Wonderful

Wonderful news for the profession; the recent IPSOS Mori Veracity Index published on 18 November 2018 demonstrates nursing once again tops the chart of most trusted professions. When asking student nurses which theme of the NMC Code (2015) (revised on 10 October 2018 to reflect the inclusion of individuals on the new Nursing Associate part of the register from January 2019) is most important to them; first years typically cite prioritising people, second years frequently debate between practising effectively and preserving safety whereas third years consistently favour promoting professionalism and trust. Third year students frequently explain the rationale for this decision as that if nurses and midwives do not command the trust and confidence of patients, people receiving care, other Health Care professionals and the public it is impossible to uphold the other themes within the Code. Nurses occupy a position of trust and are expected to maintain the standards expected of them in upholding the reputation of their profession by the regulator and perhaps, more importantly the public. Members of the public appreciate nurses. It is the things we do and how we make others feel that count for the most in the eyes of our patients and clients not the things we say. Ask many individuals what attracted them to join a health or social care profession and they will respond with “an opportunity to make a difference to the lives of others”. Often it is the small activities we execute for our patients and clients and the way in which we implement our actions that make the biggest difference to their care experience and help to ensure the care received is described as wonderful. Perhaps the promoting professionalism and trust theme is the one which resonates most with the public. Trustworthiness was explored in a previous post in this blog and it may be beneficial to re-visit that post but in doing so please remember that the regulator continues to revise its guidance.

Why; if the public hold the profession in high esteem, do so many nurses seem to dwell on the negative aspects of their role rather than celebrating the positive? This has long been a mystery. It seems that as a profession we are more adept at expanding hours of our time reflecting upon the negative rather than celebrating the positive. Perhaps our engagement with television, radio, newspapers and social media help to fuel our interest in situations where significant improvements could be made. As professionals we should continuously reflect upon our practice to ensure that the care we deliver is based on the most up to date evidence and that we learn from episodes which have been identified as providing less than optimal care. However, we should also not neglect to respond to positive feedback.

Used with permission

Care Opinion recently held a learning event in Manchester for a variety of individuals who wanted to understand the value of feedback from clients. Care Opinion offers an online space where people can post their comments; good and bad, and those caring for them can respond. Many individuals are using the site to express their views about their care, and many experiences which are told are of a positive and complimentary nature. However, it is also apparent that many individuals do not receive a response to their comments or are even sure if their remarks have been received by the right people. The number of comments posted on the site is very small when considered against NHS England’s “Monthly activity data” which relates to the number of elective and non-elective inpatient admissions and outpatient referrals and attendances for first consultant outpatient appointments. Nevertheless the site provides a useful conduit for two-way feedback and has helped both clients and providers to improve upon services, staff morale and encouraged learning in care organisations who have begun to use the website. The patient or client stories are a useful way of helping student health and social care professionals explore and understand contemporary, real patient experiences. Review the site for yourself and read stories posted by clients and service users in the area where you live and work. We should be taking every opportunity, via multiple modes, to be patient / person centred and really listen and respond to the feedback from clients and service users to improve the quality and standard of care which is delivered.

Used with permission

Thinking about person centred care was the focus of an event hosted by the University of Salford on 30 November 2018 at which The Queen’s Nursing Institute (QNI) launched its report “Nursing Care for People Experiencing Homelessness”. The report shares the experiences which homeless health nurses face in the day to day challenges of delivering healthcare to this vulnerable sector of society. The event itself provided an opportunity for individuals, including nursing students, educators, practitioners and researchers; to learn and share ideas about delivering person centred care to individuals who are homeless through hearing from several nurses about their wide range of experiences in supporting homeless individuals. Listening to the person led care of individuals from a wonderful Gypsy and Traveller Community Outreach Nurse was delightful and insightful, emphasizing the importance of creating therapeutic relationships to underpin great care for clients.

Attendees of this inspiring event, were given a hard copy of the “Transition to Homeless Health Nursing Resource”. Hardcopies of the resource can be requested from the QNI’s website.  The QNI website declares “we believe high quality nursing should be available for everyone where and when they need it”. Take some time to explore the wealth of resources the QNI provides to help community nurses deliver the highest standards of care to clients and discover the exploits of some wonderful nurses.

Graduation took place last week at the University of Salford and it was a joyous and happy occasion celebrating the success of the hard work of individuals culminating in the awarding of degrees and acquisition of professional registration. Many students obtained first class degrees and can rightly congratulate themselves in becoming wonderful practitioners. Graduation was described by Jackie Kay; Chancellor University of Salford, as a shimmering, luminous moment as she urged our graduates to give their all, to work for the benefit of others, to be a catalyst for positive change, to seize the opportunities life gives them, to use the knowledge and skills they have gained and to be the best that they can be. Patients and clients across the North West will be recipients of these wonderful neophyte practitioners.

Perhaps you may concur with the Christmas song “It’s the Most Wonderful Time of the Year” that this is the happiest season of all. As you spend time with peers, colleagues, friends and family over the Christmas period why not consider telling them how wonderful they are in what they do and they might even believe you if you tell them often enough. Please also remember members; of all ages, in our communities who struggle all year round because of their physical and mental health challenges and for whom the bonhomie of the Christmas season can be especially painful. Thank you to all those wonderful practitioners who commit themselves to delivering high standards of health care all year round to those in need.

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Vicarious

Creative Commons

Vicarious now that is an interesting word which is frequently followed by the word “liability”.  Is that just because we live in what in seems to be an ever increasing litigious environment?  Or is it because health and social care professionals continue to develop their knowledge and roles and responsibilities in relation to raising concerns?

