An evaluation of training uncovered some harsh realities about student life and significant discrepancies between nursing and other students. Alan Randall and Penny Tamkin report

TWORKThe Sussex Education and Training Consortium, covering 11 trusts, spends£21m on professional training, most of which is commissioned from Brighton University.

In 1998 the consortium decided to evaluate the quality and appropriateness of the four main training courses: adult nursing, mental health nursing, physiotherapy and direct-entry midwifery.

The consortium wanted to compare students', tutors' and trust managers' expectations of the training with the reality. It commissioned the Institute for Employment Studies, an independent centre for research and consultancy into human resource issues, based at Sussex University.

The findings

The survey showed that students were very motivated by getting a place on their chosen course. But most (81 per cent) expected it to be stressful and about half were concerned about their ability to cope academically or financially.

Most students (75 per cent) had worked in the healthcare sector previously. This was especially true for the mental health nurses. The physiotherapists were different from the other students in that they were predominantly recruited from full-time education (56 per cent).

Students' views of tutors' skills varied in different disciplines. Almost all the physiotherapy students (95 per cent) considered clinical skills teaching to be good or excellent. But only a third of nursing students agreed with that view.

Opinions on the amount of practical experience needed also differed between disciplines. Most physiotherapy students (92 per cent) felt the academic-practical balance was right, compared with only 35 per cent of the general nursing students. Most nursing students wanted more practical experience.

More than three-quarters rated peer support good or excellent and half rated tutor support good or excellent.

But one student commented: 'The course is too much. To be able to survive, each student has to work part-time, as well as full-time on the course - most weeks I work seven days a week as well as studying. I feel tired all the time.'

Two-thirds of the sample felt their studies had caused financial hardship and a third of students said they were doing paid work during their course.

'I work every other weekend, two 12-hour shifts, in order to survive financially. Therefore I work 12 days on and two days off. I know that I cannot sustain this level of commitment, ' said one student.

Placements Students were generally positive - between 70 and 80 per cent overall - about their ability to deal with patients, to question practice and about the appropriateness of their learning experiences on placements. Negative comments focused on the fact that trust staff were under pressure, which limited their scope to help students, and on the difficulty matching practice to what they had been taught.

'Although the majority are really helpful to students there are not enough staff nurses around to supervise students and we end up doing pure donkey work as supernumerary students, rather than having varied learning experiences, ' was how one respondent put it.

Good placements were identified as those where the student was made to feel welcome by a friendly team, where the preceptor took their role seriously and where they were given responsibility and the opportunity to gain experience and make contact with patients.

About 70 per cent of the students felt that the emphasis given to various elements of the assessment process (placements, essay writing, research and course work) was about right.

However, almost 30 per cent felt that there was too much emphasis on essay writing, with nursing students holding the strongest views on this.

The main criticism of assessment was one of inconsistency: 60 per cent thought tutors' assessments were inconsistent and 71 per cent thought trust staff 's assessments were inconsistent.

Differing values were attached to practical skills.

Physiotherapy and midwifery students largely disagreed with the statement, 'Practical skills are undervalued', while nursing students largely agreed with it. Overall, more than half the students (57 per cent) found the course taxing academically; among physiotherapy students 75 per cent did.

Students were asked if they felt they would get the job they wanted: around half thought they would, just over 40 per cent did not know, and a very small minority (2 to 3 per cent) did not think they would. On top of the course's other pressures, anxiety about getting a job appeared to be a major factor.

Recently qualified respondents were asked about how well they were prepared for the workplace. They had very strong views about the need for support from experienced colleagues. All the midwives, 89 per cent of general nurses and half the mental health nurses and physiotherapists agreed with the statement, 'I still need support from experienced colleagues'.

One said: 'When I qualified as a staff nurse I was totally unprepared for the amount of responsibility that I had.

Even as a third-year student I was given quite a lot of responsibility, but it is not the same.'

Another said: 'I feel that my real training has only just started. The training is four years really, with the fourth year gaining valuable practical, managerial and clinical skills not obtained during the training.'

The perceived need for colleague support was mirrored in the answers to the question about stress levels. It was the midwives who found the job more stressful than they had expected.

Nursing students were the least satisfied with the course.

The physiotherapy and midwifery students were more satisfied, with the physiotherapists - who were generally younger, were more recently students and had fewer childcare responsibilities - significantly more satisfied than the midwives.

There was a particular problem for just over a quarter of the students who had caring responsibilities. They experienced significant periods of pressure during their courses. Problems reported included holidays not coinciding with school holidays and difficulties finding childcare.

Eleven managers (three physiotherapists, one midwife and seven nurses) were interviewed from four trusts: Brighton Health Care, Worthing and Southlands, South Downs and Hastings and Rother.

There was general agreement that students from Brighton University were better equipped to challenge and question the course content - and had a better grounding in research - than previous students. The main concern was that students were not getting enough practical skills.

The newly qualified practitioners were seen as needing a lot of support in their first year because of their lack of practical skills.

Trust managers and tutors were generally positive about each others' contribution to the training process, but there was nevertheless general agreement that academic tutors need stronger links and involvement with clinical practice.

Conclusions

The Sussex Education and Training Consortium and Brighton University have found the evaluation exercise extremely helpful. The study has raised or confirmed the importance of meeting some practical needs:

better information for prospective students on the demands of the courses and their chosen professions;

more financial and emotional support for students;

help with the difficult transition from student to qualified practitioner;

closer liaison between trusts and the university;

the greater appreciation of the qualities of mature students;

better placements and improved assessment and supervision;

guarantees of employment for students, subject to satisfactory qualification.

The study has also raised some unanswered questions about the aims of the training commissions. Does the consortium, representing NHS management views, want to produce professional staff with a strong research and questioning approach to their work or do they want to see newly qualified recruits who possess competent practical skills from day one?

Most of the entrants to physiotherapy were young and reported a higher level of satisfaction with their course than the other students. The physiotherapy course is oversubscribed with candidates who have good academic qualifications. But the NHS still has difficulty retaining physiotherapists and has high vacancy levels in the profession.

Should there be a shift in the recruitment policy to try to attract more mature applicants who may stay in post longer? Or should the NHS recognise that it may not be the employer of choice for significant numbers of those in training and adjust its training numbers accordingly? The task now is to act on the survey's findings.

Who was asked what

The study began by interviewing 15 university lecturers and trust managers and four focus groups of 12 students.

A total of 1,346 questionnaires were then distributed to students and newly qualified staff and there were 745 useable returns. Of these, 415 were in adult nursing, 85 in mental health nursing, 190 in physiotherapy and 55 in midwifery. A total of 111 returns were from newly qualified practitioners. Most (69 per cent) of the respondents were aged between 20 and 34.

The survey asked about:

student preparation for training;

academic training provided by the university;

placements or practical experience within the trusts;

assessments of both academic work and clinical practice;

experience on qualifying.

Key points

An audit of nursing, midwifery and physiotherapy training commissioned by a consortium of trusts in Sussex showed diverging views on the relevance of courses.

Many nursing students wanted more practical experience.

Two-thirds of students reported financial hardship and a third were working at the same time as studying.

Alan Randall, chief executive of Worthing and Southlands Hospitals trust, is on secondment to Eastbourne Hospitals trust. Penny Tamkin is senior research fellow at the Institute for Employment Studies, Sussex University.