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Christine Hancock, then the General Secretary of the Royal College of Nursing, speaking in March 2001, said that nursing had witnessed great changes both in terms of extending nurse practice and increasing political influence. Speaking to senior nurses at the chief nursing officer’s conference in 2003, John Reid, Secretary of State, said that entrepreneurial nurses were taking the initiative, creating and implementing new ideas and winning winning contracts to provide services under new GP contracts, and running practices. Let us, he said, have more nurses employing more doctors.
Nursing education and staffing
In 1988 government accepted a new university-based system of nurse education, Project 2000. The aim had been to create a programme more firmly in educational hands, where trainees had real student status. Entry to nursing had previously been controlled partly by nursing schools associated with a training hospital, and partly by the regulations governing the state based examinations that the nurse would ultimately sit that included academic criteria. After the introduction of Project 2000 the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) continued to demand minimum academic criteria such as O-levels and national vocational qualifications. It was however the universities (often the new ones- previously Polytechnics) that selected students, and their criteria might vary, being higher at universities of prestige.
The number entering each college was determined, in part, by a local consortium that took account of the local needs of the NHS, and from 2001 by a workforce confederation, coterminous with a strategic health authority. Trusts had played a major part in determining training intake but their calculations had not taken into account non-NHS demand for nurses, for example in the rapidly expanding nursing home sector and NHS Direct. The size of the entry was progressively reduced during the 1990s, a time at which there had been no problem in retaining nursing staff. Figures from the English National Board showed an annual intake of about 15,000 in 1997, substantially less than in previous years. By the latter years of the nineties the vibrant economy offered many more possibilities to young people, and for the first time ever there was a shortfall in candidates for the nurse-training places that did exist, fuelling a staff shortage. A King's Fund report suggested that at least around London people were more critical of nurses than was once the case. Perhaps there were now fewer altruistic young women, and more alternative careers were available. Parents might view nursing as a low status occupation, poorly paid, and not the best choice for their children. Efforts were made to increase the number of entrants to nursing and midwifery pre-registration education and training programmes. In 1998 government embarked upon a new recruitment campaign.
While service based training had untoward effects, the new "uncoupled" system also had its problems. There were tensions and recriminations between the universities and the NHS. Nursing academic staff found it hard to manage the multiple roles of teacher, researcher, administrator and clinician. Because nursing students were not now members of the staff, but 'supernumerary' their clinical experience had lessened. It was soon recognised that a newly qualified nurse was often ill fitted to take responsibility. Mentoring schemes were introduced and some colleges of nursing began to increase the time spent in a clinical environment
Frank Dobson, then Secretary of State, attributed the nursing shortage in part to Project 2000. The emphasis on the academic element had put off some potential recruits. A better balance between practical and academic components of nurse training, was needed and students should have more contact with the NHS earlier in their courses. A new Department of Health nursing strategy, Making a Difference, pre-empted the report and recommendations of the Education Committee of the UKCC. Making a difference had two messages, nurses and nursing were valued and should be more powerful, but had some criticism of the academic drift while supporting the existence of a training trajectory. Perhaps, in government's view, nursing had taken the wrong path in its brief time in higher education. (Davies C, From Conception to Birth, Nuffield Trust 2002)
Nurses should have better working conditions, changes in the career structure to make it more flexible, allowing people to take breaks in their training, and better paid ‘consultant’ nursing posts for those most highly qualified. A new model of nurse training with an accent on developing practical skills earlier was piloted from 2000 and became the new standard across England. Some of the changes harked back to yesteryear. The NHS should be involved in selection, as well as educational interests, students would go to the wards earlier in the course and for longer periods, had a "home" hospital to encourage them to feel more part of the NHS, and the practice part of the course became at least 50% of the student's experience. A new registration body was established in place of the UKCC in April 2002, the Nursing and Midwifery Council, more training places were created, and proposals for cadet schemes were encouraged.
