0340759704 Nurses Professional

Student Nurses’ Guide toProfessional Practiceand Development

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Student Nurses’ Guide toProfessional Practice and DevelopmentEdited by

Jane E Schober RGN, DipN Ed, DipN (Lond), RCNT, RNT, MN

Principal Lecturer, School of Nursing and Midwifery, De Montfort University, Leicester, UK

Carol Ash RN, HV, DipN (Lond), DipN Ed, RCNT, RNT, B Ed (Hons), MBA

Independent Nurse Education ConsultantFormerly Senior Lecturer, School of Nursing and Midwifery, De Montfort University, Leicester, UK

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ContentsList of Contributors viiAcknowledgements ixIntroduction and How to Use This Book xiJane E Schober and Carol Ash

Chapter 1 1Embarking On a Career in NursingJane E Schober

Chapter 2 11Professional Issues and Implications for PracticeCarol Ash

Chapter 3 23Recent Developments in Nursing PracticeVeronica Bishop

Chapter 4 35Perspectives on Adult NursingPenny Harrison

Chapter 5 47Perspectives on Children’s NursingKevin Power

Chapter 6 63Perspectives on Mental Health NursingBen Thomas and Robert Tunmore

Chapter 7 81Perspectives on Learning Disability NursingMaureen Turner

Chapter 8 95Support Systems for Student NursesNick Salter

Chapter 9 111Career Management and Development for Registered NursesJane E Schober

Appendices

Appendix 1 127Standard 7 – First level nurses – nursing standards ofeducation to achieve the NMC standards of proficiencyNursing and Midwifery Council

Appendix 2 135The NMC Code of Professional Conduct: standards for conduct, performance and ethicsNursing and Midwifery Council

Appendix 3 143An NMC Guide for Students of Nursing and MidwiferyNursing and Midwifery Council

Appendix 4 147A Framework for Capable PracticeThe Sainsbury Centre for Mental Health

Index 149

vi Contents

List of ContributorsCarol Ash RN, HV, DipN (Lond), DipN Ed, RCNT, RNT, B Ed (Hons), MBA

Independent Nurse Education Consultant, formerly Senior Lecturer, School of Nursing andMidwifery, De Montfort University, Leicester, UK

Veronica Bishop PhD, MPhil, RGN, FRSA

Editor, Nursing Times Research and Professor of Nursing, School of Nursing and Midwifery, De Montfort University, Leicester, UK

Penny Harrison MA, BSc (Hons), RGN, ENB 100, Cert Ed

Senior Lecturer, School of Nursing and Midwifery, De Montfort University, Leicester, UK

Kevin Power MA, BA (Hons), RSCN, RGN, DipN (Lond), Cert Ed


Nick Salter RGN, DipN (Lond), Cert Ed (Adults), BSc (Hons), MA, LTM

Senior Lecturer, School of Nursing and Midwifery, De Montfort University, Leicester, UK

Jane E Schober RGN, DipN Ed, DipN (Lond), RCNT, RNT, MN


Ben Thomas MSc, BSc (Hons), DipN (Lond), RGN, RMN, RNT, CertHE, FRCN

Director of Nursing and Organisational Development, Somerset Partnership NHS and Social CareTrust, and Principal Lecturer, University of Plymouth, Plymouth, UK. Currently on secondment asChief Nurse, St Vincent’s Mental Health Service, Melbourne, Australia

Robert Tunmore MA, DGDip (Ed), BSc (Hons), RGN, RMN, RNT

Nursing Officer, Communications, Department of Health Formerly Academic Co-ordinator and Principal Lecturer, University of Plymouth, Plymouth, UK

Maureen Turner RNMH, RNM, RNT, DipN (Lond) A&B, MA



AcknowledgementsWith thanks to the Nursing and Midwifery Council for their permission to reproduce the material inAppendices 1–3, and to the Sainsbury Centre for Mental Health for permission to reproduce A Framework for Capable Practice in Appendix 4.


Introduction and How to Use This BookNursing is one of the most challenging and diverse careers available to you. Though demanding, thosewho have a commitment to care for and support those who have health and nursing needs will find avast range of career opportunities, following successful completion of a pre-registration nursing course.

If you want to know about a career in nursing, professional requirements and practice, entry into nurs-ing courses and the branch programmes, this is the book for you. This book is for anyone considering orembarking on a nursing career. It is a valuable resource for student nurses, nursing cadets, and health careassistants considering a nursing course. It contains a wealth of information about nursing as a career,being a student nurse, the four branches of nursing, support networks for students and key aspects ofprofessional development for students preparing to register as a qualified nurse. It is a detailed intro-duction to the professional issues relating to career and professional development for student nurses. Itwill also provide anyone considering a nursing career with information about nursing courses and therange of practice opportunities that exist in the United Kingdom.

Each chapter is written by an experienced nurse and author, an expert in the chosen field. Eachchapter contains an introduction summarizing the main content, reflective exercises to invite you toapply key issues to your own experiences, and detailed references and further reading options to sup-port the main issues. Most chapters contain a glossary to explain key terminology and there are manyuseful addresses and websites included to facilitate your need for further information and support.

The inclusion of three appendices containing Nursing and Midwifery Council information which ispertinent to student nurses, professional requirements and professional development, is referred tothroughout the chapters and is a convenient resource for the reader.

We hope that you find this book a useful resource as you pursue your nursing career.

Jane E SchoberCarol Ash


Embarking On a Career in NursingJane E Schober

1

INTRODUCTIONMost of us will need a nurse at some point in ourlives. By embarking on a career in nursing, you areentering a profession with a long history and areputation for having the care of others at itsheart. The motivation to care for others in variousstates of mental, physical and emotional health is characteristic of many applicants to nursingcourses. Indeed, caring has been viewed as the fun-damental value of nursing, and as such implies thatnurses are prepared to express skilled, compassion-ate care for those who require it. The complexityof nursing is evident as any interaction, nursing andhealth care activity will be influenced by the needsand individuality of those requiring a service.

Currently courses are available with branch pro-grammes in all or some of the four branches ofnursing, preparing students to register as an adult,children’s, learning disability or mental healthnurse. In addition, there is a wide range of rolesfor qualified nurses: thus the employment oppor-tunities are great, making nursing a potentiallylife-long career. This chapter aims to provide anoverview of the potential of nursing as a careerand includes the following sections:

• Introduction to nursing• Becoming a nurse: applying for a course in

nursing• Professional issues: preparing to gain your

licence to practise nursing• Your nursing course.

INTRODUCTION TO NURSINGThere are many challenges facing nurses today.The health and social care systems in the UK aim to

provide services for the population that support andpromote health, prevent illness and provide treat-ment and care for patients, clients, carers, fam-ilies and communities. This is a complex servicethat is influenced by the demands on national andlocal resources, health policies, nursing policies andhealth care priorities. Nurses form the largest proportion of the National Health Service (NHS)workforce and are also present in large numbers inthe independent and voluntary health care sectors.As such, they are an essential part of how health andnursing care is planned, organized and managed.

Raised public expectation and understandingof health care issues places increasing demands onhealth care professionals to provide quality carethat is personalized. The NHS Improvement Plan(Department of Health (DoH), 2004) explains the NHS priorities between now and 2008. Threepriorities are summarized as follows:

• ‘putting patients and service users first throughmore personalized care

• a focus on the whole of health and well-being,not only illness; and

• further devolution of decision-making to localorganisations’ (DoH, 2005).

This builds on The NHS Plan (DoH,2000) whichis a 10-year programme to reform key aspects ofthe NHS. It marked the start of the most compre-hensive shake up of the NHS since it came intobeing in 1948. It included strategies to personal-ize the service, targets to reduce waiting times fortreatment, invest in new facilities and services,increase the number of consultants and nursesand provide opportunities for staff development.National standards for health care were estab-lished including the National Institute for Health

and Clinical Excellence (NICE), which makesrecommendations about treatments, and NationalService Frameworks, which makes recommenda-tions about standards of care for care groups (seeUseful websites at the end of the chapter).

Nurses are in the front line of health care deliv-ery. They may work independently, in teams andin a range of health and social care settings. It is achallenge to summarize the essence of nursing, butit is true to suggest that the nature of the needs ofpatients and clients demands that nurses use theirskills to adapt to them in a way that promotestheir well-being, healing and care in a respectfulway. The Royal College of Nursing (RCN) sug-gests that the primary purpose of nursing is to:

provide holistic health and health care forpatients, families, carers and communities.Registered nurses are responsible for maintain-ing all aspects of the health environment so thatit is conducive to improving health, facilitatingrecovery from illness or rehabilitation, andwhere appropriate, achieving a dignified death.

(RCN, 2004, p. 4)

Compare your definition with the followingRCN definition which states:

The use of clinical judgement in the provisionof care to enable people to improve, maintain,or recover health, to cope with health problems,and to achieve the best possible quality of life,whatever their disease or disability, until death.

(RCN, 2004, p. 4)

Another definition, long respected and referred toby nurses, was given by Virginia Henderson (1966):

The unique function of the nurse is to assist theindividual, sick or well, in the performance ofthose activities contributing to health or itsrecovery (or to a peaceful death) that he wouldperform unaided if he had the recoverystrength, will or knowledge. And to do this in

such a way as to help him gain independence as rapidly as possible.

