Nurse Education Today 37 (2016) 7174

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

Review

Nursing philosophy: A review of current pre registration curricula in

the UK
Carolyn Mackintosh-Franklin
University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom

a r t i c l e i n f o s u m m a r y

Article history: Background: Nursing in the UK has been subject to criticism for failing to provide care and compassion in practice,
Accepted 16 November 2015 with a series of reports highlighting inadequacies in care. This scrutiny provides nursing with an ideal opportu-
nity to evaluate the underpinning philosophy of nursing practice, and for nurse educators to use this philosophy
Keywords: as the basis for programmes which can inculcate neophyte student nurses with a fundamental understanding of
Philosophy the profession, whilst providing other health care professionals and service users with a clear representation of
Nurse education
professional nursing practice.
Curricula
Programme specication
Design: The key word philosophy was used in a systematic stepwise descriptive content analysis of the pro-
Review gramme specications of 33 current undergraduate programme documents, leading to an undergraduate
award and professional registration as a nurse.
Results: The word philosophy featured minimally in programme specication documents, with 12 (36%) docu-
ments including it. Its use was supercial in 3 documents and focused on educational philosophy in a further 3
documents. 2 programme specications identied their philosophy as the NMC (2010) standards for pre-
registration nurse education. 2 programme specications articulated a philosophy specic to that programme
and HEI, focusing on caring, and 2 made reference to underpinning philosophies present in nursing literature;
the Relationship Centred Care Approach, and The Humanising Care Philosophy.
Conclusion: The philosophy of nursing practice is not clearly articulated in pre-registration curricula. This failure
to identify the fundamental nature of nursing is detrimental to the development of the profession, and given this
lack of direction it is not surprising that some commentators feel nursing has lost its way. Nurse educators must
review their current curricula to ensure that there is clear articulation of nursing's professional philosophical
stance, and use this as the framework for pre-registration curricula to support the development of neophyte
nursing students towards a clear and focused understanding of what nursing practice is.
2015 Elsevier Ltd. All rights reserved.

Introduction offer guidance and recommendations for improvements in the future

Nursing in the UK has been subject to a great deal of recent criticism
following the publication of a number of reports investigating poor
clinical practice (Francis, 2010, 2013; Department of Health, 2012).
Findings from these reports have identied a lack of care and compas-
sion in the treatment of patients by registered and non-registered nurs-
ing staff, leading to negligent care, cultures where poor standards were
tolerated and in some instances unnecessary suffering and deaths.
Nurse education within the UK has to some extent remained outside
the scope of these investigations which have focused on practising clini-
cians, and specic recommendations for pre-registration nurse educa-
tion have been limited in number. However in response the nursing
profession represented by the Nursing and Midwifery Council (NMC),
The Royal College of Nursing (RCN) and Health Education England
(HEE) commissioned two reports focusing on pre-registration nurse ed-
ucation and the unregistered nursing work force (Willis, 2012, 2015) to
Tel.: +44 161 306 7772.
direction of nurse education in the UK.
This background of scrutiny and criticism has enhanced an ongoing
feeling within the profession that both nursing and nurse education
may have lost their way (Draper, 2006; Darbyshire and McKenna,
2013). This paper argues that if further incidences of poor care are to
be avoided, nursing needs to take the lead in shaping and dening
what good nursing practice is by the development of a robust and clear-
ly articulated common philosophy of nursing practice. Nursing educa-
tors play a vital role in establishing this philosophy to ensure that
neophyte nurses are inculcated with this clear understanding of the
beliefs and values which make up high quality nursing practice, as
well as representing the purpose of nursing to fellow health care profes-
sionals and service users. This paper reports on a review of the under-
pinning philosophy articulated in 33 undergraduate pre-registration
nursing programmes currently run by Higher Education Institutes
(HEIs) in the UK, and raises a number of questions about the adequacy
of current philosophies to support the necessary advancement of the
nursing profession and current standards of clinical practice.

