Nurses in Society: starting the debate more

University of London Nurses in society: starting the debate Jill Maben with Peter Griffiths 2008 Nurses in society: starting the debate Jill Maben with Peter Griffiths October 2008 2 Acknowledgements e would like to thank all those made this work possible. We are indebted to the hundreds of nurses who so generously shared their experiences and insights with us. Thanks are also due to all the other healthcare professionals, patients, chief executives and academics who supported us. We are grateful to the members of the task and finish working group, chaired by Julie Burgess, and to Professor Dame Jill Macleod Clark, Janice Sigsworth and Tony Halton in the Chief Nursing Officer’s team at the Department of Health (England). This work was commissioned and supported by the Department of Health in England as part of the work of the policy research programme. The views expressed are those of the authors and not necessarily those of the Department of Health. W Contact address for further information: National Nursing Research Unit King’s College London Florence Nightingale School of Nursing and Midwifery James Clerk Maxwell Building 57 Waterloo Road London SE1 8WA nnru@kcl.ac.uk http://www.kcl.ac.uk/schools/nursing/nnru 3 Contents Foreword Introduction 1 What matters to nurses and patients What patients want from their care What nurses and other professionals value most about the nursing role What is meant by good quality nursing care? The policy context Seizing the moment The changing role of the nurse The future registered nurse: practitioner, partner, leader Enabling change to happen Ensuring high quality care Valuing and measuring the nursing contribution Continuing to attract high calibre entrants Achieving an all-graduate workforce Achieving consistency in training, quality and support for assistant nursing roles Creating cohesive career pathways Identifying robust funding streams Agenda for action: recommendations References 4 5 6 7 8 10 11 12 12 15 18 18 20 20 21 22 23 24 25 27 2 3 4 5. 4 Foreword his report is published at a pivotal moment in healthcare policy in England. It was commissioned by the Chief Nursing Officer, Professor Dame Christine Beasley and was undertaken in the spring and early summer of 2008 to support and inform work contributing to the Next Stage Review. It forms part of a wider stream of work which aims to drive up the quality of care in the National Health Service in England with nurses being at the forefront of this ambition. The work was guided by a task and finish group and supported by an evidence gathering exercise. The stimulus for the report was the sense that nursing had lost its way; that there was unacceptable variation in the quality of care. While the standard of nursing is generally high, where it falls short it has a marked impact on how patients experience the whole of their contact with the health service. The recommendations proposed in this report set out to restore public confidence in the profession, define what patients and nurses want in terms of good quality care in all healthcare settings and identify a series of measures to secure a step change in the quality of care. Some of the changes proposed are not new but their power lies in their synergies and interdependencies. Nurses work in a complex clinical and social environment and are expected to deliver high quality care with compassion. We recognise that they are equally committed to their vital role as teachers and mentors to students who will be the nurses of the future. We need to raise our game and the bar of aspiration and expectation within the profession. This is vital if we are to provide the quality of care that patients deserve and also to change the perception of nursing to a career of choice for high achievers. The new professionalism built around the nurse as practitioner, partner, and leader provides a template to define the role and identity of the profession and to develop relations between the nurse, patients and other healthcare providers. Our professionalism needs to be underpinned by a reinvigorated sense of service, one which is responsive to what patients want from nurses: empathy, compassion, keeping them informed, doing the right things at the right time, being with and available to patients and their loved ones. These are the constants of care and nurses its custodians. This report sets out the roadmap to realising an exciting and powerful ambition, but an ambition which is shared and involves the contributions of many. We have the roadmap. Let the journey begin. Anne Marie Rafferty Dean and Head of the Florence Nightingale School of Nursing and Midwifery at King’s College London October 2008 T 5 Introduction he need for compassionate nursing is as strong as it has ever been. Nurses are a central resource in the National Health Service in England and are crucial to the delivery of 21st century healthcare. They are in a powerful position to improve the experience of patients, the quality of care and health outcomes across the whole range of health services. Society is changing and so is the NHS and the need for expert nursing care has never been greater. The challenges facing society and healthcare mean that there is a need for a different kind of nurse in the future and an important agenda for change that needs to be seized. Some have questioned whether nurses have lost their way while navigating the complexity of the increasingly technical environment that is contemporary health care. This report signals critical ways in which nursing needs to build on its heritage: applying scientific learning within a humanistic framework, so it can rise to the challenge presented by major social, economic and demographic change. We set our debate within the context of the changing healthcare environment. It provides the framework within which we must act and sets the benchmark for what will be needed from today’s and tomorrow’s nurses to ensure delivery of the high quality healthcare expected by both the public and the profession. The starting point for our work was to discover what it is that patients, the public and nurses themselves most value about what nurses do, and what it is they most want from nursing. T Factors influencing the demand for healthcare 1 - 5 • Demographic change • Changing pattern of disease • Rising public and patient expectations • Increased access and choice • Shift to community-based care delivery • Continuing social inequality • Advances in treatment • Information society 6 1 What matters to nurses and patients he ideas set out in this report are drawn from the deliberations of two task and finish working groups established by the Chief Nursing Officer to inform the NHS Next Stage Review, from the nursing