Nursing is about helping, supporting and inter-vening to care for and promote the health of thosewho need interventions in a skilled, professionalway. Being sensitive, kind, communicative, non-judgemental and respectful to the individuality ofthe person concerned is essential.An awareness ofand sensitivity to individual cultures, religions andlifestyles supports this process.

Students who embark on a nursing career faceexciting challenges. The following sections pro-vide information to support this process.

BECOMING A NURSE: APPLYING FOR A COURSE IN NURSINGGetting started

There are over 60 centres in higher educationinstitutions (HEIs) and colleges in the UK offer-ing nursing courses. Choosing a course, the branchprogramme and whether to opt for a degree ordiploma course (in England only) will be influ-enced by:

• your academic qualifications• where you plan to undertake the course• your chosen branch programme• your social circumstances and family commit-

ments• your ability to travel or commute• your financial circumstances• your long-term career goals (if you know them).

Careful consideration of these factors along withdetailed fact-finding about the available courses isessential. Student numbers on the course, availableaccommodation, resources and facilities for stu-dents and how the structure of the course and thetimetable may influence your needs are essentialto your planning.

Most nursing courses are full time. They arethree years in length with a 45-week academicyear spread over three semesters. Fifty per cent ofthe course timetable is theoretical and based inthe university or college, the other fifty per cent is in practice, to gain practice-based experience.Therefore you are expected to adapt to learning in

2 Embarking On a Career in Nursing

Reflective activityFrom this introduction, aim to write your def-inition of nursing. Try to express your values andpriorities about what you think nursing repre-sents for those needing care.

two quite contrasting arenas.When in practice, thestudent nurse usually follows the duty rotas of thenurses in that ward or unit, especially of those whoare assigned to the student’s support and learningexperiences. Shift work and some night duty willbe necessary for these experiences. So unlike manyuniversity students, student nurses are subject to:

• academic and educational objectives relatingto course work

• practice placement objectives to fulfil practicestandards

• professional development objectives expectedof student nurses.

Course information

Information about HEIs and colleges are availablefrom their own websites, professional bodies, e.g.theNursing and Midwifery Council (NMC), the Uni-versities and Colleges Admissions Service (UCAS)and the Nursing and Midwifery Admission Service(NMAS) (see Useful websites below). Most HEIsoffer summer schools, open days and taster courseswhich you can attend to find out more about theuniversity and the courses of interest. Details ofthese are advertised on the HEI website.

Academic entry requirements

Usually the MINIMUM academic entry require-ments for pre-registration nursing courses are fiveGCSEs at C grade or above that include Englishlanguage and a science subject or equivalent.

A detailed range of qualifications equates with these and information about these may beobtained from either UCAS or NMAS. There arepre-registration nursing courses in all the coun-tries in the UK. Many HEIs offer pre-registrationcourses: 50 in England, seven in Scotland, three inNorthern Ireland (including the Open University)and six in Wales. Many centres offer courses in allbranches of nursing, namely:

• Adult nursing• Children’s nursing• Learning disability nursing• Mental health nursing.

The courses can be at degree or diploma level.

Degree courses

All the countries in the UK offer full time degree-level courses which are 3 or 4 years in length. Inaddition, there are a few sandwich or shortenedcourses for graduates. However, many degree andsome diploma courses do not offer all the branchprogramme options.

Entry to these courses depends on meeting the HEI entry requirements. Applicants (exceptthose with access courses) must have a minimumof five GCSEs at grade C or above or equivalent,to include, English language, mathematics and atleast one science subject. In addition, degree-course applicants would be expected to achieveadditional academic qualifications, the details ofwhich are available through UCAS (see Usefulwebsites below) and the HEIs.

Diploma courses

In England, most HEIs offer degree and diplomalevel courses. Diploma courses are usually fulltime for 3 years though there are some part-timecourses available. As with degree courses, somecentres do not offer all the branch options.Applicants must demonstrate evidence of numer-acy and literacy skills and good character, details ofwhich are available from NMAS (see Useful web-sites below).

Other routes for entering diploma and degree courses – flexible entryopportunities

Foundation degreesThese are in their early stages but may facilitateentry to year 2 of a nursing course.

Access to higher education coursesIf you do not have GCSEs or other academicqualifications equivalent to the minimum entryrequirements, you can take an access course.This is a course to Access Higher Education andfor nursing, is 1 year full time or two years parttime.

Applying for a course in nursing 3

Nursing cadet schemesIn England, there are over 60 nursing cadet schemesthat allow you to achieve a National VocationalQualification at level 3 (NVQ 3) if you do nothave other academic qualifications. This facilitatesaccess to the diploma courses.

SecondmentsIf you are employed as a health care assistant(HCA) within the NHS, there may be an oppor-tunity for you to be seconded onto a course. Thiswill mean that your salary will continue being paidand there is an expectation that you will return tothe same practice area after the course, althoughthis is not essential.

Other entry requirementsAs well as fulfilling academic entry requirements,you also need to be 17-and-a-half years of age onthe day the course starts and at least 16 yearswhen you apply. Each HEI has additional entryrequirements which include:

• health screening• Criminal Records Bureau (CRB) checks.

The HEI may also require:

• evidence of previous relevant caring experience• attendance at interview• academic qualifications additional to the min-

imum already described, especially for degreecourses.

Informal visitVisiting a prospective university or college isessential. Aim to talk to current students if youcan. Explore the campus and facilities such as thelibrary and student union. Notice boards mayreveal how active some of the clubs and supportfacilities are. Consider your accommodation needs,and if you are not familiar with the campus or areawhere the course is based, it is useful to explorethe accommodation on offer as well as transportfacilities, especially if placements are not geo-graphically near to the campus.

Being a student nurse

Student nurses often express a mix of excitementand apprehension, enthusiasm and reservation atwhat may lie ahead. Nursing courses are busy,demanding, challenging and dynamic. The varietyof practice experiences along with the educationaldemands suggest that you need to be organized,because it is also important to enjoy universitylife and to take advantage of meeting other stu-dents as well as working to your full potentialduring the course.

Several demands that face all students will alsoimpact on student nurses. Many have come awayfrom home for the first time and home sickness is very real for a lot of students (see Chapter 8).Making ends meet is a common stress and depend-ing on whether you are following a degree or adiploma course, the financial arrangements will dif-fer. Details of financial support are available throughHEIs and the Department of Health (DoH,2003). Adapting to the course, fellow studentsand new environments may be challenging. Yourmain sources of support during the course will bethe following:

Course leader and lecturers: Lecturers are respon-sible for organizing the course, providing detailedinformation, guidance and support. Each part of the course or module will have a leader and a team of lecturers who teach, assess, provideresource material and feedback about your coursework and overall performance.


Summary

• Carefully examine your motives for applying for a nursing course.

• There are different routes for accessingnursing courses in the UK.

• Ensure you have detailed knowledgeabout your chosen course, HEI and branchprogramme.

• Nursing courses demand that you adaptto learning during practice placements,produce the required academic work andassignments and develop professionally.

Personal tutor: Each student will usually have apersonal tutor allocated for the duration of thecourse. This allocation allows students the oppor-tunity gain personal, professional and pastoralsupport in addition to the academic support onoffer.

Practice-based mentor: When allocated to a prac-tice placement, you are allocated a mentor who isusually a registered nurse who is responsible foryour learning experiences and assessments duringthe period of allocation. Mentors are key membersof the practice team and as such will have a busyworkload. Therefore it is recommended that stu-dents follow the duty rota of their mentor as closelyas possible to maximize learning opportunities.

University support networks: Universities offercomprehensive services for students. Publicationssummarizing these services are usually availableand may be sent to students before a course starts.These services are user friendly and there to helpand support you. The service include:

• Careers advice• Chaplaincy and religious support• Childcare information• Counselling services• Disability support• Finance support, bursaries, fees, debt manage-

ment• Health surgeries• Legal advice• Library services• Learning support• Students union, for advice and recreational

activities.

This support network also ensures that stu-dents have a framework for:

• gaining details of their academic and practice-related progress

• knowing the university regulations, e.g. relat-ing to assessments, examinations, plagiarism,complaints procedures and behaviour

• knowing the university policies, e.g. relating tohealth and safety, fire and evacuation, dyslexia

• procedures for monitoring attendance, illnessand absence

• professional requirements• policy requirements, e.g. uniform, drug and

health and safety policies relevant to practiceexperiences.

The student portfolioEvery student is required to maintain a professionalportfolio.At the beginning of the course, you will begiven a portfolio and guidelines for its completionduring the course. This is yours to maintain andcomplete. Your lecturers and personal tutor will beparticularly supportive regarding its completion.The portfolio is a collection of evidence relating to:

• your biographical details• your previous educational experiences and

qualifications• action plans relating to key aspects of the

course• your course experiences and achievements• summaries of key learning experiences during

the course• your reflections about what you have learned,

how your competencies are developing,how youfeel about your experiences and the learningthat needs to take place.

It is a professional requirement for registerednurses to maintain a professional portfolio.There-fore the experience of maintaining a portfolioduring the course is relevant to this. In the earlystages as a registered nurse, some of the evidencecontained in it from your course will be relevantand may support your professional development,e.g. job applications (see also Chapter 9). Addi-tional sources of support are explored in detail inChapter 8.

