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Nursing, like the NHS, is at a crossroads. The NHS Plan sets out two directions for nursing, midwifery and health visiting, which on first sight may seem to be contradictory. The Plan sets out firmly what patients want, which is to get the fundamentals of care right—dignity and privacy, proper food and drink, help with personal hygiene. They want a nurse to be with them when they are sick and vulnerable. These are issues I am addressing by strengthening the role of the ward sister and charge nurse, and through the national clinical benchmarking project (see box 1).1
Box 1: Aspects of fundamental nursing care—clinical benchmarking project
Tissue viability: pressure ulcers.
Hygiene and mouth care.
Privacy and dignity.
Principles of self care.
Safety of patients with mental health needs.
Yet the NHS Plan also sets out “The Chief Nursing Officer's 10 key roles for nurses” (box 2), roles which advance and extend the traditional parameters of nursing.
Box 2: NHS Plan—The Chief Nursing Officer's 10 key roles for nurses
- To order diagnostic investigations such a pathology tests and x rays.
- To make and receive referrals direct, say to a therapist or a pain consultant.
- To admit and discharge patients for specified conditions and with agreed protocols.
- To manage patients for specific conditions and within agreed protocols.
- 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 information technology to the most appropriate health professional.
10. To take the lead in the way local health services are organised and in the way that they are run.
The patient experience
As the chair of the patient experience action team which prepared us for the NHS Plan,2 it was difficult to hear some of the stories that patients told us. The vast majority of patients receive good, indeed excellent care. But there are too many tales of untidy and dirty wards, of patients allowed to sit with their food outside their reach and no-one to help them eat it, of postoperative patients who were not offered a wash. Many patients pointed out the pressures on nursing staff, especially in acute wards—staff run off their feet, tired, with little obvious visible leadership.
Equally, patients have a clear vision of what the NHS can be. They want to know that they can have access to care in a timely way to meet their clinical needs, and care planned in a way that respects and values their own family and working lives. Existing services are seen as too slow and cumbersome, waiting is too long, and there are too many individual staff who see the patient through the process. The process of care is seen as outmoded and often unnecessarily complex. Patients recognise that it is not just the number of staff, but the way they work that holds the key to resolving these problems. Patients respond well to newer models of care such as NHS Direct and NHS walk-in centres, practice nurses in general practice surgeries, and nurse led chronic disease management clinics. They welcome new ways of delivering care, as long as the care is safe and effective.
In this article I will discuss how we intend to meet the call to improve the quality of nursing care, alongside the parallel need to use nurses' skills and talents in new, advanced ways.
Making a difference
The nursing, midwifery, and health visiting profession has many issues to address in order to meet the challenges that patients have set us. Fortunately we are well prepared for these changes. The publication last year of Making a Difference, the national nursing, midwifery, and health visiting strategy,3 addresses many of the issues of importance to patients (see box 3), and significant progress is already being made in implementing the key proposals.
Box 3: Making a difference—key proposals
Expand the workforce.
Strengthen education and training.
Develop a modern career framework.
Improve working lives.
Strengthen clinical leadership.
Modernise professional self regulation.
Encourage and support new roles and new ways of working.
Working in new ways—clinical leadership in a variety of settings
PATIENT CENTRED CARE
Innovation in patient centred care has long been a nursing tradition. However this has often been driven by individual enthusiasm and commitment, rather than top level strategic development.4 It is also true that professional tribalism and organisational constraints have sometimes prevented such innovation. The challenge is to make these ways of working mainstream, in every corner of the NHS. As the Secretary of State for Health says “there's nothing in the NHS Plan that's not already in the NHS”. If a nurse led service works for patients—and they clearly often do5—why not roll the service out to every trust and general practice?
THE MODERN MATRON
During the consultation on the NHS Plan many patients, doctors, and indeed some older nurses mourned the demise of the matron. This was hard to hear for my own generation of nurses, for whom the matron symbolised the Hattie Jacques model of an old fashioned tyrant rather than a caring patient advocate. It is clear however that both patients and staff want to see a strong clinical leader at ward level. We need clinical leaders who set high standards of care, who are skilled and knowledgeable. They need to be visible to staff and known to the patients, and act firmly in staff or patients' interests when needed. They must be credible, and gain the respect of their team, their patients, and their colleagues. We need ward sisters who value the importance of the fundamentals of care to patients, not devalue them as the “basics”. This is the “modern matron” to which the NHS Plan refers.