The UKCC established a Commission for Pre-Registration Education relating to Nurses and Midwives to explore recruitment and educational issues, fearing that as a high proportion of school-leavers now expected to go to university, a return to the traditional apprenticeship training might deter some. However the Commission's report, Fitness for Practice, in September 1999, found that the evidence supported the view that at registration nurses lacked practical skills. It recommended a shorter preliminary theoretical programme. Early in the course there should be clinical placements, more experience of the 24 hour per day, seven days per week nature of health care, and a period of at least 3 months supervised clinical practice towards the end of the course. The NHS should be more deeply involved in the selection and recruitment of student nurses, not just the universities.
While the protagonists of Project 2000 had believed that basing education in the universities would reduce the drop-out rate, a National Audit Office report (February 2001) showed that 20% of student nurses left during their course, and a further 20% did not subsequently join the NHS. The removal of student nurses from the workforce, for the best of reasons, devastated hospital staffing, though improving salaries and the expansion of training places were associated with a substantial rise in applications and additions to the register.
Nurse shortage was a global challenge. Demand continued to grow but in many developed countries the supply was falling. An ageing nursing workforce was caring for increasing numbers of elderly people. Low levels of trained nursing staff could lead to poor care, to low morale and loss of staff. A landmark study of the effect of nurse/patient ratios in acute surgical units in Pennsylvania hospitals showed that the chance of patients dying within 30 days of admission increased by 7% for every patient over four for whom a registered nurse was responsible. (JAMA. 2002;288:1987-1993)
The NHS in Great Britain employs some 300,000 whole time equivalent registered nurses and midwives. Since 1997 the number leaving the professions outstripped the number of entrants. In 1997-8, for example, 16,392 nurses and midwives joined the UKCC register and 27,173 left perhaps as a result of an increase in the number of nurses and midwives retiring and changes in post-registration education and practice (PREP) requirements in 1997. Nurses and midwives who had not maintained their practice were removed from the register. The average age of the nursing and midwifery population (in the NHS and on the register) was rising. Nearly half of NHS nurses and midwives are aged over 40, but the number leaving nursing remained roughly constant at 3-3.5% per year from death and retirement.Attempts to solve the situation included improving retention, broadening the field of recruitment (including mature entrants), attracting 'returners' and importing nurses from other countries - a few of which had an oversupply.
In England those who had to deal with previous staffing difficulties (as in the late 1980s) experienced a sense of déjà vu. Britain was not alone in looking at the possibility of substituting less skilled and cheaper staff grades. Inner city and teaching hospital trusts were worst affected by staff turnover, which could easily be 25-35% annually, for outside the conurbations recruitment of local students was easier, and housing costs were lower. As jobs became more flexible and nurses took on roles previously performed by doctors, support workers picked up work previously undertaken by nurses. With the additional resources available to trusts from 2000 onwards, the number of support workers (healthcare assistants, nursing auxiliaries and scientific support staff) grew. To cover vacancies, and partly for reasons of economy, they were in demand. By 2006 there were nearly 290,000 in England. Professional training and regulation became significant issues. Some had little training, others had National Vocational Qualifications and some nursing assistants were in fact qualified nurses who preferred the more ‘hands-on’ role of the nursing assistant. Frequently they substituted for trained nurses, undertaking responsible and complex nursing work. In 2000 the Royal College of Nursing (RCN) voted to admit trained health care assistants to its ranks. In the 1980s most nursing homes had been closed, partly to save money and partly because many nurses wished to 'live out'. Now many nurses, particularly those recruited from overseas, would have been glad of a roof over their heads, and Labour appointed a "czar" to stimulate the provision of new accommodation. To improve recruitment, the 1999 pay award for newly qualified staff was 12.5%, far above the level of inflation. Pay awards continued to be comparatively generous to nurses, annually and through regrading exercises. Extra payments were made to nurses in London and the south-east, where problems were worst. The NHS Plan (2000) recognised the shortage and promised 20,000 more nurses by 2005.