http://dx.doi.org/10.1016/j.nedt.2015.11.023
0260-6917/ 2015 Elsevier Ltd. All rights reserved.
72 C. Mackintosh-Franklin / Nurse Education Today 37 (2016) 7174
Literature Review
The idea of the nursing profession sharing a common underpinning
philosophy is not new. Since Florence Nightingale rst introduced for-
mal nurse education in the UK with the foundation of St Thomas School
of Nursing in London in 1860, she sought to dene what nursing was
and was not as part of the move to recognise nursing as a new and
worthwhile profession, and position it within the spectrum of other
health care workers, most notably at that time medical staff
(Nightingale, 1859). The need to dene and clarify what nursing is
and is not has been ongoing since that point, most predominately in
the latter half of the twentieth century when nurse education rst
started to move away from the apprenticeship model towards a higher
education base. This led to nurse educators developing and publishing a
number of competing models of nursing, with popular ones such as
Orem (1971), Watson (1988, 1989) and Leininger (1995) being subject
to considerable academic scrutiny. However few of these models trans-
lated into clinical practice and they were only minimally known outside
the profession.
Since the high point of nursing model development, focus amongst
nurse educators has largely moved away from the development of nurs-
ing models and bespoke theories, however arguments for the need for
an underpinning nursing philosophy have not disappeared. Grifn
(1980) highlighted the importance of philosophy to bring together
and unite the differing elements of the profession, and more recent ac-
ademics continue to propose differing theories and models of practice
with examples including; Finfgeld-Connett (2008) proposing the need
for a much clearer denition of what is the art of nursing to provide
a foundation for education and practice, Sawatzky et al (2009) introduc-
ing a framework for excellence in caring, which links both nursing
philosophy and educational philosophy and Meehan (2012) suggesting
that a philosophical approach identied as Careful Nursing could be
the way forward for both education and the profession.
Additionally there has been proliferation of approaches supporting
individual nurses or groups of nurses to develop their own nursing phi-
losophy (Denehy, 2001; RCN, 2003; Hemingway, 2013), as well as nu-
merous websites allowing nurses to propose and publicise their own
personal philosophies of practice (allnurses, 2015; MeganMcGahan,
2015).
Against the current background of poor standards of nursing care,
and diminishing resources there is a danger that the need for an under-
pinning philosophy will be lost, as Rolfe and Gardner (2006) argue there
are growing pressures for nurse education to focus on through put of
students as opposed to the development of the profession. Whilst
Darbyshire and McKenna (2013) strongly argue, nurse education and
educationalists are responsible for this loss of way through failures to
identify the fundamental purpose of nursing and a failure to focus on
service user needs as opposed to the perceived needs of academic
nursing. This review of UK based nurse education curriculum docu-
ments aims to clarify some of these issues, through consideration of
what philosophies nurse educators are currently using to support
their undergraduate pre-registration programmes.
Design
This review took place in May 2015, and adopted a systematic step
wise approach to descriptive content analysis. The rst step consisted
of searching for all available published undergraduate pre-registration
nursing curricula from the UK which were in the public domain. The
NMC provides information about approved programme providers and
from this 68 approved HEIs which offer full time undergraduate pre-
registration adult nursing programmes in the UK were identied; 2 in
Northern Ireland, 10 in Scotland, 5 in Wales and the remainder in
England.
A Google search was then carried out for each of the NMC approved
HEIs linked to the key words; nursing, adult and pre-registration. A
further search was then carried out on each HEI's own website using
their own site search tool. At this stage a further key search term,
programme specication was added and used in combination with the
key terms above. At total of 33 documents labelled programme speci-
cations were retrieved or 51% of the total available.
Ethical guidance on the use of information posted on the World
Wide Web is difcult to nd, but guidelines from the British
Psychological Society (2013) suggest that providing the key principles
of; respect for individuals and their dignity, scientic value, social
responsibility and minimal harm are adhered to, information which is
clearly within the public domain can be used for research purposes
without the requirement of consent. In order to minimise harm in this
paper, no individual HEI or programme is identied.
Equivalence in documentation is difcult to determine as all HEIs
published differently structured documents, however for the purpose
of this study all documents labelled programme specications were
included in the review. Programme specications demonstrated consid-
erable variation in length; from 8 pages to 157 pages, all programmes
were currently approved by the NMC and from available information
on each HEI website, actively running and continuing to recruit
students.
Each document was then systematically searched using a two stage
process. An initial computerised search took place using the nd com-
mand for both Word and Adobe Acrobat Documents (no other docu-
ment format was found) using the word philosophy, and information
from this entered into a database. A further hand search of each docu-
ment then took place to allow more indepth descriptive content analy-
sis to take place. Although the data does not directly t into the
qualitative data model of thematic analysis more commonly identied
in the methodological literature (Grove et al, 2014; Clarke and Braun,
2013), a modied version of Braun and Clarke (2006) stages of thematic
content analysis was used;
1. familiarisation with the data,
2. coding,
3. searching for themes,
4. reviewing themes,
5. dening and naming themes
6. writing up.
The key modication being the use of one pre determined search