literature, and from consulting over 1,000 nurses and other health professionals. The Next Stage Review publications High Quality Care for All 1, A High Quality Workforce 6, and Our Vision for Primary and Community Care 5 as well as the clinical visions published by the strategic health authorities have been particularly influential. They have acted as the stimulus for and set the framework for this work, and also highlighted the shared goal of continuous improvement in care for patients, and the difference nursing can make to achieving this ambition. We have distilled the essence of what we learned into the text below, using actual comments from our evidence gathering for illustration. Our informants included practising nurses, students and retired nurses, doctors, managers, chief executives, academics and nurse leaders, with nurses from acute and community care settings, and adult, mental health, learning disabilities, and child practice areas. The interview questions and the views expressed to us are provided in the ‘Nurses in Society: Full evidence’ accompanying documents at (http://www.kcl.ac.uk/schools/nursing/nnru/reviews/). Much of the content and all of the recommendations apply across the depth and breadth of nursing. The issues of greatest concern to those we spoke to were variability, perceptions, image and care in acute hospitals. The report therefore focuses on these areas. We present what patients want from their care, what nurses said they want to provide, and what people actually mean when they talk about high quality nursing care. T WHAT MATTERS TO NURSES AND PATIENTS I 7 What patients want from their care Recent work and public consultation7 suggest there are four key areas that matter to patients: • Get the basics right – don’t leave it to chance • Fit in with my life – don’t force me to fit in with yours • Treat me as a person – not a symptom • Work with me as a partner in my health – not just a recipient of care7. Many of the people we talked with had personal experiences of care as patients and spoke also of the healthcare experiences of friends or relatives. They concluded that patients want to know their nurse is knowledgeable, skilled and competent and said they wanted their nurse to: Have a caring and humane attitude • respecting privacy, confidentiality and preserving dignity • respecting patients’ values and beliefs, understanding their needs and treating them equally Put the patient first • keeping patients informed and involved in their own care; up-todate with the progress of their care, and encouraging their involvement in decision making • communicating with patients, listening to them and advocating for them • meeting patients’ basic needs for physical, mental and emotional care alongside promoting health and wellbeing, and doing that in a timely, safe and individualised manner and in a clean environment Deliver a high-standard service • demonstrating this through high-level knowledge, being adequately trained, competent and possessing up-to-date and expert knowledge • being a regulated profession: to promote patients’ trust and confidence Provide easy, timely and convenient access to the care • providing access to care whenever and wherever needed, without long waiting times and either at home, in hospital settings or in the community. In summary, patients want to be treated well, to have quality care every time and want nurses to make them feel safe and comfortable – physically and mentally, ‘cared about’ as well as ‘cared for’8. The attitude and approach of the nurse is the most important factor in securing this experience for patients, enabling them to be ‘treated as a WHAT MATTERS TO NURSES AND PATIENTS I 8 human being not a case’ with compassion, respect, empathy and by staff who are ‘interested in YOU’. What nurses and other professionals value most about the nursing role Unsurprisingly, nurses want many of the same things as patients and the public. Our evidence highlighted the passion nurses felt for their work and for being able to deliver high quality care. This is what they come into nursing for – to ‘make a difference’ in people’s lives and to offer comfort and assistance at times of personal significance, or personal crisis and distress. Nurses, together with other healthcare professionals, identified five main aspects they valued most about nursing: Making a difference to patients’ lives Through achieving positive patient outcomes and satisfaction. The big difference the ‘small things’ make to patients/carers. Lung cancer clinical nurse specialist Good quality nursing assists individuals, families and communities to optimise their health and wellbeing in whatever environment they come together. Oncology nurse working in primary care Close contact with patients Facilitating understanding to address patients’ physical and mental needs. Being able to step into someone’s life at a time of great stress and share their life journey. Macmillan gynaecology clinical nurse specialist The nurse having the time to listen to my concerns and communicate effectively. Nurse manager in primary care trust WHAT MATTERS TO NURSES AND PATIENTS I 9 Delivering excellent care Being competent and professional while treating patients with care and respect and preserving their dignity. Having the time, knowledge and understanding to ensure the patient receives the best care at the best time. Parkinson’s disease nurse specialist When a holistic approach is applied by a competent and emotionally intelligent carer in the delivery of a well co-ordinated and comprehensive package of care that is well communicated. Community mental health nurse Working in a team and being a role model Using knowledge and expertise to set an example to others. Being a role model for my peers and juniors. Breast care nurse Care which is delivered by reflective, well informed, motivated, nonjudgmental staff with the patient’s best interest in mind at all times. Community nurse Continuous development - learning and improving Maintaining and developing skills through reflective practice, education and research. Commitment to continuing education for the benefit of patients, staff, and the entire trust. Educational opportunities for nurses and more resources to enable them to attend study days. Nurse manager in primary care trust Staff nurse, acute ward WHAT MATTERS TO NURSES AND PATIENTS I 10 What is meant by good quality nursing care? Above all, people said good quality nursing meant ‘caring’ and ‘a good experience for patients’. Good nursing was said to be a ‘how’, not a ‘what’. Six core elements of good quality nursing care were identified: 1. A holistic approach to physical, mental and emotional needs, patient-centred and continuous care 2. Efficiency and effectiveness combined with humanity and compassion 3. Professional, high quality evidence-based practice 4. Safe, effective and prompt nursing interventions 5. Patient empowerment, support and advocacy 6. Seamless care through effective teamwork with other professions. Passionate about communication, empathy, attention to detail when caring for an individual. Consultant nurse Delivering safe, effective reliable care. Community palliative care nurse The nurses we spoke to cared passionately about nursing, were clear about what was valuable and about the desire to deliver high quality patient care. At the same time, they identified a number of issues the profession, and others, need to address to enable nurses to meet their own, as well as society’s aspirations. This report highlights these issues. 