Nurses, making up 70% of the workforce and costing up to 35% of a Trust's budget, were inevitably under cost scrutiny. Trusts might not have the money to recruit staff even if they were available and Professor Alan Maynard questioned whether higher salaries would accomplish much, when many of the problems of recruitment stemmed from poor ward staffing levels and the characteristics of many nursing jobs. Accommodation, particularly in London with its high prices, deterred recruitment.
The use of agency nurses increased and was criticised for its costliness. The Audit Commission said that in 1999-2000 the NHS in England spent over £790m on temporary nursing staff, 20% more than the previous year. Agency nurses were an expensive but an essential part of the workforce. With six weeks' annual leave, and rostering systems that meant that nurses might only work 14 days per month, the opportunities to put in additional hours of to work for an agency, increasing one's income, were considerable.
Nurse movement between countries
A nursing qualification is a passport to a job around the world. By 2001 some 5,000 British nurses annually were applying for jobs overseas, and the NHS in turn remained substantially and increasingly dependent on nurses who had trained overseas coming to Britain. The Department of Health established a website to encourage recruitment from India, Spain and the Philippines. Requests from overseas nurses to register with the NMC rose rapidly. In 2001/2 there was a 63% increase over the previous year. Most came from non-EU countries particularly the Philippines, but also South Africa, Australia, New Zealand and the West Indies. Hospital teams went to the Philippines, which was becoming the main source of foreign nurses. The Philippines trained more nurses than it needed (a Government policy as remittance income is a key source of economic growth), had a rigorous US style four year degree course, and it proved possible to recruit substantial numbers of hard working and responsible staff members. Patients liked them. Overseas nurses might work as ancillaries while they adapted to British ways. Some were on temporary visas; others planned to stay permanently. Almost a third worked in inner London area.
Countries such as South Africa and Zimbabwe could ill afford the loss of professional staff trained at substantial cost. In 2001 over two thousand nurses were recruited from sub-Saharan Africa where 20-30% of the population were HIV positive. Hospitals soon found themselves treating their own nurses.
Analysis of the statistics showed
Initial registration of overseas nurses/midwives with the UKCC and the NMC
New UK trained nurses
Other countries including EU
|2004/5* 10 further countries joined EU||1193||11,416||12,609||19,976|
Source: UKCC press release 14 June 2000 and August 2001, NMC release May 2002, and
of the Register
New UK registrations
New EU registrations
New o/s registrations
Total leaving the register
Nurses were pursuing new pathways. Nursing was far less homogenous; some were managers, writers of care plans, or doctor-replacements undertaking triage, administering intravenous fluids or diagnosing illness. Developments such as NHS Direct and walk-in centres might be based upon nurses rather than doctors as the first point of contact with the NHS. Cost considerations, the need to improve access and shortage of doctors - quite apart from the expertise of nurses who often had substantial clinical experience and further training - were leading to acceptance of the nurse-practitioner in England as in the US twenty years previously. Studies showed that nurses were effective in many roles, for example single consultations about predominantly minor illness in general practice. Adequately trained nurses were increasingly given the authority to prescribe, and in 2004 it was proposed that nurses might prescribe medicines for life threatening conditions such as blood clots, deep venous thrombosis and meningitis to help to relieve the burden on accident and emergency staff. Nurses could already prescribe over 180 prescription only medicines, and the consultation proposed to add sixty more for thirty new medical conditions.
