Do you consider the role of the nurse to be unique? And what does being unique actually mean? Some of the synonyms for the word unique are not so encouraging; sole, only, solitary, single, individual, lone especially when considering the current debate about the numbers in the nursing profession or that many registered nurses are the sole registered nurse in their workplace setting.

It is preferable to refer to the more positive synonyms such as exceptional, excellent, brilliant, special, extraordinary, incomparable, outstanding, remarkable, inimitable, distinctive, individual; words that may be applied to the “soon to be registered nurses” from my institution.

Musing on the word unique reminds me of the classic definition of nursing created by the American nurse, Virginia Henderson, still referred to by the International Council of Nurses “The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assist them in the performance of those activities contributing to health or recovery or to dignified death that they would perform unaided if they had the necessary strength, will, or knowledge and to do this in such a way as to help them gain full of partial independence as rapidly as possible” (Henderson, 1977, p.4).

But does it remain so as many others are involved in the care of individuals?

There is growing concern about the numbers of nurses on the Register in the UK, putting it simply there are more individuals leaving the register than joining it. Figures from the Nursing & Midwifery Council in July 2017 showed an increase in numbers of nurses and midwives leaving the professions.

The NMC in its report dated 30 September 2017 “The NMC Register” noted that 35,363 individuals left the register between October 2016 and September 2017 and 27,786 joined it. This equates to a figure of 27% more leaving than joining. Just over 29,000 UK nurses and midwives left the NMC register in 2016–17, up 9% from the previous year. 18.2% of nurses and midwives on the registered are over 56 years old and may be in a position to retire. The nursing and midwifery profession are ageing but the NMC figures also show that registrants below retirement age are leaving in increasing numbers.

Nurses and midwives from the European Economic Area make up around five percent of the register.  Between September 2016 and September 2017 there was a decrease of 89% in the number of nurses and midwives from the European Economic Area joining the register and an increase of 67% leaving the register from the previous year.

The figures on the register are constantly fluctuating as individuals join it for the first time as they embark on their careers; and those who decide to leave as they retire at the end of their careers. There are seasonal fluctuations which coincide with individuals graduating from pre-registration programme mainly in the Autumn. This blog is being written just before individuals from my institution will shortly swell the numbers on the nursing register as they complete their pre-registration programmes. Congratulations if they will be joining your teams.

NHS Digital published the NHS figures on 16 January 2018 which demonstrate that more nurses left the health service in England last year than joined, mirroring the trend published by the NMC in Autumn 2017.

The Commons Select Committee published on 25 January 2018 stated “In too many areas and specialities, the nursing workforce is overstretched and struggling to cope with demand”. It was noted that there were 36,000 vacancies in the NHS in England. The conclusions and recommendations include strategies aimed at improving: retention, professional development, working conditions, a greater focus on staff wellbeing, assessment of the impact of the withdrawal of bursaries and the introduction of student loans and apprenticeships on the numbers of individuals entering the profession, and specific plans to prevent the high attrition of student nurses.

The Committee also recommended that nursing associates; the new care role in the nursing family, “need and deserve a clear professional identity of their own” a view that is echoed by the NMC’s Chief Executive Jackie Smith who commented “There must be clear blue water between the role of a nursing associate and a registered nurse. We welcome the Committee’s recommendation that nursing associates have a clear professional identity, which is also of paramount importance to the public.” Some individuals believe that nursing associates are nursing on the cheap, some are apprehensive and still worry they will be used as substitute nurses and as a means to a solution to the current workforce crisis despite the assurances about the role from the Commons Select Committee and the NMC. Some of those older registered nurses may be experiencing a certain sense of deja vu as they themselves may have been individuals who made the transition from enrolled nurse to registered nurse as part of their professional journey and view the nursing associate role in a similar manner.