11 2 The policy context he NHS Plan in 2001 set out an ambitious 10-year programme of change underpinned by significant investment. The first years focused on building an infrastructure fit for the 21st century, recruiting more doctors, nurses and allied health professionals, and radically reviewing pay and conditions. With more staff, the NHS could set about meeting the main concern of patients and the public: improved access to healthcare with less time to wait. The second phase concerned updating and reviewing systems and processes in the NHS to make it more responsive to a modern, consumer society both knowledgeable and opinionated about how health care should be provided. Now the NHS is entering the next phase. Arguably, this is the most difficult and also the most exiting period – transforming the NHS into a high quality, high performance system engaged in a continuous cycle of improvement, whose staff readily evaluate and raise their performance, so that the best is available to all. High Quality Care for All, the report of Professor the Lord Darzi of Denham’s Next Stage Review, lays out this third phase vision for an NHS that is clinically effective, personal and safe for all, and one which: • helps people stay healthy and commissions comprehensive wellbeing and preventative services in partnership with local authorities • puts quality at the heart of the NHS, getting the basics right every time, and gives the public information about the standard of quality achieved • works in partnership with its staff enabling them to lead and manage the organisations in which they work, integrates health and social care and offers new freedoms to consider social enterprise models • works within a constitution setting out rights and responsibilities 1. It is in the context of this wide-ranging programme that nursing faces the challenge of re-affirming its role, and describing ‘an inspiring portrait of the modern nurse rooted in the values of nursing and the profession’ re-defining nursing care and establishing nurses as advocates, champions and guardians of quality. T 12 3 Seizing the moment he NHS Next Stage Review offers a new impetus and opportunity for nurses to resolve some enduring questions that have faced the profession. Nurses need to be equipped with the knowledge and skills required to adapt to a broad spectrum of changing needs and ensure that they are led and managed in ways that support compassionate, safe and effective care relevant for people in 21st century society. T The changing role of the nurse The nursing profession is rightly respected for the skills, professionalism and dedication of its members. Nurses have always been central to the delivery of high quality care. Today, as a profession, nursing faces new challenges and new opportunities. Nurses continue to deliver good quality care across settings and in some very difficult situations. Nonetheless, the quality of nursing care, while often excellent can be variable and the public perception of nurses has deteriorated in recent years, with concerns about perceived attitudes and professionalism of nurses9-17. To ensure that nursing plays its vital role in delivering the best quality care possible for patients and to ensure the profession adapts to the healthcare environment of the 21st century, the profession should be proactive in seeking to shape its future, to decide the role it wants to play and the difference it wants to make. The claim to professionalism is underpinned by a set of values and behaviours and relationships. Nursing’s fall from grace in the eyes of the public can be understood in part through the ambiguous and contradictory images the public and the profession have held about nursing. This ambiguity can be traced back to the beginning of professional nursing. The early images of the nurse as guardian angel, doctor’s handmaiden and custodian of care embody the complex interplay of roles played by the nurse. The ministering angel metaphor communicated the value of nursing, of selfless devotion and compassion. The image of doctor’s handmaiden was in part derived from the position of women in society at the time18, 19. In the past, the brand of nursing was strong. Nursing was seen to have a clear identity and people knew what a nurse was and what a nurse did. In reality this may not always have been the case and it was a time when professionals and institutions were generally highly SEIZING THE MOMENT I 13 regarded and thought to be beyond reproach. Today the brand appears less strong, nursing is more complex, and varied and multiple images prevail. There have been many changes that have reconfigured nursing in this country, such as the shift to a university education, the increasing diversity of the nursing role, the introduction of support workers, role substitution, the advent of a general management culture and the recent health reforms which focused on access, productivity and finance. These have tested some of the implicit assumptions about the role of the nurse. It has been difficult for nursing to reconcile the competing tensions in this complex and fast changing environment. Influences on the changed role of nurses • • • • • • • • • • • New roles and autonomy for community nurses Greater focus on health and prevention of ill health Increasing need to support students in practice Reduced lengths of acute stay Increased incidence of day surgery Independent nurse prescribing Greater autonomy for nurses in mental health and learning disability Management of whole episodes of care Greater supervision by nurses of care delivered by healthcare assistants Increased nurse specialist, practitioner and consultant roles Increased interdisciplinary teamwork and multiprofessional care Some of the enduring qualities of nursing such as care and compassion are thought to have been lost and not demonstrated adequately by some nurses. A false polarity has emerged between the humanity of caring and the advanced technical tasks and roles that nurses are now undertaking. This