PROFESSIONAL ISSUES: PREPARINGTO GAIN YOUR LICENCE TO PRACTISE NURSINGDuring a course, student nurses are expected toachieve a range of professional outcomes as youprepare to gain your licence to practise as a quali-fied nurse (see also Chapter 2).The NMC (2004a)

Preparing to gain your licence to practise nursing 5

has set out the competencies necessary for stu-dents undertaking pre-registration nursing courses(see Appendix 1). It offers guiding principles forthe standard of pre-registration courses and statesthat for:

Practice-centred learningThe primary aim of pre-registration nursingprogrammes is to ensure that students are prepared to practise safely and effectively tosuch an extent that the protection of the publicis assured. On this basis, it is a fundamentalprinciple that programmes of preparation arepractice-centred and directed towards theachievement of professional competence.

(NMC, 2004a, p. 13)

In addition, the NMC (2004a) offers guidancerelating to:

• Theory and practice integration• Evidence-based practice and learning• Responsibility: fitness for professional standing• Adherence to the NMC Code of Professional

Conduct: standards for conduct, performanceand ethics

• Responsibility and accountability• Ethical and legal obligations• Respect for individuals and communities.

The NMC Code of Professional Conduct (NMC,2004b; see Appendix 2) underpins the competen-cies and is an essential feature at all stages of pre-registration courses. It is essential for a studentnurse to have an understanding of the NMC Codeof Professional Conduct and the course require-ments and competencies (see Appendix 1). Theseare explained and used to determine all aspects ofthe courses and are regularly referred to in teach-ing sessions and during practice placements, aswell as being used to determine aspects of assess-ment and achievement (see also Chapter 2).Student nurses are expected to ‘work within yourlevel of understanding and competence and alwaysunder the direct supervision of a registered nurseor midwife’ (NMC, 2002). In addition, studentnurses must:

• respect the wishes of patients• always accurately introduce themselves to

patients as a student• accept appropriate responsibilities

• safeguard patient confidentiality• understand procedures for dealing with patient

complaints (from NMC, 2002; see Appendix 3).

In The NMC Code of Professional Conduct: stand-ards for conduct, performance and ethics (2004b;see Appendix 2), the NMC states that ‘As a regis-tered nurse, midwife or specialist community pub-lic health nurse, you are personally accountable foryour practice. In caring for patients and clients,you must:

• respect the patient or client as an individual• obtain consent before you give any treatment

or care• protect confidential information• co-operate with others in the team• maintain your professional knowledge and

competence• be trustworthy• act to identify and minimize risk to patients

and clients.’

This process is all part of the preparation andeducation you receive during your course. As astudent nurse, you are expected to act in a waythat is appropriate to being in contact with thepublic, this is how you learn to become a safe andcompetent practitioner.


Reflective activityCompare the quote above from the NMC Codeof Professional Conduct with the NMC Guide forStudent Nurses (Appendix 3). Consider theway that you as a student are expected to com-ply with key professional standards while at thesame time ensuring that you have appropriatesupervision and support.

Summary

• Students can expect comprehensiveteaching and support and feedback duringtheir course.

• Students are expected to adhere to professional principles as part of theirlearning experience during the course.

YOUR NURSING COURSEThere are common features of nursing coursesthat are determined, as described, by legal and pro-fessional requirements. For 3-year courses, thestructure of the course consists of the CommonFoundation Programme which is 1 year in length,followed by the 2-year branch programme. This is organized over a 3-semester year. The 4-yearcourses tend to have a shorter academic year.

All students have to complete a total of 4600 hours of study and practice: 2300 theoryand 2300 practice, as well as successfully com-pleting the required course work and practice-based objectives and assessments to achieve thecompetencies.

Common Foundation Programme

The Common Foundation Programme (CFP)provides students with opportunities to gain abroad introduction to all aspects of nursing beforeentering their chosen branch. Therefore you willshare most of this time with all the other studentson the course, gaining experience in your chosenbranch as well as the other branches of nursing.Increasingly, student nurses are taught alongsideother students, e.g. physiotherapy, occupationalhealth and medical students. Sharing experiencesrelating to a chosen profession is regarded as animportant part of a health professional’s educa-tion as well as learning about key topics together.There will be a mix of theoretical and practicalinput in most modules and you will be introducedto subjects such as:

• Nursing theory and practice• Health and social policy• Health promotion• Health and safety policy and practice• Primary health care• Anatomy and physiology• Communication studies• Sociology applied to nursing• Psychology applied to nursing• Pharmacology• Research appreciation• Professional development• Information technology and health care.

In addition, study skills, support with essay-writing techniques, time management and ensuringunderstanding of the available learning resources(e.g. the library) are included. You will be encour-aged to develop your academic and learning skills.Effective decision-making and problem-solvingabilities are essential skills for registered nurses so these are evaluated and assessed as part of the learning experiences during the whole course.Information technology has transformed manyaspects of health care, patient record systems andeducation. These are explored during the course.You are expected to use a personal computer toproduce assignments and projects, and support is on offer to ensure students are competent withthis. Students also have an opportunity to realizean introduction to and learning experiences spe-cific to their chosen branch programme as well assome exposure to experiences relating to the otherbranches of nursing. This provides all studentswith the opportunity to appreciate key aspects ofcare, practice and associated theory relevant to theother branches – but this is only an introduction.

Learning a range of practice skills is an import-ant part of the course and individual modules andincludes:

• Key aspects of patient care, e.g. observationskills, assessing blood pressure and temperature

• Interpersonal skills, e.g. patient interviewing,listening skills

• Caring for an immobile patient• Safe lifting and handling techniques• Resuscitation techniques• Aseptic technique• Hand washing and universal precautions• Drug calculations• Report writing.

Some of these skills are introduced as practicalsessions within the HEI, which usually have facil-ities and skills centres designed as wards for thispurpose. This initial introduction is linked to the-oretical sessions to ensure that students under-stand the application of the research and evidenceassociated with the skills to their application inpractice. Further experience is then necessary inpractice placements to gain competence and con-fidence, apply the skills in differing circumstances

Your nursing course 7

to adapt them to various patients and their needs.It is acknowledged that not all practical skills canbe introduced within practical sessions but arefacilitated by mentors during practice experiencesand in accordance with the objectives for the stageof the course. Assessment of the skills is part ofthis process and a record of achievement is essen-tial to the successful completion of a stage of thecourse and progression to the next.

Branch programmes

Following successful completion of the CFP, stu-dents progress to their chosen branch programmein year 2 of the course. Detailed learning com-mences to fulfil the necessary branch specific com-petencies (see Appendix 1). Student experiencerelates to a range of branch-specific modules withassociated theory and practice allocations. Thisallows students to gain experience caring for thoserequiring nursing and health care in a range of set-tings (see Chapters 4–7 for branch-specific details).

As the course progresses, so do the demands fordevelopments in academic work, competence andprofessional development. The theoretical com-ponent of the course facilitates detailed study ofkey aspects of nursing including care manage-ment, policies, legal and professional perspectivesrelevant to patients and clients.The onus is on thestudents to develop more responsibility for theirlearning by undertaking an organized study pro-gramme for reading to support the programme,meeting deadlines for submitting work, takingadvantage of tutorial opportunities and thoroughlypreparing for lectures, lessons, seminars and tutorials.

The practice-based aspects of learning will usually offer a range of placements including:

• community-based experiences in primary caretrusts (PCTs) and health centres, with districtnurses, health visitors, community psychiatricnurses

• in schools with school nurses, nurseries e.g. forchildren’s branch students

• in private sector hospitals and care homes,and in those offering social services provision,e.g. for learning disability and mental healthbranch students

• specialist units, e.g. coronary care, burns units(for adult branch students), forensic units (formental health branch students) and neonatalunits (for children’s branch students).

Elective placements are experiences that stu-dents have chosen under the guidance of course lec-turers. These may be in the UK or aboard andcomplement the chosen branch, stage of the course,level of learning and interests of the student.

As the branch programme progresses into thefinal year of the course, so the work intensifiesand realization that, on successful completion ofthe course, first posts as a registered nurse needsto be planned for. Successful completion of thebranch programme and the course as a whole willallow you entry in the nurses part of the NMCregister. The NMC register has three parts:

• Nurses• Midwives• Specialist Community Public Health Nurses.

And finally – career advice, support and prepara-tion for the transition between being a student andbecoming a registered nurse is a key focus. Makingthe all important career choices is explored inChapter 9, but the influences for these first postchoices will often relate to placements that havebeen part of the course and the positive relation-ships, experiences and feedback received fromregistered practitioners and course lecturers.

Whatever your decision and wherever yourfirst post takes you, this marks the beginning of avaluable, worthwhile career. May you grow andbenefit from it as well as find satisfaction fromsupporting those who are vulnerable and in vary-ing states of health.

REFERENCESDepartment of Health (2000) The NHS Plan. London: DoH.Department of Health (2003) Financial Help for Health Care

Students, 6th edn. London: DoH.Department of Health (2004) The NHS Improvement

Plan: putting people at the heart of public services.London: DoH.

Department of Health (2005) The NHS Improvement Plan:putting people at the heart of public services: executivesummary. London: DoH.


Henderson V (1966) The Nature of Nursing. New York:Macmillan.

Nursing and Midwifery Council (2002) An NMC Guide forStudents of Nursing and Midwifery. London: NMC.

Nursing and Midwifery Council (2004a) Standards of Proficiency for Pre-registration Nursing Education.London: NMC.

