This is a response to the NMC’s nurse revalidation proposal, as submitted in Item 10. NMC/13/146. 12 September 2013. Annexe 2 – Options Appraisal, from which I quote:
“The primary purpose of revalidation is to provide greater assurance that nurses and midwives on our register remain fit to practise and capable of safe and effective practice. It needs to include a means of checking that those nurses and midwives continue to meet our standards, both in terms of conduct and competence, and that they have continued to keep their skills and knowledge up to date. The system of revalidation that we adopt must contribute to our core regulatory purpose which is public protection. We aim to deliver a proportionate, risk-based and affordable system that will provide greater public confidence in the professionals regulated by the NMC. It is also important that revalidation raises standards of care and promotes a culture of continuous improvement amongst nurses and midwives.”
“11.1. Description: This option is similar to option 2 with the additional element of the third party input on the practice of the registered nurses and midwives. This third party input would be in the form of employer confirmation (where applicable) and feedback from patients, users, peers etc. In the case of employer confirmation, the appraisals would be the main source for confirming that a nurse or midwife is compliant with the Code and standards in their practice. The confirmation model will be
flexible to take into account the diversity in scope of practice and employment situations. The details regarding the sources of confirmation/feedback will be informed by the public consultation.”
“11.2. Any documentation collected as a part of the third party input would be retained by the registrant. They will only need to submit this to the NMC when they are selected for the audit (detailed in paragraph 10.3) where the documentation will be called for as a part of the audit. The registered nurse or midwife will be solely responsible for the submission of their revalidation information sought by the audit to the NMC. Third parties will not be expected to submit any information directly to the NMC for revalidation of nurses and midwives.”
“11.3. Advantages: There are considerable advantages to this option. Added to the advantages of option 2, the element of third party input means there
will be significant improvement on current assurance levels of fitness to practise of the registered nurses and midwives”.
“11.4. There is a strong support from the patients and public about including patient feedback as a part of revalidation to enhance public protection. This is evident from the view of patients’ organisations on GMC revalidation. These organisations value the patient feedback as an aspect of the revalidation and consider it a key resource in helping to improve the practice. This view is further supported in the Francis report … where it is recommended to the NMC that the information that feeds into revalidation be evidenced by feedback from patients and their families”.
“11.5. This will also provide NMC extended and enriched data to inform risk andenable effective triangulation with other regulators”.
“11.6. Disadvantages: There are a few disadvantages to this option. The input from third parties regarding the registrants’ fitness to practise means there is a cost element in the amount of time spent by the registrant in collecting them as well cost to the third party confirmer. In the organisations where there is a robust appraisal system it would be most cost effective to integrate revalidation into that appraisal system”.
The scope of the NMC’s proposals remains extremely limited, confining itself to a small sample of nurses chosen for audit.
The central tenet of the proposal gives undue power to employers to determine whether a nurse is fit and safe to practice.
The dangers of this proposal are:
Employers may misuse their power. The private sector of health care provision is increasingly being taken over by venture capital companies (Nightingale 2013), whose aim is to make a return to investors, a modus operandi invariably accompanied by cost-cutting measures, such as a reduced number of staff. The positive correlation between low staffing levels and poor care outcomes is well documented (UNISON 2012). The competent practice of a Registered Nurse can be negatively impacted by the nature of their work environment, with increased pressure arising from such factors staff shortages, which are an ongoing feature of organisational cultures centred on the ‘business objectives’. Nurses working within such cultures are not supported by unions, the RCN stating a desire to support the business objectives of companies* (ibid). The result is a power imbalance between employer and employed, with the latter being afraid to report poor nursing care, in that reprisals in the form of ‘cold-shouldering’, lack of promotion, or the threat of being dismissed as a ‘ troublemaker’, are an everyday reality for many nurses (Dimon 2013). The pressure to conform to the cultural norms of the work situation particularly impacts negatively on student nurses, as highlighted in research (Levett-Jones et al 2009), in which students “described how and why they adopted or adapted to the teams and institution’s values … rather than challenging them, believing that this would improve their likelihood of acceptance and inclusion by the nursing staff.” Overseas nurses may also be at risk of employer intimidation, in that many are charged large and often illegal fees by recruiters who brought them to the UK, leaving them feeling “manipulated and cheated”, stated the Royal College of Nursing. Its report – We Need Respect, Experiences of internationally recruited nurses in the UK (2003) – found that many of those questioned describe their employment, both in the NHS and the private sector, as “slavery”.