has had a negative impact on the image of the nurse and what a nurse ‘is’ and ‘does’. Changes to nurses’ roles have often been little understood by patients and the public and this has been played out in the media. Some high profile commentators have spoken about how nurses have failed to care14-16. This has shocked the profession because these stories have challenged and contradicted the values on which nursing was founded. However these stories demonstrate that patients and the public increasingly hold nurses to account for the care they give. It is a reminder that patients and the public judge nurses’ professionalism by their behaviour, appearance and the way they communicate. Patients and the public today are clearer about what they want and what part they want to play in their healthcare. In this context nursing needs new ways, means and images to communicate its essence. Nursing needs to demonstrate its commitment through innovative schemes that bring together its essential qualities – We need to re-energise the passion in the workforce … I’d like to see nurses as advocates for their own profession. Senior doctor in managerial role SEIZING THE MOMENT I 14 empowering, enabling and educating people to take control of their lives. The strategy to achieve this must be built on a unity of purpose and a vision that is shared among nurses and patients, the public and colleagues alike. We need serious promotion of the role of the nurse in the 21st century – show it as a dynamic opportunity to deal with really complex personal issues for individuals. In acute settings we’re going to be dealing with huge complexity, but in a rural economy, people are working in isolation, and care comes closer to home. So there needs to be an awareness of the different challenges nursing faces. Senior nurse, managerial role The Next Stage Review promotes a new professionalism and is a springboard from which to recast and reset the values, behaviours and relationships that nurses will have with patients in the future. A rebalancing of principles and a clarification of values are required, rather than a complete rejection of what has gone before. ‘Nursing is more than the sum of its parts. Any health system needs nurses who are intellectually able and emotionally aware and who can combine technical clinical skills with a deep understanding and ability to care, as one human to another. This is a constant of nursing. It is the value base on which public trust rests and the profession is grounded. As a profession it is our promise to society’. Christine Beasley, 2006 20 The Nursing and Midwifery Council’s newly revised Code21 captures the professional values that nurses aspire to. The Code highlights using knowledge to advance patient care, working in partnership with patients and their carers and families, always putting the patient first, acting with care and compassion and respecting patients’ dignity, always striving for excellence and continuous improvement and working in partnership with members of the wider healthcare team. Whilst the Code robustly sets out the individual accountability of the registered practitioner, the responsibilities of nurses go much further. SEIZING THE MOMENT I 15 The future registered nurse: practitioner, partner, leader In the past, the registered nurse’s role within the team has often been as a practitioner, an expert in their clinical discipline. Yet frontline nurses have the talent to look beyond their individual clinical practice and act as partners and leaders of care and service. In looking to recast the role of the nurse the work undertaken by the task and finish group created a vision of tomorrow’s nurse. It defined registered nurses as: • skilled and respected practitioners providing effective high quality healthcare across a range of settings • vital and valued partners in the delivery of healthcare – partners in the multidisciplinary team, co-ordinating different resources and skill sets to ensure high quality care, partners with patients and carers in delivering personalised care, and responsible members of the broader healthcare system taking personal responsibility for efficient and effective functioning • confident and effective leaders and champions of care quality with a powerful voice at all levels of the healthcare system, from policymaking to the frontline. The practitioner, partner, leader vision is rooted in the core values and ethos that underpin the profession but also recognises the dynamic and changing nature of nursing and healthcare that will shape the future. These three ways in which nurses can use their talents are already in evidence in parts of the NHS and internationally 6. The exact balance between the three roles will vary and be different for each patient episode of care. What is clear is that this new professionalism, acknowledging nurses’ roles as practitioners, partners and leaders, gives registered nurses the opportunity to focus on improving not just the quality of care they provide as individuals but also within their organisations and the whole NHS. There is a need to continue to set frontline nurses free – both as providers and commissioners – to use their expertise, creativity and skill to find innovative ways to improve the quality of care for patients. This requires a new, stronger accountability that is rooted in the people that the NHS is there to serve. Nurses need to be empowered to make the daily decisions that improve quality of care and we suggest ways to make this happen. There is a need to create the right environment for high quality care to happen, requiring further development of clinical and managerial leadership in nursing. The practitioner, partner, leader framework also gives an opportunity to look again at the nurse patient relationship through the partner role in an environment of increasing choice and patient empowerment. No longer will it be enough for the nurse to care and care alone. Nurses need to build on their traditional care planning skills to take the process to new levels, creating partnerships with SEIZING THE MOMENT I 16 patients, built on reciprocity and mutual recognition of expertise. Nursing care needs to be individualised and tailored to each patient contact, by the co-production of care and caring in partnership22. Within this new framework entrepreneurial nurses with high level understanding of local issues and needs will find there are opportunities to develop new kinds of organisations, to be able to respond flexibly and appropriately, and to deliver the effective services people want. Traditional ways of working within the NHS are no longer sufficient to deliver high quality care for all. Co-production – a partnership between the NHS, local authorities and key stakeholders, is needed to realign the