term, rather than developing this through familiarisation and coding.
However stages 4 and 5 allow for the search term to be reviewed and
redened, and at this stage the search term and its results were
scrutinised to ensure that it remained t for purpose and fully captured
the intention of the review. Basic quantitative data was also taken from
the data base to support the descriptive content analysis.
For the purpose of this review a denition of philosophy as provided
by the Oxford Dictionaries (2015) was used which identies it as, The
study of the fundamental nature of knowledge, reality, and existence,
especially when considered as an academic discipline, and this empha-
sis on the fundamental nature of knowledge as applied to nursing was
used to direct the qualitative hand search of all documentation.
Findings
From an initial computerised search of the 33 programme specica-
tions as detailed above, only 12 (36%) contained the use of the word
philosophy, 10 of these used the word once, one used the word 3
times (twice in the main body, and once in reference to the NHS Educa-
tion for Scotland [2007] Core Curriculum Framework) and one used the
word 5 times (once in the main body and in 4 separate module descrip-
tors). All of the documentation contained sections on programme aims
and learning outcomes and it was anticipated that this might be the
natural place to highlight any underpinning philosophy for the
programmes, however close scrutiny of these sections in all 33 docu-
ments failed to identify any further references to an overarching
 C. Mackintosh-Franklin / Nurse Education Today 37 (2016) 7174
programme or professional philosophy supporting the development of
the stated aims and outcomes. Additionally some documentation
contained sections labelled programme summary and overview, and
again close reading of these failed to identify additional philosophical
references.
Analysis of where reference to the underpinning philosophy oc-
curred identied two HEIs whose sole reference occurred in the details
of module descriptors; on a module learning outcome referring to the
philosophy, art and science of nursing within the syllabus and the
second, a eld specic learning outcome for a module adult eld stu-
dents will consider the philosophy and policy underpinning contempo-
rary adult services. No further reference or explanation of the
philosophy occurred in either of these documents. One further pro-
gramme specication made reference to an underpinning philosophy
guiding the development of the programme, but provided no informa-
tion as to what the philosophy actually was.
A further two HEIs referred to philosophy specically in the context
of the NMC Standards for Pre-Registration Education (2010) e.g. the
philosophy underpinning the adult nursing eld reects the Nursing
and Midwifery Council (NMC) Standards (2010) and encompasses the
four identied domains. Although the NMC Standards (2010) make
considerable reference to the underpinning values of professional
nurse education and the constituent domains, at no point do they artic-
ulate a philosophy of nursing practice, and it is unlikely that these stan-
dards constitute the fundamental knowledge of nursing the use of the
word philosophy implies.
Of the remaining 7 programme specications, three programmes
philosophies were directly linked to education e.g. our philosophy for
education practice, is to identify, dene and enthuse with our
students and none of these 3 programmes articulated a profession
specic nursing philosophy. Two programmes articulated both an
educational philosophy and a professional nursing philosophy, with
one educational philosophy described as the programme values the
unique characteristics of the individual within the context of teaching
and learning while recognising the collective responsibility and ac-
countability of students, academics and practitioners, and the other
acknowledges that students are adults and bring to this educational
experience a diversity of previous learning, experience and skills and
that learning will be experienced and processed differently by individu-
al students.
This meant only 4 (12%) of the identied programme specications
articulated a philosophy of nursing. Of these 2 HEIs provided a descrip-
tion of a philosophy which appears to be specic to their programme
and made no reference to supporting literature. Both focus on care,
one stating, care is the essence of nursing practice and takes the
position that caring is not totally innate but can be learned and cultivat-
ed, the other that nursing requires the ability to provide empathetic,
responsive care to people and their families Additionally both these
programme specications also provide details of the overarching con-
ceptual framework/curriculum model which underpins the develop-
ment of the programmes.
Of the remaining 2 programme specications, one makes reference
to the Relationship Centred Care Approach which was rst suggested
in a paper by Nolan et al (2004). This programme specication clearly
articulates what the philosophy of relationship centred care is and
goes on to state, this dynamic and innovative programme uses rela-
tional care as a focus to prepare you to register as a nurse with the
NMC and attain a BSc. It enables you to develop into a knowledgeable,
adaptable, reective, culturally sensitive and compassionate practition-
er with a strong capacity for critical thinking.
The nal programme specication containing reference to an under-
pinning philosophy is explicit about using the Humanising Care Philos-
ophy (Todres et al., 2007) although the description of philosophy is
limited and largely consists of one statement, that those responsible
for the development of the programme would like to see an increased
emphasis around core nursing values such as dignity, care and
73
compassion; these will be central to the new education programme.
To that end we will utilise the Humanising Care Philosophy
Discussion
Overall the number of programme specications which identify an
underlying philosophy was disappointing, and for those programmes
which did make use of the word philosophy closer examination re-
vealed the supercial nature of its inclusion. Two programmes identi-
ed both an educational and a professional philosophy and in total
only 4 (12%) programme specications clearly articulated their pro-