The Department of Health's Chief Nursing Officer set 8 clinical benchmarks that related to fundamental features of nursing care, such as nutrition, and skin and mouth care. In addition were ten "key roles" that nurses might undertake, in a developing health service, roles that crossed previous skill boundaries.
|To order diagnostic investigations such as pathology tests and X-rays|
|To make and receive referrals direct, say, to a therapist or pain consultant|
|To admit and discharge patients for specified conditions and within agreed protocols|
|To manage patient caseloads, say for diabetes or rheumatology|
|To run clinics, say, for ophthalmology or dermatology|
|To prescribe medicines and treatments|
|To carry out a wide range of resuscitation procedures including defibrillation|
|To perform minor surgery and outpatient procedures|
|To triage patients using the latest IT to the most appropriate health professional|
|To take a lead in the way local health services are organised and in the way that they are run.|
Hospital clinical nurse specialists were also on the increase. Some took over functions traditionally undertaken by hospital junior staff or family doctors, pre-admission clinics, minor injury services, emergency psychiatric assessment or the coordination of termination of pregnancy. The European Working Hours Directives that limited the time junior doctors could spend on duty led many hospitals to look at the possibility of nurse-substitution. The nurses involved had often spent ten or more years in their profession, and many years in their particular specialty. Government introduced the idea of the "consultant" nurse, few in number but paid on a significantly higher scale, stressing the need to break down the division between the responsibilities of the doctor and that of the nurse. In some fields nurses increasingly lead services, admitted and discharged patients, and made autonomous clinical decisions, organizing programmes of care. Mental illness was one of these. The largest group were Macmillan nurses providing palliative care, followed by specialists in diabetes, asthma, stoma wound care, infection control and AIDS.
Too posh to wash
Hospital nursing had changed radically as patients came and went far more often and treatment was of a complexity undreamt of by the founders of the NHS. Patients were often either too sick to eat, or could feed and wash themselves. The recruitment of staff from an aggressive society where the love of one’s brother was not always evident, created a new dynamic in the wards, mitigated by nurses from gentler cultures overseas. Many nurses still delivered exemplary care, but it was distressingly clear to the elderly or their relatives that basic levels of care were often not provided. Some seemed to believe that the caring aspect of nurses' roles should be devolved to health care assistants to enable registered nurses to concentrate on treatment and technical nursing. However Beverly Malone, General Secretary of the RCN, told a press conference at the College's 2004 conference that "the argument that you are too posh to wash is ridiculous. A nurse who doesn't want to provide basic care has missed what an important part this plays in nursing. Nurses that don't want to 'wash' have missed the point of what it is to be a nurse. When bathing a patient, nurses are also assessing them, checking their breathing and emotional wellbeing."
The conscientious nurse faced massive problems. Staff shortage because it was difficult to recruit, even if the budget was there, lowered staff morale on the wards. This in turn, resulted in nurses leaving the profession for other, less stressed and better paid, jobs, a vicious circle. and the proportion of qualified nurses was falling. Could staffing levels that pushed staff beyond their limits of stamina and compassion be condoned? How could nurses who had received what was planned as a rigorous and systematic education be party to such poor quality of care? Two thirds of hospital beds are now occupied by people over 65. The Standing Nursing and Midwifery Advisory Committee, reporting in March 2001 on Caring for Older People, found major problems.
"Studies suggest that there are deficits in the core nursing skills required to meet the needs of older patients. Too many nurses see fundamental skills, such as bathing, helping patients to the toilet and assisting with feeding as tasks that can be delegated to junior or untrained staff. The emphasis on qualified staff being involved in patients’ activities of daily living may have shifted as other aspects of the nursing role, such as technical and managerial components have developed. But skilled nursing care cannot be delivered from a distance or through agents. It is a “hands-on” activity. ….. In the past, any qualified nurse would have been expected to be able to assist with activities of daily living, including the management of incontinence, nutrition and skin integrity. However, this may not now be the case. Nurses may identify these areas as requiring specialist skills. …. The rapid expansion of specialties within nursing and the developing role of the allied health professions, e.g. physiotherapy, occupational therapy and dietetics, mean that several separate professional groups are now responsible for aspects of care, such as nutrition, that were previously nursing domains. There are also a large and growing number of nursing specialties, such as tissue viability, continence and infection control, whose areas of expertise overlap with traditional nursing practice. Increasing specialisation may have had the unintended detrimental effect of de-skilling adult nurses."