system so that quality is at the heart of the way healthcare is organised. Nurses as practitioners, partners and leaders The practitioner, partner and leader is at the heart of care, co-ordinating multidisciplinary teams and resources, across care settings and agencies. Practitioners • highly qualified, respected, competent graduate professionals • committed to people who use services through being conscientious, competent, safe, compassionate, care-focused and patient-orientated practitioners • committed to professional values: integrity, compassion, continuous improvement, advocacy and partnership working • excellent role models for students, new nurses, nursing and healthcare assistants • significant contributors to improved health outcomes and wellbeing for people through effective nursing interventions across the full range of health services Partners • advocates and managers of care pathways, working in partnership with patients • accountable for and guardians of the quality of nursing care and accountable partners in the whole patient experience • valued partners in the delivery of healthcare as part of multidisciplinary teams Leaders • continually challenging and improving care quality and championing the experience of people who receive services • co-ordinating resources and skills to deliver high quality care • responsible for efficient and effective care delivery • ambitious for nursing as a profession • confident innovators, keen for the nursing contribution to be demonstrated • exerting influence and credibility from point of care to board room • supervising, monitoring, teaching and mentoring healthcare assistants’ practice to support excellent patient care delivery SEIZING THE MOMENT I 17 To achieve these ambitious aims the profession, regulatory bodies, the public, patients and education providers will need to work together to set out a common set of standards to support nurses in developing these three roles in their practice. The role of the nurse group articulated an exciting vision of the future in which nurses take ownership of the quality of care, holding themselves and others to account if quality slips below the highest standards, and having at their disposal the authority, skills and tools required to drive continuous quality improvements. If changes to systems, processes and environments that are needed can be made, not only would the quality of patient care be raised but also patients and the public would hold nurses in higher regard and nursing would be the attractive career option it deserves to be. Clinical leadership and ownership is fundamental to delivering high quality healthcare. Greater freedom, enhanced accountability and empowering staff are necessary but not sufficient in the pursuit of high quality care. Making change actually happen takes leadership. There are many routes to excellent leadership and people need to be able to have meaningful conversations that transcend organisational boundaries. All those engaged in leading change in the NHS need to embrace the following three core elements in their approach: • Vision – What quality improvements are they trying to achieve and how will these benefit patients and local communities? • Method – How will they make change happen – what management methods will they use for implementation, continuous improvement and measuring success? • Expectations – What difference will the changes mean for people, what behavioural change that will be necessary and what values underpin it? 23 Leadership has been one of the neglected elements of the reforms of recent years. This must now be a priority. The vision for tomorrow’s nurse needs to be shared and debated by members of the profession so that the vision becomes tangible, compelling and aspirational, in a way that each and every nurse knows what they need to do to bring it about. 18 4 Enabling change to happen N urses work within a wider healthcare system and there are factors far beyond the control of frontline nurses that affect the delivery of high quality care. Nurses are also human – they undertake a demanding job, physically, intellectually and emotionally and the profession needs to offer excellent working environments, support and rewarding career opportunities for nurses if it is to attract and retain the very best practitioners for the future. Tomorrow’s nurses expect a healthcare system that is focused on quality, is patient-centred, clinically driven, and one which is flexible, values people and promotes learning. For change to happen and to ensure high quality care we need to focus on valuing and measuring the nursing contribution to healthcare; we need to continue to attract high calibre entrants, move to a graduate registered nursing workforce, own and be responsible for the training quality and support for assistant roles, create cohesive career pathways for nurses, and identify robust funding streams for nurse education. Ensuring high quality care Valuing and measuring the nursing contribution The Next Stage Review set out a vision of an NHS that delivers high quality care for patients and the public and places great emphasis and focus on the safety, effectiveness, and experience of care1. Accurate and meaningful outcome measures for nursing (metrics) are central to the specific changes proposed to promote a new focus on quality. These include quality accounts, commissioning for quality and innovation, the publication of results to practitioners, the public and commissioners, the annual National Quality Board reports on NHS quality and the development of new clinical standards. In recent years attention has been drawn to the failure of boards and NHS leaders to consider the ‘business of caring’ 24, 25 and to ensure that the improvements that matter are measured. There is ongoing professional concern that nursing’s contribution to quality healthcare is under-recognised, leaving nursing services vulnerable to cost-reducing efforts26, 27. The reiteration of quality and the focus on safety, effectiveness and experience in the Next Stage Review creates ENABLING CHANGE TO HAPPEN I 19 an opportunity and places nurses in a unique position to step up to the leadership challenge that this brings, not only to lead nursing improvement but to lead on quality across the multidisciplinary team. In considering the nursing contribution to driving up the quality of care, there are two important elements with which nurses must engage. Firstly, to identify a set of metrics for inclusion in the clinical dashboard that is under development by the NHS Medical Director so that the nursing contribution is made visible. The second is to advocate and embrace a model of service management that defines responsibility and accountability for care quality from the point of care to