There is currently a lack of clarity about the nursing associate role. Nursing associates will be registered professionals in their own right, with a supplementary role working alongside the unique role of the nurse from the Spring of 2019. A Nursing Times investigation revealed a wide variety of approaches to the training of nursing associates had been implemented across the pilot sites. Whilst it has now been agreed that the NMC will become the regulator for nursing associates the professional standards against which they will be regulated are still being developed and the underpinning legislation to give the NMC the power to regulate nursing associates has yet to be passed. It is expected to happen in July 2018.

NMC 2017

The NMC published the Draft Nursing Associate Skills Annexe on 16 February 2018. The list of skills will form part of the NMC’s overall competency standards for nursing associates. The list is still in development and has been released “to allow people to see how the skills annexe is developing and what it contains”.  A final draft version will be published for consultation in April 2018. Once the NMC is the regulator in law, it will approve nursing associate programmes. This is likely to be from Autumn 2018.

Everyone is likely to benefit from the recommendation that “a ‘plain English’ guide to the new role should be developed, published and communicated at both a national and a local level. This guide should include examples of tasks that nursing associates will, and will not, be expected to undertake, but will need also to reflect the scope of their practice across a range of healthcare settings”, The Commons Select Committee 2018. It is essential that it is understood that the role of the nursing associate is the support the unique role of the registered nurse and not to replace it.

Added to this situation are the concerns about the reduction of individuals engaging with educational programmes leading to professional registration. The Universities and Colleges Admission Service published its latest statistics in January 2018 about applicants across all undergraduate programmes including specific information about nursing applications. The Royal College of Nursing and The Council of Deans of Health have both expressed concern about the decline in applications to nursing programmes, particularly from mature students, albeit from different perspectives Both organisations comment about the need for a strategic plan and investment in the current and future nursing workforce to ensure the workforce which is needed to care is available. The introduction of alternative routes into health careers such as the nursing associate and registered nurse apprenticeship programmes are expected to improve the situation.

Consideration of the latest information about the numbers of nurses in the profession, the vacancies in the NHS and the current information about applications to nursing programmes may indeed lead us to believe that the profession is in crisis.  There is evidence of serious challenges for the nursing workforce. Undergraduate and post-graduate pre-registration degree programmes continue to be an important route to an internationally recognised professional qualification and the springboard to a wide range of professional opportunities and personal achievement in the unique role of the nurse.

Returning to the synonyms; let us hope that the “unique” role of the nurse never becomes rare or scarce and that registered nurses are not few in number but rather that the term recognizes the valuable, special and unique contribution registered nurses can, and do, make to the care of everyone in need of healthcare.




How much does trust matter to you? Is it something you value? Trust is a key component of the fourth theme of the Code; promote professionalism and trust.

Students and registrants are expected to be committed to the standards of practice and behaviour set out in the Code. Such an approach should gain from clients, carers, members of the public and other Health Care professionals, trust and confidence in the profession of nursing.

The NMC (2015)

Why is trust so important?  Nurses and midwives have the privilege of engaging with individuals who are often vulnerable as a result of the effects of distress and or disease.  Ideally members of the nursing profession are individuals that no one wants to have to encounter but when they need to they expect that the nurses they meet will be reliable, responsible and dependable.

Nurses and midwives must tell the truth. Members of the public expect nurses to be honest and trustworthy, at all times but perhaps particularly so when things have gone wrong and mistakes have occurred. This was recently illustrated by the comments of an individual with a terminal illness that she made to those responsible for her care, and shared with her permission, “all I want, and expect, is that all staff caring for me treat me as an individual and always tell me the truth.  Telling me now that the primary cause of my illness cannot be found and that things I have been previously told about my condition were wrong is not going to affect my situation, but I appreciate you telling me. I know I am going to die and there is nothing more that can be done for me so please don’t shake my trust in you by pretending otherwise. I need to be able to trust you, to know you will always tell me the truth. It’s not your fault I’m dying, it’s the disease which is killing me.  I’m not interested in suing you, I just want you to be honest with me”.