Nursing and Midwifery Council (2004b) The NMC Code ofProfessional Conduct: standards for conduct, perform-ance and ethics. London: NMC.

Royal College of Nursing (2004) The Future Nurse: the RCNvision. London: RCN.

ANNOTATED FURTHER READINGBurnard P (2002) Learning Human Skills. An experiential

and reflective guide for nurses and health care profes-sionals, 4th edn. Oxford: Butterworth-Heinemann. Thisbook supports two important themes for nurses: thedevelopment of effective nurse–patient relationships andlearning through reflective practice.

Cronin P, Rawlings-Anderson K (2004) Knowledge forContemporary Nursing Practice. London: Mosby. Thisbook is a useful introduction to the relationship betweennursing knowledge and nursing practice. Reference tokey writers on nursing and key professional issues, e.g.how care is managed, is included.

Hinchliff S, Norman SE, Schober JE (eds) (2003) NursingPractice and Health Care, 4th edn. London: Arnold. A pop-ular and comprehensive text for all student nurses prepar-ing for registration. It provides essential information in 19chapters relating to a wide range of professional issuesincluding patient care, professional development and caredelivery as they relate to the NMC competency framework.

Lanoe N (2002) Ogier’s Reading Research, 3rd edn.Edinburgh: Ballière Tindall. It is a professional require-ment to apply up-to-date information and research topractice. This book is a valuable introduction to this andto the process of research appreciation.

Nursing and Midwifery Council (2004) Guidelines for theAdministration of Medicines. London: NMC. The NMCproduces a range of publications to support professionalpractice and professional development for registerednurses. This document contains guidelines relating to theadministration of medicines.

Nursing and Midwifery Council (2005) Guidelines forRecords and Record Keeping. London: NMC. As above,these guidelines support standards for record keeping.

Royal College of Nursing (2004) The Future Nurse: the RCN vision. London: RCN. A brief but valuable account of issues relating to nursing and the future role of nurses.

Whitehead E, Mason, T (2003) Study Skills for Nurses.London: Sage. This is one of a range of texts aimed at sup-porting the study necessary during a course and covers anumber of important skills including time management,exam technique, producing assignments and reflectivepractice.

USEFUL WEBSITESNational library resources and key sources of information

NHS knowledge grid for healthEngland: www.library.nhs.ukN Ireland: www.honni.qub.ac.ukScotland: www.elib.scot.nhs.ukWales: www.wales.nhs.ukNational Service Frameworks. National standards for care

groups and services available at www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics – theseinclude coronary heart disease, cancer, paediatric inten-sive care, mental health, older people, diabetes, long-termconditions, renal and children.

National Institute for Health and Clinical Excellence (NICE).www.nice.org.uk – guidance on arthritis, asthma, cancer,diabetes, infections and infectious diseases, lung cancer,nutritional disorders and violence.

Professional issues, Agenda for Change

For further general informationDepartment of Health. www.dh.gov.ukNHS Modernisation Agency. www.modern.nhs.uk/agendafor

changeNursing Standard. www.nursing-standard.co.ukRCN Agenda for Change. www.rcn.org.uk/agendaforchangeNHS Scotland. www.show.scot.nhs.uk/sehd/paymodernisation/

AfC/index.htmNHS Wales. www.wales.nhs.ukThe Northern Ireland Executive. www.nics.gov.uk/

Useful websites 9

www.library.nhs.uk

www.honni.qub.ac.uk

www.elib.scot.nhs.uk

www.wales.nhs.uk

www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics

www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics

www.nice.org.uk

www.dh.gov.uk

www.modern.nhs.uk/agendaforchange

www.nursing-standard.co.uk

www.rcn.org.uk/agendaforchange

www.show.scot.nhs.uk/sehd/paymodernisation/AfC/index.htm

www.show.scot.nhs.uk/sehd/paymodernisation/AfC/index.htm

www.wales.nhs.uk

www.nics.gov.uk/

www.nics.gov.uk/Useful

www.modern.nhs.uk/agendaforchange


Professional Issues andImplications for PracticeCarol Ash

2

INTRODUCTIONIndividuals entering or considering application to apre-registration nursing programme in higher edu-cation need to be aware that as well as embarking ona nursing career they are also preparing to becomemembers of a profession. In practice, this means thatone learns nursing within the framework and stan-dards published by the regulatory body, the Nursingand Midwifery Council (NMC, 2004a).

The route to registration and the license to prac-tise is clearly defined through the NMC (2004b)standards of proficiency for pre-registration nurs-ing education including practice and conduct (seeAppendix 1).The educational standards set by theNMC apply to pre-registration students at the entrypoint to an educational programme as the NMCis empowered to determine the entry level, typeand length of the programme (NMC, 2004b).

The implications for students preparing for regis-tration and the licence to practise are detailed in thepublication An NMC Guide for Students of Nursingand Midwifery (NMC, 2002a; see Appendix 3).Thisleaf let gives brief guidelines for students on therole and functions of the NMC and also providesclear guidance on clinical experience for students.The overall aim of the NMC is to establish andimprove standards of nursing care to protect thepublic.Therefore, nursing students should familiar-ize themselves with the guidelines for professionalpractice identified in The NMC Code of ProfessionalConduct: standards for conduct, performance andethics (see Appendix 2). The code of professional

conduct handbook (NMC, 2004a) has beenincluded in Appendix 2 but it can also be obtainedfrom the university providing the educational pro-gramme or from the NMC website.

Nurses must respond to the changing health careneeds of the patients and communities they serve(NMC, 2004b). Therefore, education for nursingpractice must be designed to meet the needs ofhealth services as well as the specific needs of theprofession. The demands of professional practiceare increasingly complex in terms of the rapidlychanging nature of health care provision and theexpectations of patients and communities.The aimof this chapter is to explore the professional back-ground to nursing and the implications for studentspreparing for a nursing career. The key areas thatwill be explored in this chapter include:

• Nursing as a profession• The framework for professional practice• Professional self-regulation and accountability

for practice• The role of professional organizations and trade

unions• Dilemmas and conflicts in practice.

NURSING AS A PROFESSIONTraditionally a profession has been characterizedby the provision of a unique service to societyrequiring specialized knowledge and skills, and thecontrol of education and standards of practicethrough a statutory body.Additionally, a profession

usually protects the public interest through a codeof professional conduct based on ethical and legalprinciples (Davies, 1995). Examples include theprofessions of medicine and dentistry. These areacknowledged as professions because educationand preparation of practitioners has been charac-terized by a lengthy full time university educationas well as the development of clinical competencewithin clinical practice settings. Professional prac-tice is underpinned by research and the evidenceis used to support practice. Many practitioners par-ticipate in the research process, therefore increasingthe knowledge base in their particular area of prac-tice. These recognized professions are also self-regulating and have developed and maintainedprofessional autonomy.

The principle whether nursing can be definedas a profession continues to be debated by studentsand registered nurses.Twenty years ago, Jane Salvagequestioned whether nursing should want to be aprofession and challenged nurses to define the termprofession (Salvage, 1985). Nursing has struggledin the past to develop a body of knowledge that isuniquely nursing knowledge. However, the adventof funded nursing research and the developmentof university-based education for students and regis-tered nurses has assisted nursing in the quest forprofessional recognition.

It may be helpful here to distinguish betweenprofessional conduct commonly referred to as pro-fessionalism and professionalization.The latter termis generally understood to be the route that an occu-pational group takes to establish the rules, standardsand procedures of a profession (Davies, 1995).

The central role of nursing is to care for patientsand the professional and caring side of professionalpractice is at the core of nursing. Professionalismneeds to be informed by models of caring. New pro-fessionalism promotes partnerships with patientsand the empowerment of patients as being moreimportant than the role of the expert (Davies,1995). Partnerships with patients are based on thispremise and care management is a joint endeavourbetween patient and nurse. This principle under-pins modern nursing with the registered nurseacknowledging personal and professional account-ability for practice.

Registered nurses act as role models for studentsas well as mentors and assessors of practice. Davies

(1995) argues that students of nursing learn to actin a professional way in their everyday work withpatients and colleagues. However, students mustlearn to practise nursing in accordance with theNMC code of professional conduct (NMC, 2004a)within an ethical and legal framework that ensurespatient interest and well-being.

Development of nursing as a profession

The history of nursing has been well documented(Baly, 1997). Students may gain insights andenhance their understanding of the influences onthe developments in nursing by reading some of thesuggested texts listed at the end of the chapter. Keylandmarks (Box 2.1) will be identified in this partof the chapter in terms of the progression towardsprofessional registration and self-regulation.

12 Professional Issues and Implications for Practice

Summary

• Professions require specialized knowledgeand skills.

• Education and standards of practice areregulated by a statutory body.

• A code of professional conduct based onlegal and ethical principles determinesprofessional behaviour (Davies, 1995, p. 133).

Box 2.1 Key landmarks influencingthe development of nursing asa profession

• Nurse Registration Act 1919• Nurses, Midwives and Health Visitors Act

1979, amended in 1992• The United Kingdom Central Council for

Nursing,Midwifery and Health Visiting codeof professional conduct (1984)

• The United Kingdom Council for Nursing,Midwifery and Health Visiting Commissionfor Nursing, and Midwifery Education(1999)

• The Nursing and Midwifery Council (2002)

The Nurse Registration Act 1919A register for nurses was established before 1889for women who had undertaken a year’s training.Subsequent campaigns by prominent nurse lead-ers and medical practitioners of the time resultedin The Nurse Registration Acts of 1919 and thefirst principles of nurse registration and regulationemerged as a result of these Acts of Parliament.