board using metrics as a tool. A companion paper by the National Nursing Research Unit details the ‘State of the Art’ of such measurement and metrics which provide indicators for the quality of nursing care28. The metrics identified encompass safety, effectiveness and compassion. While indicators and metrics cannot provide a complete solution they can provide a powerful mechanism to incentivise quality. Although the contribution of nursing can be difficult to measure, and the identification and use of indicators is by no means straightforward28, metrics can reflect the important contributions of nursing and can be used at all levels to maintain and enhance quality in nursing. This is an important step forward in assisting nurses to drive up the quality of healthcare in England, and further work in this area is required. Current metrics are quantitative in nature: we tend to measure success in terms of the things we can grasp - cost, time, numbers treated, etc. But none of that takes into account the key thing about nursing: what was it like for the patient? Senior nurse in clinical role Many NHS organisations we spoke with have developed excellent systems of management and quality measures, but we did not find a comprehensive national approach that would enable benchmarking across and between organisations with an ability to share best practice. The work of the NHS North West Strategic Health Authority Nurse Directors was inspiring in terms of their agreement to sign up to putting into practice a set of agreed metrics as well as an arrangement to share results for benchmarking purposes. This work should be reviewed and could be built upon across the country. Other developments also create opportunities for the profession. The position of nurses in the community, as providers of the greater part of direct care and with their access to stories people tell, places them in the best position to transform service through multidisciplinary practice-based commissioning and integrated care ENABLING CHANGE TO HAPPEN I 20 pilots. The proposals to develop Health Innovation and Education Clusters (HIECs) needs analysis and the nursing contribution to these clusters will need to be developed to place nursing in a position to have a legitimate place at the table. Equally, the emergence of Academic Health Science Centres (AHSCs) which bring together health service, research and education, offer nurses opportunities to develop and improve care for patients in addition to providing potential venues for meaningful clinical academic careers so that the research base underpinning excellent care can further develop. Continuing to attract high calibre entrants Attracting and recruiting the best people into nursing is important to maintain and drive forward high quality healthcare initiatives. Nursing should be one of the top career choices for high potential candidates and be perceived as a worthwhile career for talented people with aptitude and motivation. Other public sector careers have undergone such a transformation. Teaching moved from being the 92nd most desirable career for 25-35 year olds to 1st through promotion work undertaken by the Training and Development Agency for Schools called Use your head and more recently Turn your talent to teaching campaigns29. In research undertaken 10 years ago30 nursing was rarely considered as a career option by many school pupils because they were ‘indifferent’. They had not actively rejected nursing; rather they had just not given it any consideration. In 2003 research with those considering nursing as a career found nursing was viewed in terms of hard work and long hours rather than as caring and helping, although nurses themselves were seen as caring and dedicated31. Young people have a multitude of career options open to them in the 21st century. The non-visible aspects of nursing (intellectual and decision making) need to be more identifiable to them. An on-line survey of 776 11-18 year olds undertaken by NHS Employers32 in 2006 found that these students wanted a future job that was interesting, made the best use of their skills, was well paid and included working in a team and helping people. Yet only 2% were interested in a career in nursing and only 5-7% in medicine. I did consider medicine, but no-one spends as much time with the patient as the nurse - they have to be able to do everything and anything for the patient. I like the focus on the holism with nursing. I enjoy the hands on care, you can build a better relationship with the patient. Student nurse ENABLING CHANGE TO HAPPEN I 21 Nursing needs a clear message and a refreshed campaign to attract new high calibre recruits. This can only be achieved if we promote nursing as a career by emphasising the: • intellectual challenge of nursing • autonomous practice of nurses with authority to make decisions • high level of medical knowledge involved • personal rewards through job satisfaction • variety of work in nursing at all levels • wide range of career opportunities within nursing • opportunities for career progression • idea of ‘helping’ people • notion of being able to ‘make a difference’ to people’s lives30. Achieving an all-graduate profession The case is compelling for a rapid move to a graduate profession, because of the need for highly knowledgeable, skilled autonomous registered practitioners fulfilling increasingly complex roles. A High Quality Workforce supports a ‘shift to a graduate registered nursing workforce’6. Scotland, Wales and Northern Ireland have already moved to degree pre-registration nursing courses, as have many developed countries, including Australia, New Zealand, Scandinavia, and Italy33. Studies from the USA point to the added value of a nursing workforce that contains more degree qualified nurses. A high proportion of degree qualified registered nurses has been associated with lower mortality in surgical units34. Economic modelling based on US data35-37 suggests that investment in fewer better qualified nurses may yield better results for lower overall costs than simply investing in more qualified nurses. Investment in high quality, high-level training and education may be the best possible approach, especially in the face of a potentially declining supply of candidates for nurse training. This could raise the perceived job satisfaction of nurses38. There is evidence of potential for higher retention of graduate nurses in the profession, with graduates more certain about their career plans and with an initial higher commitment to nursing. An all degree pre-registration education in England may help attract the best recruits to nursing, confirming research evidence39. There is no objective evidence to support the anecdotal view held by some that educating nurses is linked to the ‘loss’ of caring from the heart of the profession40. On the contrary the evidence suggests39 that that those who are degree educated are just as competent and caring. In September 2008 the Nursing and Midwifery Council agreed a number of outline principles to shape a new framework for preregistration nurse education and to enable the second phase of their work to progress. While there is more detail to be agreed, two of the most important principles for this report are the NMC’s commitments to move nursing registration to degree level, and to make Quality nursing is about having a highly qualified workforce that will be achieved by having a graduate workforce – yet care is so important patients say, the nurses were the people who made it bearable for them - they don’t think about the person who worked out the correct dose. People don’t understand what goes into nursing - the complexity - thinking, reasoning, problem solving. Student nurse ENABLING CHANGE TO HAPPEN I 22 preceptorship mandatory. See www.nmc-uk.org for further details and updates. The evidence we gathered also highlighted the need to address the future potential of assistant nursing roles and their management, training and regulation, and suggested this had been neglected for too long. This debate is particularly necessary in the context of an allgraduate profession. Achieving consistency in training, quality and support for assistant nursing roles The role of the healthcare assistant developed initially in the areas of housekeeping and clerical tasks to support the maintenance of the care environment. However the role evolved so that by 2003 a review of staff activities in 19 hospitals found ‘tasks’ that many regarded as nursing care, such as feeding, toileting, washing and observation were being undertaken by healthcare assistants41. Some nurses are uncomfortable with the evolution of the assistant role, feeling they have lost some of the ‘essence of the nursing role’42, 43. The use of non-registered assistants has been critiqued for reducing the quality of care through fragmentation44 and has been seen as a cost-cutting exercise45. However, in an era of nurse shortage and concern over rising costs, others have been pragmatic and argued this is a natural and realistic progression towards a smaller cadre of registered nurses who can support assistants to undertake nursing work46. The real challenge is the lack of ownership and responsibility for healthcare assistants by registered nurses. There has been wide variation and insufficient investment in policy, training and support for these assistant roles and expectations have been too low47. Much of what I’d call ‘care’ - spending time with the patient and addressing their needs, hour by hour, is now given to the care assistants - yet the continuity, the overall picture of the patient, and the expertise may not be there. First year student We suggest it is now time for the nursing profession to engage wholeheartedly in ownership of assistant nurses and healthcare assistants (levels 1-3) and assistant practitioners (levels 3-4). The profession also needs to take more responsibility for their education, retention, management and even regulation. There have been consistent calls for regulation of this workforce, predominantly on the grounds of patient safety, yet this is complex and it has not been readily achieved to date48. The nursing profession could learn from ENABLING CHANGE TO HAPPEN I 23 the airline safety industry where lower grades of staff, maintenance personnel, are often the most important links in the safety chain49. In healthcare the safety implications of having well trained staff of all grades to detect changes in patient status are vital. Training staff in the basics of ‘customer care’ is also important in terms of its impact upon the quality of the patient experience. Creating cohesive career pathways Modernising Nursing Careers advocated the need for new and cohesive nursing career frameworks to meet society’s changing needs for nursing, to enable nurses to meet future healthcare needs and improve their career opportunities46, 50. The recently published document Towards a Framework for PostRegistration Nursing Careers: consultation response report has set out a vision for the development of nursing careers in the future by aligning nursing careers with patient and service need through a number of pathways. It suggests there is wide support for standardisation, particularly at advanced levels, with clarity required on academic and experiential benchmarks50. Our respondents also suggested there should be a new emphasis on clinical academic roles able to facilitate and help students and newly-qualified nurses manage tensions between theory and practice, tensions highlighted in the research literature51-53. It is vital to support both students and newly-qualified nurses. Registered nurses in all specialities and healthcare settings play a crucial role in giving students and newly-qualified nurses the skills and confidence they need to practise in a dynamic environment. The commitment to funding announced in the Next Stage Workforce Review is recognition of the important role registered nurses play in supporting newly-qualified nurses through preceptorship. Practitioners require nursing knowledge and an evidence base for nursing interventions to create and underpin improvements in nursing care for patients54, 55. The usual career route for nurses has not allowed them to combine practice and research. Proposed academic clinical careers for nurses and Academic Health Science Centres would enable clinical nursing problems to be researched more readily and for new research evidence to be implemented in practice, thus enhancing the quality of nursing care. We have a unique insight into patient care which we are poor at articulating, we need research to drive us forward and create more nursing leaders and role models. Gynaecology oncology clinical nurse specialist New ventures in clinical academic careers have already been established in some strategic health authorities with academic partners. Two early schemes have demonstrated considerable success. The scheme initiated at King’s College London as part of the award of the NIHR Biomedical Research Centre at Guy’s and St ENABLING CHANGE TO HAPPEN I 24 Thomas’ NHS Foundation Trust and King’s College Hospital NHS Foundation Trust within the Academic Health Science Centre has resulted in doctoral awards to nurses, midwives and allied health professionals. At NHS South Central joint posts between trusts and the University of Southampton have been established with PhD studentships combined with band 5 posts for newly-qualified staff, and post-doctoral fellowships combined with band 7 clinical posts. Such moves together with the ‘Research