Nurses occupy a position of trust and are expected to maintain the standards expected of them upholding the reputation of their profession at all times. The NMC in its guidance regarding Cases with particular risks for public confidence  comment that “dishonesty, even where it does not result in direct harm to patients but is related to matters outside of a nurse or midwife’s professional practice can undermine the trust the public place in the profession. Honesty, integrity and trustworthiness are to be considered the bedrock of any nurse or midwife’s practice“. NMC 2017.

Third year students at the University of Salford will shortly be grappling with some recent registrant fitness to practise cases as a part of their ongoing professional development.  They will perhaps discover that, as Mark Twain commented,  “truth is stranger than fiction”.

You may be familiar with the courtroom oath / affirmation “The truth, the whole truth and nothing but the truth” perhaps not because you have spoken those words yourself but have witnessed them being spoken in some form of dramatic setting. Telling the truth in court is essential and not just because there is a fear of being charged with perjury should it subsequently be discovered that witness lied but because judgements about the truth can only be made fairly if everyone behaves and speaks honestly. In a criminal court the standard of evidence must be “beyond all reasonable doubt”, the logical explanation / interpretation of the evidence is that the defendant committed the crime.

The civil standard of proof; “balance of probabilities” requires that the decision makers must the conclusion that what is alleged to have occurred is more likely to have occurred than not to have done so. This is the standard of proof which is used to adjudicate the fitness to practise of registrants.

Dishonesty in a registrant, even if short lived, and if it did not cause any harm to clients is always a serious matter. The Nursing & Midwifery Council’s consideration of fitness to practise cases which involve dishonesty frequently include reference to  Mr Justice Mitting’s comments in the case Parkinson v Nursing and Midwifery Council [2010] EWHC 1898 in which it was made clear that dishonesty always gives rise to a “severe risk” of having the registrant’s name erased from the register. Dishonesty comes in many forms and must be carefully assessed. There is a difference in  severity between deliberate, planned, deceptive acts which pose a risk to clients or involve client harm, or breach the trust of vulnerable clients and opportunistic, one-off incidents arising in the registrant’s private life which pose no risk to clients. The former modes of dishonesty are most likely to result in consideration of the continuance on the register of the individuals who perpetrate such acts.

We may spend many years building up trust only to discover that suspicion, not proof, destroys it. Think of how many public figures; including actors, sports people and politicians, you are aware of who have had their reputations shattered by comment not proof.

The Nursing & Midwifery Council published its latest guidance on “Making decisions on dishonesty charges” on 15 December 2017, and it makes for interesting reading. It is well worth the effort to read the Supreme Court Judgment given on 25 October 2017 which is referred to by the Nursing & Midwifery Council in its guidance. The case is about a professional gambler who sues a casino for winnings and raises questions about “the meaning of the concept of cheating at gambling, the relevance to it of dishonesty, and the proper test for dishonesty if such is an essential element of cheating”. The judgment of the Supreme Court Ivey v Genting Casinos [2017] UKSC 67, The more warped the defendant’s standards of honesty are, the less likely it is that he will be convicted of dishonest behaviour……..” is the problem with the Ghosh test for dishonesty (the leading authority on the concept of dishonesty in law). The Supreme Court concluded that Ghosh does not correctly represent the law and directions based upon it ought no longer to be given.

Truth would seem to have the ability to elicit a whole raft of emotions and feelings; the truth will set you free, the truth hurts, it is its own reward said Plato, it is rarely pure and never simple commented Oscar Wilde. Many individuals claim to experience great relief and peace from telling and hearing the truth as was the case of the woman cited in the anecdote above.

We should all ensure that all our actions, comments and thoughts make us trustworthy practitioners.

Social Media

NMC 2017

The Nursing and Midwifery Council uses social networking sites to engage with nurses and midwives, students and the public, and they have been leading the UK’s health and social care regulators in developing our online communications activity. They are active on Facebook, Twitter and LinkedIn, and they have thousands of subscribers to their regular email newsletters. At the same time, they are seeing an increasing number of cases before the fitness to practise panels which involve the use of social networking sites and other online activity. Even as a student it is important that you conduct yourself professionally at all times and in all places, real and virtual, in order to justify the trust the public places in our professions.