We know from the Royal College of Nursing clinical leadership programme that ward cultures can be transformed by investing in leadership development. This is why the government is investing in a comprehensive leadership programme for all ward sisters and charge nurses.
NURSE, MIDWIFE, HEALTH VISITOR CONSULTANTS
Nurses have been working in advanced ways for many years. Advanced roles have developed in many areas, such as clinical specialist roles in cancer nursing, or nurse practitioners in the community, and many of these roles truly improve patient care. However in the past there has been very little national drive behind the development of such roles. Different job titles have proliferated. There has been only limited professional recognition, with few accepted development pathways for the nurses, midwives, and health visitors concerned.
The government's support for the new role of nurse, midwife, and health visitor consultant now sets a firm foundation, together with the United Kingdom Central Council work on the higher level of practice. For the first time there is a nationally agreed career pathway and payscale, a common level of educational attainment (master's level), and a job profile in which the emphasis is on expert clinical practice. These roles provide a formalised clinical career pathway, allowing nurses to develop their practice alongside service development, research, and education. Over 400 posts have now been approved. The first posts are being targeted at areas of clinical priority—critical care, cancer, mental health, coronary heart disease.
Nurses, midwives, and health visitors are also developing their roles in public health. This has traditionally been a less visible role for the nurse. The present emphasis on disease prevention, and eradication of health inequalities, has now pushed public health nursing to the forefront. Again, it will require innovative working in all corners of the NHS and social care.
This year I became aware of the work of Hazel Stutely, a health visitor who is now a member of the NHS Plan Prevention taskforce. Hazel runs a community development project in Cornwall. She believed that her clients' health was as much influenced by their environment and their sense of personal empowerment, as by their physical health. Hazel has been able to transform the outlook (and hence the health needs) of a “problem” estate in Cornwall by working directly with the residents and the many relevant agencies.
I was also most impressed by the school nurses I met in Sandwell, who work in imaginative ways to tackle high rates in teenage pregnancy. More and more practice nurses are taking on smoking cessation work in order to prevent cancer and coronary heart disease. We will be encouraging these developments through our health visitor/school nurse development programme, and support for public health leadership roles for nurses, midwives, and health visitors.
The future of the clinical team
It is impossible to discuss future nursing roles without discussing the nurse's role within a multiprofessional team. Good teamwork will be critical to the success of the NHS Plan. The strapline for the recent NHS careers recruitment campaign “Join the team and make a difference” is very apt. A happy, healthy team is what motivates people to go to work in the NHS, and it is often what affords people their sense of personal reward.
A hierarchical approach to management, together with professional tribalism and a culture of personal empire building have characterised the NHS for too long. The inquiries into problems in Bristol and Oxford illustrate only too clearly colleagues' experiences of a lack of equality and mutual respect. Teamwork is tough. It requires honesty and generosity of spirit on all sides, and the courage to face up to weak relationships.
All professions will need to take responsibility for nurturing and developing a new sense of team spirit. I am encouraged by recent developments in interprofessional training, and the growth of collaborative multidisciplinary projects such as the public health work I described above, or integrated clinical pathways in hospital and community care.
Above all teamwork requires a common focus, a common objective. If we all truly believe that we are here to serve the patient, his family and community, we cannot go far wrong in developing new roles for the future.
1st Asia Pacific Forum on Quality Improvement in Health Care Three day conference Wednesday 19 to Friday 21 September 2001 Sydney, Australia
We are delighted to announce this forthcoming conference in Sydney. Authors are invited to submit papers (call for papers closes on Friday 6 April), and delegate enquiries are welcome.
The themes of the Forum are:
Improving patient safety
Leadership for improvement
Consumers driving change
Building capacity for change: measurement, education and human resources
The context: incentives and barriers for change
Improving health systems
The evidence and scientific basis for quality improvement.
Presented to you by the BMJ Publishing Group (London, UK) and Institute for Healthcare Improvement (Boston, USA), with the support of the the Commonwealth Department of Health and Aged Care (Australia), Safety and Quality Council (Australia), NSW Health (Australia), and Ministry of Health (New Zealand).
For more information contact:or fax +44 (0)20 7383 6869