"Care Pathways" were being developed as a way of systematizing the treatment patients received, building upon the long standing nursing procedures. While few were actually available, over 2,000 care pathways were under development in over 200 NHS organizations and were predicted to be a key NHS resource for ensuring that patients were looked after along the lines specified in the National Service Frameworks. They dealt with specific clinical problems, for example breast cancer. They were available on line through the developing National Electronic Library.
Nursing uniform remained a vexed issue. Few nurses now had ever seen the traditional uniform save in films and documentaries. Trouser suits or clothing appropriate to an operating theatre (particularly in intensive care units) was becoming the norm. Academics wrote of the traditional wear as a badge of servitude, akin to the domestic dress of the 19th century servant. Uniform was redolent of a class and power structure in society, and should therefore be opposed. Some hospital wards experimented with the total abolition of nursing uniform. Nurses might like this, although it made it harder for patients to identify who was, and who was not, a nurse. Other service industries, placing an accent on ‘customer care’ had uniformed staff, but nurses in the NHS were moving in the opposite direction. Cross infection appeared to be a serious problem; few hospitals now had laundries where uniforms were washed at high temperatures, reducing bacterial contamination. Nurses usually washed them at a lower temperature at home, and might wear them to and from work for several days. A survey at Southmead hospital showed that more than a third of nurses' uniforms were contaminated by significant organisms before going on duty. (Journal of Hospital Infection, Volume 48, Issue 3, July 2001, 238-241)
To talk of nursing administration, following the introduction of the general management function after Sir Roy Griffiths' Management Review (1983), had seemed odd. Few hospitals in 1998 had a senior nurse who could be seen as a role model, a champion of nursing and from whom leadership could be expected. However the increasing perception that not all in nursing was well, that the wards might be dirty and noisy, and that patients did not always get the care that they needed, led to a re-evaluation. The NHS Plan (July 2000) recognised a need for a new generation of managerial and clinical leaders, including "modern matrons" with authority to get basics right on the ward. And, recognizing the dirty state of some hospital wards, the plan provided additional money to help to get the wards cleaner. As a result, ward housekeepers were introduced, and ward environment budgets under the control of sisters and charge nurses.
In April 2001 Alan Milburn, the Secretary of State, said that Matrons would be brought back, after thirty years. Their role however in no way resembled Matrons of days past, being that of the Nursing Officer (Grade 7) of the Salmon Report; (their starting pay in 2002 was £33,900). Their job was to be visible, with the authority to get things done, lead the nursing team in groups of wards, demonstrate to other nurses the high standards NHS patients should expect, make sure patients got quality care, and that cleaning and food standards were met. They would oversee the spending of ward budgets and resolve problems for patients, working with the new Patients Advocacy and Liaison Service. They might be concerned with infection control, and might have the power to order tests, admit and discharge patients, run clinics, triage patients and, where appropriate, prescribe medicines. The Royal College of Nursing, in a volte-face, welcomed the decision. Christine Hancock, its General Secretary, said '"Patients have been crying out for someone they know to be in charge on hospital wards," a welcome recognition of the validity of ideas for some while condemned by the nursing establishment as out-moded. Over the next few years increasing numbers were appointed. The RCN said that Trusts were implementing the initiative in diverse ways, some giving senior nurses the title without changing their jobs much, others creating exciting jobs but not using the title.
In November 2001 the Secretary of State announced that all ward sisters and charge nurses were to get control over ward staffing budgets worth as much as £800,000 a year, to give more power to senior nurses to manage the staff on their wards, plan rosters, shift patterns and assess the need for agency or bank nurses. Ward sisters would decide on the mix of grades, mix of skills and mix of jobs on each ward so that nurses can maximise the amount of time spent at the patient's bedside.