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Strategy for Nursing & Midwifery in Scotland : Pre - Consultation Discussion Document - CPHVA Response

The Professional Officer for Scotland (Anna Daley) gratefully acknowledges the contribution of Debbie Smith (school nurse), Janice MacLeod (school nurse), Kim Milledge (health visitor), Annie Hair (paediatric facilitator/ chair) and Maxine Moy (LHCC lead nurse/ health visitor) in the preparation of this response.

Who is the Strategy for?

Some have expressed concern about the omission of the HV title in the heading. Whilst this may be reasonable, if one adopts the view that health visitors are nurses with a specialist qualification, perhaps it may be helpful to be more explicit as to the rationale behind this

The circulation list appears reasonable. This document should be widely available but also ought to include the voluntary sector, nursing homes, private sector and hospice.

The Strategy format

The chapter headings appear to be comprehensive and appropriate.

This document should be available in two formats and be easily accessed via journals / libraries / Trusts / employers/ LHCCs etc. Also be available through postal request as well as via the internet. Practising nursing staff (including nursing support) could receive copies of the document attached to wage slips. Access to nursing students may be gained via their retrospective educational establishments. Perhaps the summary could be disseminated by professional bodies (e.g. UKCC, NBS, RCN/M, CPHVA, Unison) and nursing organisations (e.g. BNA, etc).

Policy Context

List appears reasonable too highlight the policy context within which the Strategy will sit. May also consider the recent work relating to child protection and young children.

Nursing and Midwifery Contribution

Emphasise the shift towards partnership working and the need for nurses to become more visible in driving professional and policy agendas (political / economic / social issues), rather than the often perceived role of ‘doctors handmaiden’. After all potential recruits are a priority in helping to change future perceptions of healthcare professionals. The public must also be constantly made aware of the professional’s responsibilities and accountabilities within nursing.

Demographic information relating to the age profile of the profession, succession planning, the triple/ double duty nurse and development of ‘new’ nursing roles, e.g. community children’s nurses, nurse consultants. The profession must reflect the challenge of changing demands becoming adaptable, with the greater emphasis on preventative healthcare as a social and economic necessity.

There are many examples of innovative practice and the document should seek these by categories of nursing. In particular examples which demonstrate working ‘with’ rather than ‘for’ patients/ individuals/ communities. It will be important to show not only examples of nurse-led initiatives but also initiatives where the nurse is part of a collaborative effort to promote patient well being.

The future will be challenging for nurses. These challenges are likely to include proof of effectiveness, effective skill mix, demonstrating ‘added value’ or ‘value for money’, workforce numbers, getting the theory/ skill mix right to prepare nurses for practice, promotion of holistic views and cross boundary working. However, nurses also face another challenge in that they must stop trying to be ‘mini-doctors’ by accepting the jobs that doctors no longer want, but strive to improve and define the nursing contribution through research and evidence based practice.

Key ingredients to keeping morale high include monetary incentives, access to education and training, transparent support mechanisms for students and staff. However, the application of non-monetary reward must become more prominent within the NHS, e.g. recognition of effort, role enhancement, etc.

Strategy Content and the Scoping Group

(a) Nurses can reflect their knowledge of patients/ public and acknowledge that this is valued. Professionals must "ask & keep asking, listen & keep listening, then act".

Emphasis of the public/ patient’s contribution into determining care must begin in basic training and with ongoing emphasis post-registration. If the public/ patient does not feel valued then the professional has failed.

Teamworking is core to nursing delivery of service; we must promote this skill. Nursing must learn to market their role, as a matter of routine, thinking laterally to broaden their concept of health to work in partnership.

Increased joint working must become an expectation of the norm. However, time must be resourced and support systems engaged to facilitate communication within practice. Joint training sessions and multi-agency educational approaches (e.g. incident analysis) would foster a greater understanding of professional contributions and roles, networking examples of practice, identifying problems and solutions.

(b) More input to careers events by practising nurses and midwives – promotion of profession in schools and within community groups. Young people need improved knowledge of career potential. However, nurses also need this knowledge.

Career pathways should be visible with accessible resources and appropriate reward to promote developments.

Increased flexibility within the service to accommodate needs of staff and service developments, e.g. weekend/ evening clinics.