(*In this regard, the independence of the NMC is called to question. The NMC and the RCN both place organisations involved in patient care as central to policy; the NMC would give employers a key role in revalidating nurses, and the RCN gives consideration to the profit-making goals of organisations, making employers more likely to allow the RCN to have bargaining rights within workplaces. (Other unions, such as UNISON, take a similar stance). The NMC website (http://www.nmc-uk.org/About-us/The-Council/) informs that its central committee is composed of twelve members, six of those being registrant members, with previous nursing experience. Of these six, three are shown to have declared in the NMC’s register of interests membership of either the RCN or RCM; the remaining three registrant members not having declared their interests. Would it not be reasonable to require all NMC committee members, whether of its central committee or its various sub-committees, to declare any affiliation to the RCN or RCM, and whether they serve on any RCN or RCM committees? Any suggestion of the RCN having undue influence within the NMC needs to be considered.
The NMC’s central committee are appointed by the Privy Council – a formal body of advisers to the Sovereign in the United Kingdom. Its membership is mostly made up of senior politicians who are (or have been) members of either the House of Commons or the House of Lords. The Council has a delegated authority to issue Orders of Council, which are mostly used to regulate certain public institutions – which is to say that they are appointed at the behest of the Political Establishment, which has generally been supportive of the principle of the privatisation of state assets and institutions. The NMC’s register of interests asks members to state any affiliation to a political party, and those members who have made entry in the register declare no such affiliation; yet, being a member of a political party is not the sole criteria of being ‘political’, or politically biased. Will the NMC ask its committee members to state their views on two current issues? – private sector acquisition of NHS services; the RCN’s sympathetic approach to the business objectives of companies involved in nursing care – so as to reassure the public and nurses that the NMC’s committees are composed of people with a diversity of views, and not ones carefully selected to sing from the Establishment’s hymn sheet. Further, would the NMC and the Privy Council comment on why NMC committee members are not democratically elected by a postal ballot of all current nurse practitioners? The principle of elected governance has often been used to justify the overthrow of unelected and unpopular (to some) governments; why do nurses deserve any less than, say, the ‘liberated’ citizens of Iraq and Libya? Although it can be safely assumed that NMC central committee members, and members of their family, do not have any personal or business association with members of the Privy Council, can the same claim be made regarding any such association with the hierarchy of the RCN? The apparent independence of the NMC is stated in an email (16 July 2013) to Carol Dimon, researcher and author, from an official of the Department of Health, where it is stated to be “an independent body”. To what extent is this the case?
Further, the very high academic eminence of NMC committee members suggests that it may be some years since they worked ‘on the shop floor’. Will NMC committee members comment on how they make themselves acquainted with the everyday experiences of nurses working in understaffed hospital wards or privately run nursing homes? – other than by attending RCN conferences, that is. Do committee members consult the many blog posts of nurses complaining of understaffing and employer intimidation? Do they maintain their registrations by, say, working an occassional shift in a nursing home owned by a private equity company? On the same theme, it is noticeable that the NMC’s revalidating proposal is fronted by a non-nurse academic. Can nurses be assured that the result of the revalidating exercise is research-based – were questionnaires sent to a large sample of registered nurses of various specialities, and their responses analysed? Has recent literature that comments on the everyday experiences of nurses been consulted? (http://qualityofnursingcare.webs.com/) Or is the revalidating proposal of the logico-deductive school? – wherein a conclusion has been drawn from ‘sound arguments’; a definition of which might be – not ones necessarily favoured by the NMC).
There have also been fabricated NMC cases that falsely accused nurses who did not fit in with their colleagues (Middleton 2012). One way of encouraging a member of staff to leave is to collect minor issues against them. The NMC’s proposals are a blueprint for the abuse of power by an employer, and will severely lessen the likelihood of nurses ‘whistleblowing’ about poor care standards. Employers may use their input to attempt to ‘get rid’ of unliked employees through the NMC’s validation process, rather than risking being taken to an industrial tribunal. Colleagues may be coerced into giving false witness.
The above mentioned considerations apply equally to the public sector, which is also run on a business model of management, geared to reducing costs, and employing a ‘flexible’ workforce; i.e., one which has little say in the types of contract offered. The increasing use of zero-hours contracts in both the private and public care sector makes it less likely that nurses will complain on behalf of patients, fearing not being offered work. The fear of being called to audit will make for a compliant workforce, which will not be in the best interests of patients.
In short, the NMC’s proposal to give employers a major role in determining whether a nurse is fit and safe to practice is one which is naeve, if it is based on a belief in employer impartiality, and is an abrogation of a duty to protect nurses if not. The proposal is an abstract based on a false premise, rather than the result of research into the realities facing nurses. It seeks to enforce a dictatorial paradigm in which the the abilities and personal qualities of nurses are interpreted by the whims of potential dictators, as opposed to the right of an individual nurse to make claims about themselves and their situation.