Subsequently, the formation of the general nurs-ing councils gave responsibility to the councils forprofessional discipline and regulation. Standards oftraining were established for nurses to register asqualified practitioners (Glover, 1999). This was animportant landmark for nursing as the frameworkfor professional self-regulation was established aswell as the acceptability of nursing as a reasonablecareer.

United Kingdom Central Council forNursing, Midwifery and Health Visiting

The general nursing councils existed for over 50 years until the Nurses, Midwives and HealthVisitors Act of 1979 resulted in the establishmentof the United Kingdom Central Council (UKCC)for Nursing, Midwifery and Health Visiting and thefour national boards for England,Wales, NorthernIreland and Scotland.The UKCC was established in1983, although it had existed in shadow form since1981. This regulatory body replaced nine otherstatutory training bodies which had existed by Actsof Parliament or ministerial decisions whose powershad been fragmented across professions and theUK.The new statutory body, was now responsiblefor maintaining the register for nurses, midwivesand health visitors (Pyne, 1995).

The UKCC recognized that its main responsibil-ity was to protect the public through standards ofeducation, training and professional conduct. TheNurses, Midwives and Health Visitors Act 1979clearly stated that the principal function of thecouncil was to establish and improve standards oftraining and professional conduct for registerednurses, registered midwives and registered healthvisitors.A statutory instrument (Rule 18a) formal-izing the level at which a registered nurse couldperform and personal accountability for practicewas acknowledged.

Development of self-regulation andprofessional accountability

The first code of professional conduct was imple-mented in 1984 and the principle of professionalaccountability of registered nurses was estab-lished (Dimond, 1995).The guiding principle wasthat upon registration and following educationand training, patients could reasonably expect anurse to be competent and to be able to practisesafely. Additionally, registered nurses had a dutyof care to their patients by the very nature of thenurse–patient relationship (Glover, 1999).The dutyof care principle and implications for registerednurses and students will be discussed in moredetail later in this chapter.

The Nurse,Midwives and Health Visitors Act wasamended in 1992. The amended Act reinforcedthe principles of professional self-regulation to beexercised in the public interest. Changes to the con-stitution were made which allowed for two-thirdsof the membership of the council to be democrat-ically elected by the professions and one-third to beappointed by the Secretary of State. Rule 18 of theNurses, Midwives and Health Visitors AmendmentAct (1992) determined that practice should beunderpinned by identified competencies.

A number of separate criminal cases, involvingdoctors and nurses in the early 1990s attractedmedia attention and public interest. The govern-ment subsequently commissioned an independentreview of professional regulation and the report waspublished in 1998 (JM Consulting, 1998).The per-ception at that time was that there was a need tomake professional self-regulation more responsive,open and accountable in terms of public confidence.The report provided the basis for the most recentreforms in professional regulation and resulted inthe demise of the UKCC and the establishmentof the NMC in 2002.

The Commission for Nursing and Midwifery EducationNursing and Midwifery Education was integratedinto higher education in the early 1990s, and a new curriculum, Project 2000, was implemented.Nursing students were able to access the resourcesof higher education institutions (HEIs) in pursuit of an academic and professional qualification.

Nursing as a profession 13

A subsequent evaluation of Project 2000 raisedsome concerns among employers and the public interms of a nurse’s fitness to practise at the point ofregistration. As a result, the UKCC Commissionfor Nursing and Midwifery Education were asked‘to prepare a way forward for pre-registrationnursing and midwifery education that enables fitness for practice based on health care need’(UKCC Commission for Nursing and MidwiferyEducation, 1999, p. 2).

The commission recognized that the basic prin-ciples of Project 2000 were sound in terms of thepreparation of practitioners to participate in theplanning, assessment and development of services.However, the perception of employers and to someextent the public, was that newly qualified nursesdid not possess the practice skills expected of them.This situation improved when registrants gainedexperience after a short time in work (UKCC,1999).

Employers concerns were addressed through a re-focusing of pre-registration programmes on outcomes-based competency principles whichhave subsequently been developed by HIEs in closecollaboration with service providers.The effectivedelivery of integration of theory and practice withinthe educational programme was considered to bevital to produce ‘knowledgeable doers’ (UKCC,1999).

Increased f lexibility in terms of access by stu-dents from differing personal, academic and voca-tional backgrounds to educational programmes wasrecommended. In addition, closer working partner-ships between HIEs and service providers was con-sidered to be important in support of teaching andlearning in practice (UKCC, 1999).

Establishment of the Nursing andMidwifery CouncilA smaller council and a streamlined regulatoryframework for nurses, midwives and health visit-ors was established following an interim councilthat managed the change for a two-year period.Thefour national boards were disbanded and the cur-rent Nursing and Midwifery Council became oper-ational in April 2002.The NMC is required by theNursing and Midwifery Order (2001) to establishand maintain a register of qualified nurses and mid-wives and to establish standards of proficiency

required by entrants to the different parts of theregister to ensure safe and effective practice. TheNMC also has additional powers to deal with pro-fessional misconduct and individual health issues,and employers and the public are able to establishthe status of nurse registrants.

The professional register was simplified in 2004.There are now three parts to the register for nurses,midwives and specialist community public healthnurses. Additionally, new registrants will be iden-tified in terms of the branch in which the standardsof proficiency have been met (NMC, 2004a).Details of the structure and functions of the NMCcan be found in Appendix 2.

FRAMEWORK FOR PROFESSIONALPRACTICENursing is a profession grounded in practice, there-fore,professional competence is mandatory in termsof fitness to practise as a registered nurse.The NMCpublication (NMC, 2004b), defines the standards ofproficiency for pre-registration education and linksfitness for practice to fitness for purpose, profes-sional academic awards and professional standing.

Fitness for practice is generally understood tomean the achievement of the required standards ofproficiency (previously competencies) in prepar-ation for entry to the professional register. Fitnessfor purpose is linked to the ability of registerednurses to respond to the changing needs of thehealth service and the communities that they serve(NMC, 2004b). In practice, registered nurses shouldbe able to function competently in clinical practice,


Summary

• Nurse Registration Act 1919 establishedthe first principles of nurse registration;standards of training identified.

• Nurses, Midwives and Health Visitors Act1979, amended 1992.

• First code of professional conduct forNurses, Midwives and Health Visitors in1984.

• Nursing and Midwifery Council established in 2002.

and accept responsibility for their professionaldevelopment.

The NMC provides a confidential professionaladvice service for registered nurses and midwivesas well as other health care workers and the pub-lic.Advice is focused on the NMC’s standards andguidelines for practice, education and conduct(NMC, 2002b).

Standards of education and proficiency

Educational programmes are based on the principlethat nursing is practice based with patient/clientsat the centre of care. Guiding principles (Box 2.2)relate to the professional standards of proficiencyand fitness to practise.The standards of proficiencymust be reflected in all programmes of preparationfor the register, and students must achieve the stand-ards of proficiency in a specific branch of nursingbefore they can apply for registration. Formerly, thestandards of educational and practice outcomeswere known as competencies (NMC, 2002b).Thecompetencies have now been adopted as standardsof proficiency (NMC, 2004b).

The standards of proficiency are underpinnedby standards of education with four related domains(Box 2.3). The domains may apply to more thanone standard of proficiency. The standards of pro-ficiency are incremental in terms of entry to thebranch programmes and subsequent completionof the educational programme. It is essential that

students develop the knowledge and skills under-pinning clinical practice in combination with anunderstanding of the professional role. Nursing careis delivered within a professional practice frame-work consistent with the values of the professionalgroup (Fryer, 2003).

The implications for nursing students are thatthey learn nursing within this framework and arenovice members of the group. The NMC (2004b)code of professional conduct provides the frame-work for registered nurses in terms of standards,conduct and performance, therefore, studentsshould use the code as a key reference point. Theprimary aim of the NMC and the profession is toensure that students practise nursing safely andeffectively ensuring that the public is protected.

Continuing professional development

An essential feature of professional practice is theneed for continuing professional development.Registered nurses must accept responsibility fortheir continuing education and life-long learning.They are now required to demonstrate responsibil-ity for their own learning through the developmentof a portfolio of learning and practice and recogni-tion of when further learning and development maybe required (NMC, 2002c). The maintenance ofprofessional knowledge and competence is not an

Framework for professional practice 15

Box 2.2 Guiding principles for nurseeducation (NMC, 2004b, p. 23)

• Evidence should inform practice• Students are actively involved in nursing

care delivery under supervision• The NMC Code of Professional Conduct:

standards for conduct, performance andethics, applies to all practice interventions

• Skills and knowledge are transferable• Research underpins practice• The importance of life-long learning and

continuing professional development isrecognized

Box 2.3 The four domains

• Professional and ethical practice• Care delivery• Care management• Personal and professional development

Source: NMC, 2004b, pp. 26–34

Reflective activityIdentify the following: (i) the key principles interms of the license to practise nursing (ii) thefour professional domains where students needto achieve standards of proficiency and (iii) thekey responsibilities of the registered nurse in thecontinuation of fitness for practice.

option for registered nurses. This requirement isstated in the code of professional conduct (NMC,2004a) and is a condition for continuing registra-tion and the licence to practise (see Chapter 9).