There have been many significant reports following inquiries;  such as The Mid Staffordshire NHS Foundation Trust Public Inquiry, The Report of the Morecambe Bay Investigation and more recently The Gosport Independent Panel, which have reflected upon situations where patients and clients have not received a high standard of care.  Often the crux of what had gone wrong in the organisations, which were the subject of investigation, was a failure to ensure the protection of the very people the organisation existed to serve.  Students and practitioners are frequently encouraged to read and reflect on these reports as reminder of how not to care for patients and their families.  Several of such reports when reported in the media were accompanied by a phrase that went something like “these matters have been explored in great detail so that we might reflect and learn from what this situation has shown and so ensure that it will never be repeated in the future”. Sadly we all know that not to be true, otherwise there would be no need for any such further reports.

Many such reports have been influential in shaping the delivery of high quality care and improving the manner in which organisations manage situations which raise concerns. You might also argue that eventually there should be no need for disciplinary and fitness to practise processes and procedures within a health and social care environment if all health and social care practitioners consistently demonstrated the standards of conduct and behaviour that their various professional preparation programmes have carefully explained to them.   Whilst we still rely upon human beings for the delivery of health and social care there will always be the possibility of errors and mistakes.  In the wake of the Mid Staffordshire Inquiry Report 2013 chaired by Robert Francis, into the breakdown of client care, Professor Don Berwick, an international expert in patient safety, was asked in 2013 to advise about how to improve patient safety in the NHS. His report made a raft of recommendations including moving away from blaming an individual to looking to learn from errors. The report was subtitled “A promise to learn  – a commitment to act”. Individuals working within organisations such as the NHS should not fear raising concerns or speaking up when they make a mistakes or something goes wrong.  Merely dismissing or punishing people is insufficient if no attention is paid to helping people understand what happened in an open and transparent manner and apologising when things have gone wrong. The Freedom to Speak Up Report 2015 further emphasized the need to foster a culture of learning and safety in all organisations so staff feel safe when raising concerns. Organisations must cease to foster a blame culture which fuels fear and move to a culture “which celebrates openness and commitment to safety and improvement”. Several of these issues have been explored in previous posts within this blog such as Duty of Candour, Honesty, Integrity, Professional and Trustworthy.

There is a company in the United States of America called Vicarious which is concerned with developing artificial general intelligence for robots.  Human level intelligent robots may be a long way from completely replacing Health Care practitioners but they are certainly making a significant contribution to Health Care. Artificial intelligence permeates our lives. We travel in planes flown by auto pilots and driver less cars are becoming a reality on our streets.  There is conceivably a place for increasing artificial intelligence in the delivery of Healthcare but we should also possibly be cautious in giving vicarious authority to robots in place of human practitioners. You may be interested to view a video from the Chief Executive Officer of Vicarious talking about future data applications.

The NHS as the largest employer in the United Kingdom is the likely destination for the first post of the majority of neophyte practitioners. It is important to remember that the vast majority of professionals adhere to their professional Codes and are safe, competent and caring practitioners who consistently make a valuable contribution to ensuring the health, safety and well-being of patients, clients and service users. In so doing they also help to maintain the integrity of the NHS. The number of individuals who have their conduct and behaviour scrutinised by the regulators is tiny in comparison to the number of registered practitioners. The number of individuals who it is deemed necessary that they receive a sanction in order to protect the public is even smaller.

Professionally qualified staff within the NHS have the security of knowing that the NHS takes vicarious liability very seriously. The NHS accepts full financial responsibility where negligent harm has occurred as a result of the actions and omissions of its employees provided they were working within the sphere of their competence. All employees must exercise a duty of care and registered healthcare practitioners are accountable to their regulatory body for the standards of their practice and patient care. The Royal College of Nursing published their latest guidance on Accountability and delegation in September 2017.  It is a useful document to review, particularly for those for whom delegating tasks to others will be their experience in their new post rather than having tasks delegated to them as has been during their experience during their education.

The NMC (2015)

Appropriate Indemnity Insurance has been a legal requirement for all healthcare professionals since 17 July 2014.  It is a mandatory requirement of the Code that all nurses and midwives have an appropriate indemnity arrangement in place. The Nursing & Midwifery Council publish guidance on its website about professional indemnity arrangements.  It is important that healthcare professionals appreciate that whilst they may not need to individually hold an indemnity arrangement it is their responsibility to make sure that appropriate to cover for their practice is in place and confirmation of this is required from all registrants on re-validation.

Maybe over the coming month there will be many academics across the UK experiencing vicarious enjoyment as the students they have taught and supported conclude their Pre-Registration studies and embark on their professional careers. Personally it is a joy to read positive feedback from students confirming their knowledge and understanding of the demands of their future professional lives. These neophyte practitioners will be moving into their new posts acting under vicarious authority performing clinical care that is being delegated to them.  It is important that these, and all, practitioners remember their responsibilities under the NMC Code 2015 with regard to practising effectively when undertaking delegated tasks. Many of those practitioners will be meeting family members and carers who express the view that they wish they could vicariously suffer for their loved ones.  Countless times in a paediatric environment practitioners will listen to parents expressing the view that they wish they could endure on their child’s behalf or act as a substitute in their place.  It is hoped to that these neophyte practitioners will always deliver the highest possible standards of care, mindful of all they have learnt about professional conduct and behaviour, always putting the client first, treating them as individuals with dignity and respect. If the clients’ care and safety is paramount and enhances their health, practitioners may just have a vicarious experience of well-being themselves and feelings of joy and celebration rather than fear in their working lives. Make every experience count,

Unique

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.