Fields of nursing: do we need them, what should they be and when should nurses choose theirs?

This month’s Opinion relates to an EBN twitter chat that explored the value of fields of nursing and their future within the United Kingdom (http://blogs.bmj.com/ebn/2016/11/10/fields-of-nursing-do-we-need-them-what-should-they-be-and-when-should-nurses-choose-theirs/).

In the UK, preregistration nurse education provides a route into one of the four ‘nursing fields’—Adult, Child, Learning Disabilities and Mental Health. Student nurses select their chosen field at the time of application to University, and then complete a degree (or higher) level programme of study focused on that field (albeit with some shared elements across fields). This early choice of field therefore shapes a nurse's practice focus for their subsequent career.

The rationale for this field-based structure to the registered nurse workforce is a simple one—by providing entrants to the nursing profession with a skill set focused on a particular client group, they will be better able to provide specialist, evidence-based care. However, the current model is not without its critics. Most notably, the latest review of nurse education in the UK (entitled Shape of Caring ) has suggested that the current system does not produce flexible practitioners with the transferable skills necessary to work with …


David Barrett
This month's Opinion relates to an EBN twitter chat that explored the value of fields of nursing and their future within the United Kingdom (http://blogs.bmj.com/ebn/ 2016/11/10/fields-of-nursing-do-we-need-them-whatshould-they-be-and-when-should-nurses-choose-theirs/).

Background
In the UK, preregistration nurse education provides a route into one of the four 'nursing fields'-Adult, Child, Learning Disabilities and Mental Health. Student nurses select their chosen field at the time of application to University, and then complete a degree (or higher) level programme of study focused on that field (albeit with some shared elements across fields). This early choice of field therefore shapes a nurse's practice focus for their subsequent career.
The rationale for this field-based structure to the registered nurse workforce is a simple one-by providing entrants to the nursing profession with a skill set focused on a particular client group, they will be better able to provide specialist, evidence-based care. However, the current model is not without its critics. Most notably, the latest review of nurse education in the UK (entitled Shape of Caring) has suggested that the current system does not produce flexible practitioners with the transferable skills necessary to work with patients and clients in a range of settings. 1 The review proposes a more generic model, specifically suggesting that students complete 2-year 'whole-person' education, before specialising in the final year of their programme and first year postregistration (the so-called 2+1+1 model).
Since the publication of Shape of Caring, concerns have been raised about this proposed, more generic model. The potential implications of a more generic approach to the nursing workforce have been outlined in particular relation to Mental Health, 2 Learning Disabilities 3 and Child 4 fields. These discussions highlight the need to endow student nurses with the specialist skills and knowledge required to care for their client groups, and argue that a more generic educational approach may lead to dilution of those skills.
There is, of course, no question that nurses caring for specific client groups need to develop a specific set of knowledge and skills to supplement their core nursing competences. This is applicable not just to those areas of care with existing fields, but also subspecialities such as palliative care or primary care nursing. The issue then is not whether nurses need to specialise, but at what stage? Should student nurses make a choice of specialism-a decision that will dictate the course of their entire career-when they enter University, or would this decision be better informed if made further into a programme of study? Is the ideal model one of a generic nurse workforce that specialises only when working in a particular area following registration? With complex issues such as this, it is often useful to be guided by practice globally. Unfortunately, it is difficult to learn much about specialisation from nursing at an international level, because practice is so disparate. Though there are some countries that operate a system of entrylevel specialism similar to the UK, others adopt a completely generic model within preregistration education (including generic preregistration preparation of nurses and midwives). 5 In parallel with discussion of when specialisation takes place, there is also debate on how many fields of nursing there need to be. Shape of Caring advocates the development of an additional field in community care, but there is also support within the profession for a preregistration specialism in care of older people. The number and foci of specialist fields will always be a matter of debate and will often change according to the needs of the population (eg, there was still a specific place on the UK nursing register for Fever Nurses until the mid-1960s). However, while the idea of new fields may be superficially attractive for those working in those areas, care must be taken not to try to fragment the nursing community to an extent where there is a danger of 'silo' working and a loss of core identity.

Key messages from the twitter chat (#ebnjc)
There was recognition among participants of the potential strengths and weaknesses associated with a field-based model of nursing. In particular, there were concerns that fields encouraged 'silo' care that reduced the ability of nurses to care for a wide range of patient groups. For example, there was a perception that adult field nurses may not feel capable of meeting the mental health needs of their patients (and, conversely, that EBN engages readers through a range of online social media activities to debate issues important to nurses and nursing. EBN Opinion papers highlight and expand on these debates. mental health nurses may not adequately understand physical health needs). As a result, there was some support for the more generic model of education advocated by the Shape of Caring.
One particularly interesting area of discussion was when nurses should seek to specialise in a particular field or area of care. Though some participants argued that making a decision at point of entry to education was appropriate, others supported more generic preregistration education, supplemented with a wider portfolio of postregistration education (figure 1).

Where next?
The extent to which the recommendations of Shape of Caring are implemented will become apparent over the coming months and years. It is possible that we may see adoption of a '2+1+1' model of nurse preparation, with or without alterations in the number and focus of nursing fields.
Whatever the future, the profession must ensure that a balance is struck that provides nurses with specialist skill sets, but does not reduce their ability to provide fundamental care to people with a broad range of needs.

Twitter Follow David Barrett @barrett1972
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed. Figure 1 Twitter discussion on the strengths and weaknesses of a field based nursing structure.