Used properly, social networking sites such as Facebook are a great way to find old friends, join interest groups and share information. However, nurses and midwives should remember that anything posted on a social networking site is in the public domain and could be read by patients or even future employers. Be careful what you post and who you post it to. What may be considered to be letting off steam about a situation at work can potentially be read by someone who may take offence at the content of a posting. Nurses and midwives could be putting their registration at risk if posting inappropriate comments about colleagues or patients or posting any material that could be considered explicit. The NMC believe there is a clear relationship between conduct in the real world and conduct online.

The NMC (2015)

In referring to the Code (2015) in the NMC social networking advice, the NMC set out a clear expectation that both online and offline conduct should be at a similar high standard.
The NMC; nor the School of Health & Society at the University of Salford do not advocate blanket bans on nurses, midwives or students joining or using social networking sites. Both support the responsible use of social networking sites by nurses, midwives and students through their advice and guidance. As a School we encourage you to use social networking responsibly and remind you of your responsibilities to the NMC, and hence direct you to the NMC advice and other relevant standards and guidance.

NMC (2015)

The NMC has published guidance on using social media and students are encouraged to explore this information. This guidance should be read together with The Code: Professional standards of practice and behaviour for nurses and midwives (The Code) (NMC, 2015).  Nurses and midwives should refer to this guidance along with any guidance issued by their employer on social media. This guidance is not intended to cover every social media situation that you may face, however it sets out broad principles to enable you to think through issues and act professionally, ensuring public protection at all times. As the nature and scope of social media is constantly evolving, guidance is reviewed and updated as necessary and the principles of the Code are re-applied to new and evolving situations. Given the large proportion of the population using social networking sites, healthcare providers and universities can derive benefits through engaging with social media, both at a corporate and individual level. Having a corporate presence on social networking sites can also lend credibility when engaging students, nurses and midwives around these issues, and can provide a platform for encouraging responsible use.

It is difficult to understand why some student nurses and midwives choose to engage inappropriately with social media. Despite the pitfalls of social media being carefully explained to them in the early stages of their professional lives some individuals potentially jeopardise their futures in the profession they aspire to join through their ill-chosen and unacceptable contributions to social media. Stay safe when using social media by following the “top tips” in the chapter entitled “Professional values and decision making” by Ruth Chadwick in Nursing: Decision-Making Skills for Practice (2013) edited by Karen Holland and Deborah Roberts, Oxford University Press. ISBN 978-0-19-964142-0

NMC 2015

Social networking sites should not be used for raising and escalating concerns (commonly referred to as whistleblowing). The NMC has guidance about Raising Concerns (NMC 2015) which sets out your professional duty to report any concerns which put the safety of people in your care or the public at risk, and the steps you should take to do this.

Seek out Nursing Students at the University of Salford on Twitter @nursingSUni or WeNurses @WeNurses for examples of how social media can be used in a positive manner to share knowledge and stimulate ideas with the objective of sharing the best evidence based practice for the enhancement of client care.

Think before you post via any social media; T – is it true? H – is it helpful? I – is it inspiring? N – Is it necessary? K – Is it kind? Answering these questions should increase your confidence that what you intend to post will be valuable to others.
But there is one final variable when thinking about social media which is just as important: YOU. If you would not read it, if you would not comment or share or click, do not post it. Real people get hurt in the real and virtual world. Use your words to inspire and not to destroy. Treat your online conversations as if you were talking with people in a public space where you can be seen and overheard.

This week the UK Government has launched an Internet Safety Strategy green paper;  please consider responding online or email internetsafetystrategy@culture.gov.uk with your thoughts about the proposed strategy and help to ensure that the safest place in the world to be online is Britain.

All NMC related images are used with the permission of the Nursing & Midwifery Council.