for Patient Benefit’ funding stream offer opportunities to strengthen academic leadership and research in practice. Identifying robust funding streams A High Quality Workforce sets out to improve transparency, promote fairness and reward quality in education funding. The detailed proposals will be developed over the coming months and will need to ensure fair funding to support each of the following five core activities6: • student support • placement support • tuition support • preceptorship; and • workforce change. It also recommends that in the future organisations receiving central funding for education and training should publish annual expenditure on continuing professional development (CPD). ‘For the first time, nurses have been given the directive by government to hold their employer to account if they do not deliver or invest sufficiently in their education’ (p10)56. They should have the same opportunities that doctors are given – study leave, the support they need, opportunities to go off site, financial support, etc. Doctors do have a budget, nurses … have to help themselves. Senior nurse in managerial role These changes are to be welcomed and will go some way to preventing the ‘boom and bust’ situation in the supply of registered nurses over previous years57-59. The NHS depends on effective workforce planning and sufficient registered nurses should be educated to ensure a competent and adequate workforce supply. Our agenda for action challenges key stakeholders, the Department of Health, the Royal Colleges, the higher education sector, and nurses themselves to take this opportunity to make sure that nurses deliver what the public and society need for the 21st century. 25 5 Agenda for action: recommendations e have presented a range of evidence about nursing in a changing world. We are mindful that the pace of change is rapid and that the Next Stage Review signals the potential for both new relationships and new expectations for individuals and the health service. Our evidence makes clear that current approaches and professional frameworks within nursing are no longer fit for their future purpose. Nurses of tomorrow need to be practitioners, partners and leaders. In order to achieve this we propose an agenda for action to be taken forward by the nursing profession, the Department of Health, the Royal Colleges, the education sector, individual nurses, all key stakeholders and with the active participation of patients and the public. This is the beginning of a transforming journey. Our recommendations are addressed to stakeholders across all specialties and healthcare settings. All should review this report and our recommendations to examine how they can make sure their needs are fully addressed. Time constraints meant that it was not possible to consult with patient and user groups during our evidence gathering, and we strongly suggest the agenda for action is tested with patients and the public. W Recommendations The Department of Health and NHS Employers should develop a promotional campaign for nursing based on the successful model provided the Training and Development Agency for Schools’ Use your head and Turn your talent to teaching campaigns. The Nursing and Midwifery Council, NHS Employers and the Department of Health should support the move toward an allgraduate profession and work together to identify a strategy to support, retain and develop the current and future workforce. The Department of Health in association with NHS Employers, the Council of Deans, the RCN and trades unions should develop a ‘manifesto for change’ – asserting the need to embrace all aspects of the practitioner, partner, leader roles, the demonstration of quality AGENDA FOR ACTION: RECOMMENDATIONS I 26 care through metrics, and the importance of assistant nurses and practitioners as part of the healthcare team. Practitioner, partner, leader roles should be embedded in the nursing curricula. NHS organisations in collaboration with service users should draw on lessons from successful customer focused organisations and systems from patient feedback to improve quality and underpin the development of a new professionalism in nursing. Professional bodies and senior members of the profession should reinforce and reiterate the centrality of caring and the patient experience, using tools such as metrics and quality accounts to enhance nurses’ sense of responsibility and accountability and to drive up the quality of care. NHS Employers and commissioners and regulators should use nursing metrics as part of their assessment of quality and the commissioning process to create positive incentives to reward good quality care and clinical excellence. The Department of Health in association with professional regulatory bodies the NHS Confederation and NHS Employers should bring forward a scheme to regulate and oversee the education of assistant nurses and practitioners. The Nursing and Midwifery Council in association all key stakeholders should review the content and structure of both pre- and post-registration education for nurses to ensure that they properly support the roles that current and future nurses will undertake. Issues to consider include: • core professional values • acting as guardians of care quality and the patient experience • working as practitioners, partners and leaders • new care pathways and increased work in the community • public health roles • clinical academic careers. NHS commissioners and providers should ensure that adequate resources are provided to support ongoing education and training and professional development to enable nurses to fulfil their future roles. The Department of Health should undertake further appraisal of the implications of this work for nurses across the profession including mental health, learning disability, and the full range of nursing services outside hospital. 27 References 1. Darzi A. 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Fourth Report of Session 2006-07. 2007;1. To order further copies Please contact: The National Nursing Research Unit at King’s College London Waterloo campus, 57 Waterloo Road London SE1 8WA Telephone 020 7848 3057 Fax 020 7848 3069 http://www.kcl.ac.uk/schools/nursing/nnru PDF download: free Hard copy: administration charge £15 (including UK p&p) Edited, designed and prepared for publication by Jill Rogers Associates, Cambridge Cover picture: Collector’s piece [ Inspired by the work of Florence Nightingale, it represents building on nursing’s heritage and forging a new path for the future ]. Laura Potter 2007 Cotton, found objects, gold, buckram Approx. 250cm long Photo: Tomás Valenzuela Part of the Florence Nightingale School of Nursing and Midwifery Culture & Care project ISBN: 978-0-9555991-3-2 © King’s College London 2008