Current developments in the NHS

Current developments in the National HealthService (NHS) include the establishment of theNHS Modernisation Agency supporting the currentmodernization of the NHS as the major providerof health care in the UK.The present governmentagenda is to improve and monitor the patientexperience at different levels of care. Examplesinclude the reduction of patient waiting times forsurgery and in out-patient departments.The estab-lishment of foundation hospitals is a governmentinitiative designed to give flagship hospitals moreautonomy and financial control.

The NHS Plan (Department of Health (DoH),2000) and The NHS Plan – an action guide fornurses, midwives and health visitors (DoH, 2001)are strategic plans aimed at the provision of ahealth service focused on the needs of patients. Aseries of documents aimed at different profes-sional groups within the NHS identifies organiza-tional and professional needs to be addressed toimprove services and to provide opportunities forstaff. Similarly, ‘Agenda for Change’ determinesnew frameworks for the employment of nurseswithin the NHS in terms of pay and employmentconditions. ‘Agenda for Change’ (DoH, 2004)recognizes the contribution of nurses as key play-ers in the delivery of effective health care.

Modern nursing is now supported by a philoso-phy and practice focused on the promotion ofstandards of nursing care and the quality of ser-vice offered to patients and clients.Therefore, col-laboration with other agencies, for example, NHStrusts, voluntary organizations and other health careprofessionals is vital if students are to learn nurs-ing to the required standards of proficiency and towork within multi-disciplinary teams (see examplein Box 2.4). Students will also need to understandthe clinical and professional roles of other healthworkers and to respect and use the knowledge andskills necessary for effective patient care.

The complex and rapidly changing health careenvironment needs to be informed by evidence to

support practice (NMC, 2004b). This principlerequires students and registered nurses to searchfor the best available evidence, using research out-comes and evidence emerging from practice.

PROFESSIONAL SELF-REGULATIONAND ACCOUNTABILITY FOR PRACTICEThe core function of the regulatory body, the NMC,is to establish and improve the standards of nursing,midwifery and health visiting to protect the public.Its key tasks include (NMC, 2002a):

• maintaining a register for all nurses, midwivesand health visitors

• setting standards and guidelines for nursing,midwifery and health visiting education, prac-tice and conduct

• providing advice on professional standards forregistrants


Box 2.4 The multi-disciplinary team

• Nurses: specialist community public healthnurses and midwives

• Doctors• Physiotherapists• Radiographers• Pharmacists• Occupational therapists• Technicians• Significant others

Summary

• Students learn nursing supported by anacademic programme provided by an HEIin combination with learning in practice.

• Students must complete the educationalprogramme and achieve the NMC (2004b)standards of proficiency before they areeligible to be considered for registrationon the professional register.

• Students learn nursing within a professional framework that is determinedby the regulatory body, the Nursing andMidwifery Council (NMC, 2004a).

• providing quality assurance for nursing and midwifery education

• consideration of allegations of misconduct or unfitness to practise due to ill health.

The powers of the NMC are detailed in theNursing and Midwifery Order 2001 and are avail-able to students on the NMC website (www.nmc-uk.org).

The NMC Code of Professional Conduct

The NMC Code of Professional Conduct: standardsfor conduct, performance and ethics sets the stand-ards for practice and defines the responsibilities ofaccountable registered nurses (NMC, 2004a). Thecode is clear that registered nurses should act at alltimes in a manner to safeguard and promote theinterests of individual patients and clients and toenhance the reputation of the profession.The codeprovides a framework for professional decision-making, therefore, professional behaviour is gov-erned by explicit standards. The purpose of TheNMC Code of Professional Conduct: standards forconduct, performance and ethics (p. 4) is to:

• inform the professions of the standard of pro-fessional conduct required of them in the exer-cise of their professional accountability

• inform the public, other professions and employ-ers of the standard of professional conduct theycan expect of a registered practitioner.

Accountability has been defined as ‘therequirement that each nurse is answerable andresponsible for the outcome of his or her profes-sional actions’ (Pennels, 1997). The NMC statesthat registered nurses, midwives and specialistcommunity public health nurses are personallyaccountable for their practice and answerable fortheir actions and omissions regardless of advice ordirections from other health care professionals(NMC, 2004a). Nurses are also accountable to(Dimond, 1995):

• the patient – through a duty of care, and thecommon law of negligence and through civil law

• the public – through criminal law• the profession – through The NMC Code of

Professional Conduct: standards for conduct,performance and ethics

• the employer – through contract law.

Duty of care

The duty of care principle has been established formany years. Nurses have a duty of care to theirpatients when there is a pre-existing relationshipbetween nurse and patient and the patient haspresented for potential treatment or care or hasaccepted treatment or care. The duty of care isunderpinned by the concept of ‘reasonableness’which is the standard defined by the law (Glover,1999). The NMC (2004a) defines the concept of‘reasonable’ by citing the case of Bolam v FriernBarnet Hospital Management Committee (1957):

The test is the standard of the ordinary skilledman exercising and professing to have that special skill. A man need not possess the highestexpert skill at the risk of being found negligent.… it is sufficient if he exercises the skill of anordinary man exercising that particular art.

This definition is referred to as the Bolam Testand arose out of case law and applies to all healthprofessionals including nurses.The registered nursehas discharged the duty of care if the actions car-ried out are reasonable. However, the duty of caremay be breached through an act or omission thatis usually foreseeable in terms of causing injury tothe patient (Dimond, 1995).

This definition has established the principle ofpersonal and professional accountability for regis-tered nurses in practice, and has been used in legalcases involving alleged professional negligence.However, if registered nurses practise within theterms of their employment and guidelines definedby their employers, vicarious liability on the partof the employer may apply if a patient pursues acivil claim against a nurse. This means that theemployer will take legal responsibility for the regis-tered nurse’s actions if the actions took place during their employment. The NMC (2004a)advises registered nurses to establish their insur-ance status and if their employers do not acceptvicarious liability then the regulatory body rec-ommends that registrants obtain professionalindemnity insurance.

Implications for nursing studentsPre-registration students are not professionallyaccountable because they are not qualified or

Professional self-regulation and accountability for practice 17

www.nmc-uk.org

www.nmc-uk.org

eligible to register with the NMC.Therefore, nurs-ing students cannot be professionally accountablefor their actions or omissions by the NMC.The reg-istered nurse supervising the learning activities ofa student is professionally responsible for the actionsor omissions of students (NMC, 2002a). However,students are personally accountable for their actionsor omissions and can be held to account by theuniversity providing the educational programme, orby the law (NMC, 2002a).

It is essential that nursing students understandthat they should learn nursing practice through thedirect supervision of a registered nurse. Althoughstudents are not professionally accountable they areresponsible for their actions. Registered nurses areaccountable for delegated activities but the NMCguidance for students states clearly that they shouldonly work within their level of understanding andcompetence and always under the direct supervi-sion of a registered nurse (NMC, 2002a). Studentsshould also acknowledge that patients have the rightto refuse to allow students to participate in theircaring and the rights of patients have priority overthe students’ rights to knowledge and experience(NMC, 2002a).

ROLE OF PROFESSIONALORGANIZATIONS AND TRADE UNIONSProfessional organizations and trade unions play a vital role in the support of nurses in terms ofemployment conditions, including pay and work-ing conditions as well as improved education.They are also instrumental in terms of influencingdecision-making and represent nurses at the highestlevels of management and policy making (Salvage,2003).

The Royal College of Nursing

The Royal College of Nursing (RCN) was foundedin 1916 and is an accredited independent profes-sional union, working with political parties in theinterests of patients and nurses. On its website theRCN states that it is ‘the leading professional unionfor nursing’ and campaigns on behalf of the pro-fession, inf luencing the development of nursingpractice. The RCN is also active in lobbying thegovernment in safeguarding the interests of patientsto ensure that the views of the profession are heard(RCN, 2005).

The college is managed by nurses and workslocally and internationally to promote nursing asa profession as well as the interests of individualnurses. The objectives of the Royal Charter aredetailed on the RCN website (www.rcn.org.uk).The RCN offers a wide range of services for regis-tered nurses and students (Box 2.5).

The RCN legal services offer an indemnityservice that provides cover for students as well asother RCN members. Details of the scheme canbe found on the website. The conditions for stu-dents are that they only undertake responsibilitiesthat they have trained for and feel competent toperform under supervision. This is an importantpoint and students should refer to the NMC(2002a) guide for students of nursing and mid-wifery (see Appendix 3). All student members ofthe RCN are automatically members of the RCNAssociation of Nursing Students and have access


Reflective activityDefine the personal and professional account-ability of the registered nurse and the personalaccountability of students for their practice.

Discuss the rights of patients, and the legal dutyof care to patients, the public, employers and theprofession.

Box 2.5 RCN services

• Advice on work-related problems• Legal representation• Education and professional development

activities• Professional advice• Counselling and personal advice service• Immigration advice• Support and activities for nursing students• Free publications on nursing• Health care and employment issues (largest

library in Europe)

www.rcn.org.uk

to RCN-trained stewards representing studentsand staff on the campuses of most HEIs.

Other trade unions and organizations

UNISON is one of the larger trade unions andmembers work in the NHS, colleges and schools,the police force and other public sector services. Itdiffers from the RCN as the membership is opento all public sector workers, with health care mem-bership comprising one of six employment groups.