fessed use of an underpinning professional philosophy.
Findings from this sample suggest that the need for an underlying
nursing philosophy is either not recognised by nursing educationalists,
or not considered to be important enough to include in key programme
documentation. As Rolfe and Gardner (2006) have argued, nurse educa-
tionalists may now have different priorities and obligations which
preclude the development of the profession at the expense of student
through put to commissioned targets. Nursing students and registered
students may now be regarded as commodities, to be trained
and employed with little reference to any underlying philosophical
principles or as Bradshaw (2015) suggests subject to Macdonalised
Dehumanisation.
The need for a unifying philosophy that underpins nursing education
and subsequent professional practice is as essential as ever. In 1989,
Johns argued that philosophy is an essential rst step to the develop-
ment of clinical, educational and managerial objectives, whilst Page
(in Kikuchi and Simmons, 1993) argued that philosophy is the frame-
work for the discipline. Since then arguments focusing on the essential
importance of a unifying nursing philosophy have largely disappeared
from the literature. Holt (2014) in a commentary on the 16th Interna-
tional Philosophy of Nursing conference held in 2012, highlights the
ongoing difculty caused by the failure of the profession to dene exact-
ly what nursing is, resulting in numerous competing denitions. Given
the current lack of clarity of purpose it is unsurprising that individuals
within the profession have had to propose their own philosophies,
however this leads to divergence and misunderstandings and where
cultures of poor care are the norm an individual philosophy of nursing
is inadequate and inappropriate to support improvements in practice.
The current climate within the UK of intense scrutiny into the
established short falls in nursing practice, is an ideal opportunity for
the profession to refresh the debate about what nursing is and is not.
If the nursing profession is to regain public condence in its practi-
tioners as well as regaining the respect of our fellow health care profes-
sionals, it is essential that we determine what nursing is about through a
clearly articulated explication of our underpinning philosophy of
professional practice. The danger is that without this clarity nursing
becomes subject to external forces who may seek to impose a direction
on the profession that may not be to its liking or benecial to the profes-
sions development (Bradshaw, 2015), and without clear underpinning
philosophical foundations nursing has no counter argument.
Conclusion
Education has a key part to play in the discussion of the current state
of nursing in the UK and nurse educationalists are already well aware of
their importance in educating the future registered nursing work force,
and their role in the transformation of the neophyte student to profes-
sional registrant. Our programmes should clearly establish not only
the required professional standards but the underlying philosophical
stance of the profession. Draper (2006) and Darbyshire and McKenna
(2013) have already cast doubt on the state of current nurse education
within the UK, highlighting nurse educations possible loss of way and
contribution towards the perceived decline in professional standards of
clinical practice. However as this review has demonstrated, without any
key philosophical foundation in place, it can hardly be surprising that as
74 C. Mackintosh-Franklin / Nurse Education Today 37 (2016) 7174
a profession we may appear lost. Willis (2015) highlights just how
crucial it is to get pre-registration education and training right (page
4) and although Willis (2015) focuses on the need for pragmatic chang-
es, a key message is the need for unication within the profession and
for the disparate bodies currently responsible for providing and
supporting education to work together. A common shared professional
nursing philosophy is an essential rst step to moving forward, and it is
the role of nurse educators to ensure that this is clearly articulated
within our programmes and our student's subsequent professional
working life.
Limitations of the Study
This study focused on published curriculum documentation, and it
could be argued that this is an incomplete picture of pre-registration
nurse education, and that a philosophy of nursing may be clearly artic-
ulated elsewhere. However programme specications are the key guid-
ing documents upon which pre-registration nursing programmes are
based and approved, and if a fundamental guiding philosophy exists
then it would seem inherently sensible to use it as the basis for the
development of the programme and to clearly explicate it within it.
It is possible that the authors of the included programme specica-
tions feel their programmes do have a clear philosophical underpinning,
and this has been missed or misinterpreted by the author. However the
danger or misperception was minimised through the use of a broad
standard denition that focused on the fundamental nature of nursing.
Additionally information published on websites is provided for public
scrutiny and may serve a variety of purposes including marketing and
recruitment. In this study care was taken to ensure that posted docu-
mentation was specically identied as programme specications
rather than bespoke material provided for individual HEIs websites.
As mentioned above the standards of published documentation var-
ied greatly in terms of content, and detail, and a multiplicity of formats
were identied which mitigate against direct comparison of documen-
tation. However again the central importance of an underpinning phi-
losophy to nurse education should mean that however few in number
the pages in the programme specication aims or how differing the
format, this should have been clearly and explicitly articulated.
Finally this review used a sample of 51% of UK programmes, based
on the availability of these documents in the public domain. It is unlikely
that a larger sample would affect the overall picture of the use of an
underpinning philosophy within UK HEIs, but this cannot be asserted
with condence.
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