An incremental entry, e.g. modular vocational training may widen the entry post for recruits. However, these should not depend only on practice based competency and must have academic standards.

Students need improved support at various levels to complete courses. Undergraduate students should be salaried not bursaries with appropriate financial remuneration (in advance) for ‘remote’ placements.

Adequate mentorship is an issue for under and post graduate students. This requires identification and preparation of individuals in the clinical area to undertake ‘supervision’. Time should be made available to those undertaking a ‘supervisory/ mentoring’ role. Whilst teaching should be an integral part of the work of all nurses. Those who undertake a clinical teaching role more formally should receive additional reimbursement.

Perhaps these individuals should undertake the position of ‘clinical teachers’ or lecturer/ practitioner posts. More interaction between educational establishments and the practice area is required to bridge the theory/ practice gap, to promote an up-to-date approach from both theory and practice and to seek research questions that are applicable to practice.

The intricacies of student placement must be considerable; however, care must be taken to ensure that all students get a broad coverage of experiences (within health, social, voluntary). Practitioners within community must make an effort to plan for an undergraduate student to ensure that enthusiasm for the area is generated.

Education Increased use of joint appointment system. Working in the community – students require experience and training to embark on such work. Present balance is not appropriate – tools are written for acute not community nursing.

Academic departments may seek to involve clinicians more in the development and monitoring of curriculum, and to update clinicians of the requirements of students. Clinicians could also invite lecturers to relevant practice development meetings.

More interactions between educational establishments and the workplace are required to create a sense of shared responsibility and co-operation. Creation of such a culture would lend itself to bridging the theory/ practice gap, promoting an up-to-date approach in within academics and practitioners and in recognising potential research areas, which have pragmatic significance.

Should be acknowledged as fundamental to the provision of a quality service and funded appropriately. Safety of public should be emphasised. Rotational opportunities for staff within the workplace (e.g.i day per month) to research practice area and feedback to other team members may be ‘workable’

Professional practice

The idea of incremental steps towards registration is regarded as a positive way forwards. However, this again has funding implications. For example, at point of registration could be a first entry level with a pathway for development built on, this leading to degrees/masters as career progression. Specialist Practitioners should be at degree level and should include acute as well as community specialists.

New Practitioners One year with rotation is an interesting idea but how would it be funded. The problem may be that it will continue to be regarded as a training year and staff will not be appropriately paid. In addition, the placements would have to e sufficiently long to allow for the ‘intern staff nurse’ to consolidate and gain confidence to operate as a qualified member and not continue as a student. Problems may occur in areas, which are remote (with disparate working groups), or in areas which are short staffed which may lead to increased stress on existing staff. Perhaps the system could be introduced to co-incide with new intakes of students. This may afford an opportunity for a greater emphasis of working within the primary care setting.

Alternatively, newly qualified staff may be supported with a standard series of study days within their first year. Improved preceptorship and shadowing opportunities, as the norm would also be of value.

Clinical Supervision On the whole the feeling that this was positive but will present challenges in terms of implementation, especially in the community. Also likely to be costly.. In terms of expected outcomes (improved staff working and consequently better patient care) then clinical supervision should be advocated within Scotland. It would be necessary to compare models throughout the country, as this will be operationally complex.

Leadership Should include clinical component. Often leaders may not be managers and as such not regarded as adding value to the service. Individuals who demonstrate an ability to lead others should be rewarded locally. This need not be monetary but present in recognition. Opportunities for exploit the skills these people have should be sought so that the service fosters/ retains innovators.

Management Individuals may be identified through annual appraisal/ staff reviews and encouraged. Managers should be expected to have a relevant qualification (as one would expect of any other specialist) and be subject to regular review of performance on a series of hard/soft measures. What about 360 appraisals as a norm?

Career progression Again there must be systematic approaches to staff appraisal to identify competencies and career opportunities. Need to think broadly about the opportunities that may present. However, competency related pay should reflect ability/ merit which will require appropriate funding. It would be unfair to embark on such a path if the intention was to ‘cap’ the reimbursement deserved/ promised.

Again the need for better networking and increased opportunity for practitioners to share with others. Nurses may feel that getting access to reasonable study time, similar to medical collegues may reward efforts towards quality improvement.

,Professional Officer, CPHVA Scotland

18 July 2000