Unions address issues such as discrimination in the work place and negotiate agreements thatimprove the working lives of members. UNISONbenefits include representation for members, legalservices, education and training advice, as well ashelp with pay and conditions of service. Addition-ally, UNISON offers health and safety advice andis also known for campaigning and lobbying on keyissues affecting members and the public. It is alsothe largest union affiliated to the Trades UnionCongress (TUC).

The TUC claims that ‘it campaigns for a fair dealat work and for social justice at home and abroad’(see www. tuc.org.uk). Students may obtain fur-ther information from the TUC website and thewebsites of the organizations listed there.

Other professional associations and organizationshave been established representing the interests ofnurses working in clinical and non-clinical special-ities. Examples include associations representingtheatre nurses, critical care nurses, and nurses work-ing in accident and emergency departments. Simi-larly, specialist community public health nurseshave their own organization. The RCN has alsoestablished research, education and practice forumsfor the exchange of ideas and the promotion of

developments in practice. Representatives of theRCN and other unions visit higher education sitesto communicate the benefits of joining their unions.Students need to gain information in terms ofmembership benefits and costs and avail themselvesof the opportunity to discuss these details with theunion representatives.

DILEMMAS AND CONFLICTS INPRACTICEMembers of the public and patients do not alwaysunderstand the distinction between registered nur-ses, student nurses, and other health care person-nel working in health care environments.The NMCrecently reported that it had received enquiriesrelating to the use of the title of ‘nurse’ (NMC,2005). The title of nurse is not prohibited by law,however, the title of ‘registered nurse’ is protectedby the Nursing and Midwifery Act 1983 and it is acriminal offence to falsely and deliberately presentas a registered nurse or midwife.The NMC suggeststhat the title of nurse has major implications forpatients, employees and employers as patients havethe right to expect and demand the level of edu-cation, skills and knowledge from any person whouses this title.

The dilemma for student nurses is that patientsand relatives may be unaware of their student sta-tus and seek information and professional adviceinappropriately.This is particularly important whenpatients and relatives are distressed and are unhappyabout treatment or care or when a complaint isbeing made. Nursing students are advised by theNMC (2002a) to introduce themselves accuratelyto patients directly or on the telephone and tomake it clear to patients and the public that theyare pre-registration students and not registeredpractitioners. The advice of a registered nurse,preferably the supervising nurse, should be sought ifpatients are unhappy about their treatment or care.

Students should be aware of local complaintsprocedures. Shortages of qualified nursing staffand the resulting pressures of an excessive work-load may place additional pressures on studentnurses. Students are advised by the NMC (2002a)not to participate in any procedure for whichthey have not been fully prepared or have been

Dilemmas and conflicts in practice 19

Reflective activityDefine the role of professional organizations and trade unions influencing the development ofthe NHS.What are the advantages/disadvantagesof belonging to a professional organization ortrade union?

What is professional indemnity and when is itnecessary?

www.tuc.org.uk

adequately supervised. Students should discussissues with their supervising nurse as soon as pos-sible and with the link lecturer from the HEI. It isimportant to communicate concerns in terms ofpatient safety and it is vital that students shouldbe advised to exercise caution if they are unsureof their proficiency in particular situations.

Students should also familiarize themselves withthe local policies for the handling and storage ofrecords (NMC, 2002a). Entries to patient recordsby students should be counter-signed by a regis-tered nurse. In addition, students should not refer toconfidential information in their written assign-ments that could identify patients. Students mustwork within the framework of the code of profes-sional practice (NMC, 2004a) and protect confi-dential information.

The nature and extent of supervision of stu-dents by registered nurses in practice areas hascaused some concerns to students mainly due tothe shift patterns of supervising nurses as well asstaff sickness and annual leave. However, studentsshould discuss supervision issues with their prac-tice supervisors and link lecturers at the HIE aswell as nurse managers when appropriate.

It is in the best interests of students on entry tothe educational programme to read the studentregulations and familiarize themselves with thecurriculum as well as the guidelines for the attain-ment of the academic award. Guidelines are avail-able in terms of the criteria for the presentationand completion of written assessments and theachievement of practice outcomes, as well as theresources available to students for academic sup-port. The RCN Association of Nursing Studentshas detailed information on its website in terms ofissues of interest to nursing students. Other sup-port mechanisms for students are also detailed inChapter 8 of this book.

Student nurses come from different age groups,and educational and cultural backgrounds. Thisdiversity adds a wealth of human experience to astudent nurse’s educational experience as well asfuture nursing practice. Many students have exter-nal responsibilities such as part-time employmentand the need to care for other family members.Personal conflict may occur between the effort required to achieve the required standards of pro-ficiency in practice and the attainment of the

academic award, as well as managing responsibil-ities external to the university.Additionally, studentsare encouraged to participate in the social side ofuniversity life.The management of these prioritiesis an issue that students need to reflect on andaddress in terms of allocating dedicated time forstudy.

Students learning nursing are also learning tobecome professional practitioners within a complexhealth care environment. Many students respondto these challenges positively and are able to lookforward with optimism to an interesting and ful-filling career in nursing. Nursing offers an excitingvariety of career opportunities and further detailsare explored in Chapter 9.

GLOSSARYIn the context of this chapter the meanings of the followingwords are described:Accountable Responsible for something or someoneCompetent Possessing the skills and abilities required

for lawful, safe and effective professionalpractice without direct supervision

Evidence-based Analysing, critiquing and using researchpractice and other forms of evidence for practicePatient/client Any individual or group using a health

servicePractice-centred Programmes of preparation are directedlearning towards the achievement of proficiency


Summary

• Students should practise nursing withinthe standards identified by The NMC Codeof Professional Conduct: standards forconduct, performance and ethics.

• Students should not participate in anyprocedure when they are not fully prepared or have not been supervised.

• Students should discuss problems in practice with their nurse supervisor andpersonal tutor.

• In written assignments students shouldnot refer to confidential information thatcould identify patients.

• Students need to prioritize responsibilitiesand allocate time for continuing study.

Standards of Standards to be met by applicants to proficiency different parts of the professional regis-

ter. Standards necessary for safe andeffective practice. Previously referred toas competencies

Theory and Theoretical knowledge that underpins practice practiceintegration

REFERENCESBaly M (1997) Florence Nightingale and the Nursing Legacy.

London: Whurr Publishers.Bolam v Friern Barnet Hospital Management Committee

(1957) In: The NMC Code of Professional Conduct: stand-ards for conduct, performance and ethics. London: NMC (p. 5).

Davies C (1995) Gender and the Professional Predicament inNursing. Buckingham: Open University Press.

Dimond B (1995) Legal Aspects of Nursing. London: PrenticeHall.

Department of Health (2000) The NHS Plan. London: DoH.Department of Health (2001) The NHS Plan – an action guide

for nurses, midwives and health visitors. London: DoH.Department of Health (2004) Agenda for Change: final

agreement. London: DoH.Fryer N (2003) Principles of Professional Practice. In:

Hinchcliff S, Norman SE, Schober JE (eds), Nursing Practiceand Healthcare, 4th edn. London: Hodder Arnold.

Glover D (1999) Accountability. Nursing Times Monographs.No.27.

JM Consulting (1998) The Regulation of Nurses, Midwivesand Health Visitors. Bristol: JM Consulting Ltd.

Nurses, Midwives and Health Visitors Act (1979) London:HMSO.

Nurses, Midwives and Health Visitors Amendment Act (1992)London: HMSO.

Nursing and Midwifery Order (2001), Norwich, The StationeryOffice (www.opsi.gov.uk).

Nursing and Midwifery Council (2002a) An NMC Guide forStudents of Nursing and Midwifery. London: NMC.

Nursing and Midwifery Council (2002b) Professional Advicefrom the NMC. London: NMC.

Nursing and Midwifery Council (2002c) Supporting Nursesand Midwives Through Lifelong Learning. London: NMC.

Nursing and Midwifery Council (2004a) The NMC Code ofProfessional Conduct: standards for conduct, perform-ance and ethics. London: NMC.

Nursing and Midwifery Council (2004b) Standards ofProficiency for Pre-registration Nursing Education.London: NMC

Nursing and Midwifery Council (2005) Using nurse as a title.NMC News (10) 9.

Pennels C (1997) Nursing and the Law: clinical responsibility.Professional Nurse 13(3): 162–164.

Pennels C (1998) Nursing and the Law. London: ProfessionalNurse E/Map Healthcare.

Pyne R (1995) The professional dimension. In: Tingle J, Cribb A (eds), Nursing Law and Ethics. Oxford: BlackwellScience, pp. 36–58.

Royal College of Nursing (2005) Agenda for Change – aguide to the pay, terms and conditions in the NHS.London: RCN.

Salvage J (1985) The Politics of Nursing. London: Heinemann.Salvage J (2003) Nursing today and tomorrow. In Hinchcliff S,

Norman SE, Schober JE (eds), Nursing Practice and HealthCare, 4th edn. London: Hodder Arnold.

United Kingdom Central Council (1999) Fitness for Practice.The UKCC Commission for Nursing and Midwifery Educa-tion. London: UKCC.