Other means of revalidating a nurse’s abilities and attitude have been successfully used in the USA, where mandatory continuing education for all nurses is required by a number of states. This is not claimed to ensure competency, or compassionate attitudes toward patients, but it can form the cornerstone of an approach which promotes competency and compassionate attitude on an ongoing basis.
It is suggested that:
(1) Nurses within the same locality, working within the same speciality, be placed into ‘educational cohorts’.
(2) There will be a number of same speciality cohorts within each locality, restricted to a membership of approxomately twenty.
(3) Each cohort to be affiliated with a local university.
(4) Individual cohort members to be given a ‘continuing competency’ and ‘personal observation’ computer file by their university.
(5) Members of cohorts to have access to university library facilities.
(6) Members of cohorts to have the (non-compulsory) opportunity to be ‘guests’ at lectures of their choice, or of simulated practical sessions.
(7) Universities to assign cohort co-ordinators with experience of their cohorts speciality.
(8) Cohort co-ordinators to collate (and disseminate via email on a monthly basis to cohort members) research articles pertinent to each speciality, and articles concerning compassionate care, pertinent to all specialities.
(9) Cohort members to read this information, and reflect on how it may enable them to deliver competent and compassionate nursing care, entering such reflection into their ‘continuing competency’ file. Entries can be short and simply expressed, without any formal academic format, thus being of a non-threatening nature. Nurses without the simple computer skills necessary to maintain their file, to be given tuition in doing so. Attendance as a guest at any lecture or practical session to be similarly recorded. Cohort co-ordinators to inform members of available lectures and practical sessions.
(10) Each cohort to attend, every twelve months, a two day ‘school’ at their designated university, with each ‘school’ delivering lectures concerning updated practice information, practical demonstrations where applicable, discussion concerning members individual experiences of attempting to deliver competent and compassionate care, and any factors which mitigate against this in their practice setting; discussion about how to better promote professional competency and compassionate care in their practice setting. Discussion to be led by the cohort co-ordinator. Some members may not wish to disclose factors, such as continuing low staffing levels in their working environment, which may negatively impact on their ability to deliver competent and compassionate care. Such disclosure can be entered on an ongoing basis in their ‘personal observation’ file. This file should be personal to them, to be accessed only by code. The file may be used as mitigating evidence against claims of poor practice by employers. Distinctly, the ‘continuing competency’ files should be in the public domain, accessible to employers and patients’ relatives. Each cohort member will record in them a yearly review of their continuing effort to remain a competent and compassionate nurse after the two day ‘school’.
Members will receive travel expenses to attend the ‘school’, and, in the case of transport problems, financial assistance to obtain overnight accomodation in the university campus.
(11) Cohort members will be able to scan any written evidence from patients’ relatives or colleagues which details their competency and compassionate attitude, and download it to their competency file, or take such evidence to their ‘school’, where it can be scanned and downloaded on their behalf.
(12) Employers will submit a brief statement before the ‘school’, giving their opinion of their employee’s competency and attitude toward patients and colleagues, which will be seen by the employee, who will be able to attach their response to it. This evidence to be downloaded to the ‘continuing competency’ file.
(13) This file will be available for download by a validating agency, which will check a random sample of files to be assessed against set criteria, and will be tasked with reporting any concerns arising from their assessment to a standards agency, which will inform the nurse, who will be asked to submit a corrective action plan.
(14) This proposal will be funded by a levy paid by employers of 20p a hour for each nurse they employ, which will be partly tax refundable, with greater discount to smaller organisations.
(15) Attendance at the ‘school’ is mandatory, except in the case of certified sickness, and employers will be legally obliged to release employees to attend. Limiting a cohort to twenty members from a range of organisations will ensure that employers should not face staffing shortages relating to ‘school’ attendance.
Continuing competency requires lifelong learning. Nurses are responsible to continually reassess competencies and identify needs for additional knowledge, skills, and personal development. This must be a collaborative process including individual nurses, educators, patients’ relatives, colleagues, and employers, not a process which gives undue emphasis to employers’ evaluations of nurses, which are open to abuse. Employers must be made aware that the competent practice of a nurse can be impacted by the nature of the work environment, and that employers have a duty to provide a suitable environment for good practice.
Current procedures allow nurses not to keep updated records of professional development, with anecdotal evidence of nurses running the risk of being audited, and concocting records only when notification of auditing is given. Mandatory continuing education ensures a framework of professional and personal development, uniting nurses of different generations in a common goal of improving the care given to patients.
Dimon, C. (2013). The Commodity of Care, pp. 69-72. Coister House Press.
Nightingale, L. (2013). Who Owns Care Homes?, cit. The Commodity of Care, Dimon, C., appendix.
UNISON (2012). Care In the Balance. A UNISON Survey Into Staff/Patient Ratios On Our Wards. Web: unison.org.uk. 1 February 2013.
c. lenin nightingale 2013 email@example.com