes

Identify and respect different current statutory,

mandatory and professional regulations.
Apply a client-focused curriculum not a professionfocus curriculum.
Identify shared learning topics and subjects.
Application in practice should be led by a current
relevant professional.
Pilot new themes or subjects and evaluate before
introduction in the curriculum.
As previously mentioned for any development to
move forward, it is crucial that we have an understanding of our colleagues in other professions. At
present, we are governed by different professional
bodies and therefore, we have to know about and
respect each others statutory and professional requirements. The time has possibly arrived to have a radical
rethink on this and explore the development of one
governing body for those working in the field of health
and social care.
Shared learning comes under much scrutiny, but
unless learning is shared then outcome will never be
changed. This shared learning could begin to take place
across different higher education institutions as many
universities have specific geographical patches that
could enrich learning if placements were shared. More
use of technology, more use of the virtual learning
environment, the use of simulation and using interactive
assessment on line to not only enhance learning, but
also test outcome should become the norm for modern
healthcare education. The use of technology as a
learning tool could be applied via validation requirements from the professional body.
If healthcare were move to one professional body for
all, then application to practice would be easier. It could
and should be guided and decided by the professional
body with a strong voice from practitioners. There
would need to be a major rethink on the amount of
hours required for achieving multi-skilled competence/
proficiency and more work on continuous professional
development. However, until such time as the professional bodies merge (or a new one replaces existing
ones), a registered practitioner should provide applied
clinical skills and supervision to students who are
learning to be multi-qualified. The student could have
outcomes to measure their understanding of the
advantages and limitations related to the professions
presenting their skills.
Bringing professions together will inevitably bring
about new ideas, new subjects and new themes. These
need to be rigorously tested, and any evaluation should
consider the evidence outcomes before implementation
in a curriculum. Evaluation should have at the centre,
530

the client and the question must be, whether the new
type of professional is giving a better service to the
client. Once piloted, then there should be a process of
disseminating the information nationally. Above all
else, there should be rigorous quality assurance mechanisms which need to be realistic but not bureaucratic.
Following pilot trials, there should be a formal process
to disseminate results for each aspect of learning scrutinized. There should be quality assurance mechanisms
for the introduction, application and monitoring of
inter-professional programmes. These would help to
ensure support for the philosophy and objectives of
such programmes and to present a robust picture for
external scrutiny. Nevertheless, if the goal is for applied
collaboration to work then the five principles need to be
underpinned by trust, teamwork and transparency.
It is evident from the current debate that the increase
in multi-professional education and working is necessary in order to find a best fit with the client population. There remains a large gap in curriculum
development and also in the present evidence that
professions would be willing to collaborate to the
extent of showing awards.

Conclusion
We have discussed here the importance of outcome
rather than process in terms of inter- and multi-professional learning and education. In essence, it is necessary to think ahead of the game in relation to the
practitioner required to care for the complex health
needs of the future. A case in point is the length of
courses and the long run-in between recruitment and
qualifications which causes such headaches with human
resource planning in healthcare. Having suggested the
development of a hybrid, we recognize that the length
of a programme is just one of many changes required if
this is to become a possibility.
It seems evident that to embrace inter-professional
education fully there is a strong need to consider fully
multi-professional outcome. People should not become
too precious around their own specialism, which while
essential and necessary will always detract from interprofessional education. They should not become hung
up on what this coming together of learning and outcome will be called; it is not that important what term is
used. What is important is that professional bodies
begin discussion around sharing common learning
hours with an aim to interpreting and encompassing
these hours into one programme that gives dual or triple
qualification. While acknowledging that this has been
carried out in areas such as learning disabilities nursing

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

The times they are a changin

and social work, it is interesting that from those programmes the professional usually chooses only one
route to practice, while still holding the dual qualification. This is because no specific employment route
exists for them. This is an important lesson. For the
future, careful consideration needs to be given as to
where a new hybrid could be employed in order to
make the clients journey through the health service a
satisfying one; a journey during which the client experiences care which is fit for purpose and practice.

References
Barr H. (2002) Interprofessional Education Today, Yesterday and
Tomorrow: A Review. Centre for Health Sciences and Practice,
Learning and Teacher Support Network, London.
Barr H. (2007) Interprofessional Education in the United Kingdom 1966 to 1977. Higher Education Academy, London.
Centre for Advancement of Interprofessional Education (1997)
Bulletin No 13. CAIPE, London.
Centre for Advancement of Interprofessional Education (2005)
Proceedings from Inter Professional Education Conference,
Bradford. CAIPE, London.
Centre for Advancement of Interprofessional Education (2007)
Creating an Interprofessional Workforce: An Education and
Training Framework for Health and Social Care in England.
CAIPE, London.
Department of Health (2001a) Delivering the Workforce.
Department of Health, London.
Department of Health (2001b) The Expert Patient. A New
Approach to Chronic Disease Management for the 21st Century. Department of Health, London.
Department of Health (2001c) Preparation of Mentors and
Teachers. A New Framework of Guidance. English National
Board and the Department of Health, London.
Department of Health (2002a) The NHS Plan. Department of
Health, London.
Department of Health (2002b) Liberating the Talents. Department of Health, London.

Department of Health (2003) The Victoria Climbie Inquiry. Report

of an inquiry by Lord Laming. Department of Health, London.
Department of Health (2004a) Agenda for Change. Department
of Health, London.
Department of Health (2004b) Choosing Health: Making
Healthier Choices Easier. Department of Health, London.
Department of Health (2005) Creating a Patient-led NHS.
Delivering the NHS Improvement Plan. Department of Health,
London.
General Social Care Council. (2005) Post qualifying framework
for social work education and training. Available at: http://
www.gscc.org.uk
Hartman D. & Zimberoff D. (2004) Corrective emotional experience in the therapeutic process. Journal of Heart Centred
Therapies Autumn.
Horrocks S. (1998) Heidegger and Nurse Education. PhD Thesis.
University of Durham, Durham, UK.
HPC (2004) Standards for Education and Training. Health Professions Council, London. Available at http://www.hpe-uk.org.
Miller C., Freeman M. & Ross N. (2001) Interprofessional
Practice in Health and Social Care: Challenging the Shared
Learning Agenda. Arnold, London.
Nursing and Midwifery Council. (2003) General entry required
for pre registration education. NMC Circular 18/2003.
Ovretveit J., Mathias P. & T. Thompson. (eds) (1997) Interprofessional Working for Health and Social Care. MacMillan
Press, Basingstoke.
Percy-Smith J. (ed.) (1996) Needs Assessment in Public Policy.
Open University Press, Buckingham.
Thomas M. & Hynes C. (2002) The Times They are a Changin.
National Childrens Conference. RCN, Cardiff.
Thomas M. & Hynes C. (2004) 6th International Conference.
The Times they are a Changin presentation. Strategic Issues in
Health Care Management. Reforming Health Care Systems:
Analysis and Evidence. University of St Andrews, St Andrews,
UK.
United Kingdom Central Council for Nursing Midwifery and
Health Visiting. (2001) Fitness for Practice and Purpose.
UKCC, Portland Place, London.

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 17, 523531

531