ANNOTATED FURTHER READINGHinchliff S, Norman SE, Schober JE (eds) (2003) Nursing

Practice and Health Care, 4th edn. London: Arnold. A com-prehensive textbook suitable for pre-registration studentsas well as registered nurses. A wide range of professionaland practice issues provide the reader with essential infor-mation including issues for reflection and debate. Thisedited book has contributions from nurses working inpractice and nurses teaching and researching in HEIs.

Tingle J, Cribb A (eds) (1995) Nursing Law and Ethics.Oxford: Blackwell Science. A useful edited book for pre-registration students analysing the legal and ethicalbackground to modern day health care from a historicalperspective. Students may use this book for reference interms of background information leading to the currentlegislation and professional regulation.

USEFUL WEBSITESDepartment of Health. www.doh.gov.ukNursing and Midwifery Council. www.nmc-uk.orgRoyal College of Nursing. www.rcn.org.ukUNISON. www.unison.org.uk

Useful websites 21

www.opsi.gov.uk

www.doh.gov.uk

www.nmc-uk.org

www.rcn.org.uk

www.unison.org.uk


Recent Developments inNursing PracticeVeronica Bishop

3

INTRODUCTIONThe aim of this chapter is to introduce the readerto recent developments in nursing practice, andhow they have influenced nursing and healthcare. Constant changes in politics and ever-increasing advances in technology have combinedto present greater challenges than ever in meetingthe health demands of the UK population.Therefore the need for practitioners to developsupport mechanisms will be stressed. Nursing hasa complex history and key landmarks are summa-rized in Table 3.1.These serve to complement thethree main sections of this chapter, which are asfollows:

• Developments in clinical practice• Research and development in nursing• Support for clinical excellence

DEVELOPMENTS IN CLINICALPRACTICE: THE LYNCHPIN OFPROFESSIONAL NURSINGThis section stresses the importance of clinicalpractice to nursing, not only with a view toimproving patient services, but also in terms ofpolitical power and the associated ability to shape

the future of the nursing profession rather than itbeing shaped by others. Examples of clinical inno-vations will be discussed, such as clinical super-vision, clinical governance and evidence-basedpractice. Relevant publications will be identifiedto assist the student to grasp a foothold in thepolitical and clinical environment which makesup the National Health Service (NHS). Keyreports include the United Kingdom CentralCouncil (UKCC) 1999 report Fitness for Practicewith its stress on clinical support, and its recogni-tion of the need for collaboration between theNHS and higher education.

Clinical practice is fundamental to nursing.Thepower and value of nursing is its ability to provideknowledgeable care, using knowledge to bring aquality dimension to a period of a patient orclient’s life that would be unlikely to be achievedby a lay person. Caring is not the prerogative ofnurses, there are many people who may providecare: ‘it is the provision of professional, knowl-edgeable care that must identify the nursing pro-fession’ (Bishop, 2001). Nursing care may be veryspecific, such as is performed by specialist nurses,e.g. a dialysis nurse or an intravenous therapynurse. However, much of general nursing practiceis very diffuse, and identification of single inter-ventions and judgement of their effectiveness issometimes impossible with existing measuring

instruments. There are so many other variableswhich cannot be controlled, such as the overallenvironment, other staff, family and so on. Thereis a view, which I share, that ‘nursing must nowface the reality that past professional strategieshave denied it the power base in clinical practiceit now requires to promote leaders who willremain in nursing practice and to have its voiceheard in the clinical decision making process’(Kyzer, 1992). A career structure, which supportsand maximizes the potential of nurses in clinicalpractice is now becoming a reality.The Agenda forChange (Department of Health (DoH) 2004, RoyalCollege of Nursing (RCN), 2005) provides nurseswithin the NHS with details of how terms andconditions of service are determined, the relationbetween grades and pay bands and how careerprogression may be supported (see also Chapter 9Useful addresses, page 121).

Never have nurses had more scope, such abreadth of areas in which to work, nor as muchpossibility for support. In 1992, the UKCC pub-lished The Scope of Professional Practice with the

aim of providing the nursing and midwifery pro-fessions with the means to develop responsiveand flexible health care services. The Scope ofProfessional Practice established the principle ofextended roles for nurses and has facilitated thepotential for nurses to determine aspects of theirown role development. The undertaking of newroles and crossing traditional barriers requires nursesto demonstrate their competence and accounta-bility.These important initiatives have shaped thecurrent strategic Nursing and Midwifery Council(NMC) developments we have today, e.g. in rela-tion to advanced nursing practice (see alsoChapter 2).

Other forces driving forward changes have beenpolicy driven, such as the reduction in junior doc-tors’ hours (NHS Management Executive, 1991)and the imperative to have a primary-care-ledNHS (NHS and Community Care Act 1990),whichhave had a significant impact on community-based staff (Jenkins-Clarke et al., 1997). While inthe view of Luker (1992) no-one was too surewhat a ‘primary-care led NHS’ meant (a view

24 Recent Developments in Nursing Practice

Table 3.1 Influencing events for nursing 1966–2000

Year Event Category

1966 Salmon Report Management1972 Briggs Report Education

Nursing Process Practice1977 Extended role of the nurse Practice1983 Creation of the UKCC Education1983 Griffiths Report Management1986 NVQ Education1988 Clinical Grading Management1990 Project 2000 Education1991 Internal Market Management1991 Nursing Development Units Research1992 Multidisciplinary Audit Practice1992 Scope of Professional Practice Education1992–1995 Integration into Higher Education Education1995 Clinical Guidelines Practice1999 Nursing Strategy Practice and Education1999 Peach Commission (UKCC, 1999) Education2000 New pay structure due Management

NVQ, National Vocational Qualification.UKCC, United Kingdom Central Council for Nursing, Midwifery and Health Visiting.

more recently echoed by Ross (2000), who recog-nized that this presented opportunities for com-munity nurses to consider new ways of working).Add to this rapidly changing NHS scenario thefact that the ‘user’ of the NHS has been verymuch at the focus, this often led to the develop-ment of nursing roles which had previously notbeen considered, where medical interventionswere not needed but professional care was.

This does not mean that nursing has arrived inan ideal professional environment – the challengesare still there! However, the culture of change neednot be seen as threatening, rather it provides aunique opportunity to embrace new ideas andcreate what Scott (2001) calls a ‘let’s have a go’mentality: in her view key to success in change is excellence in leadership at both clinical andmanagerial levels. One of the world’s richest men,Bill Gates, said in a television interview that goodleadership is about inspiring passion in colleagues.To have a passion for nursing is to embrace thechallenges that accompany any demanding careerand develop strategies to support the best of nurs-ing care. Changing health needs and patterns of careoffer unique opportunities, opportunities for thenurse–patient relationship to become stronger andless fragmented, for the nurse to offer care whichis sensitive to the cultural needs of the patients,to really make care ‘user centred’. Opportunitiesabound within the newly developing frameworksof care for health promotion and health educationto come to the fore – an undervalued aspect ofnursing which perhaps only health visitors havereally taken forward to date.

Much of the success of any individual willdepend on the vision and support of good man-agement and careful career planning. What is sogood now is that the combined efforts of membersof various bodies, such as the nursing officers in theDoH, RCN, Unison and others have roles based inclinical practice as part of career advancement innursing alongside education and managementroles. These developments grew from the WhitePaper The New NHS – modern and dependable(DoH, 1997) and a second report, perhaps mostuseful for nursing, Making a Difference (DoH,1999). Both make it clear how the government ofthe day was committed to extending developmentsin the roles of nurses. Making a Difference is an

important platform to help the nursing professionsto pursue a radical and progressive agenda (Moores,1999).This is all set in the context of clinical gov-ernance (see below), and highlights the importanceof research and development.The impact of clinicalgovernance on nurses and the responsibilitiesattached to this are discussed below.

The creation of nurse consultant posts hasbrought further recognition of nursing expertiseand attached higher salaries to these posts.Although some media reports have mocked thisinnovation, seeing it as a drop in the ocean, I sharethe view that we can only achieve the recognition,empowerment and concomitant funding for nurs-ing care if we have advanced leading practitionershighlighting our work. These posts, if properlysupported and filled by professional experts, willbe the forerunners of the qualified nurses of thefuture, and we would all do well to watch theirprogress carefully.The key roles of modern matronsare designed to have a major impact on hospitalcleanliness and reduction of the number of hospital-acquired infections.

Crossing professional boundaries and nurse-led services

There has been a move to develop nurse-led ser-vices, partly driven by the nursing profession andpartly by a supportive DoH which is anxious toconfigure services to meet as many needs of theconsumers as possible with a limited workforce.This is in part due to the reduction in junior doc-tors’ hours (NHS Management Executive, 1991;Calman, 1993) and in part due to a need to movefrom the existing models of care, which have beentraditionally medically focused, and provide amore patient-centred model of care, which isresponsive to the specific needs of patients andclients. There are many nursing practices todaywhich are either well established or are, with thenew current ethos of collaborative partnerships,breaking across old barriers. A few exampleswhich come to mind are: establishment of nurse-led clinics, collaboration of nurses with the policein the development of nurse-led assessment serv-ices at arrests, out-reach services for the sociallyexcluded, NHS Direct (the nurse-led healthhelpline), and nurse-led walk-in centres.

Developments in clinical practice 25

These developments owe much to the work ofPearson and colleagues (1995) and later to theSainsbury Family Trust funding of four nursingdevelopments units (NDUs) based on the philoso-phy of Pearson and like-minded colleagues. Nursingdevelopment units are based on the concept ofpatient empowerment, clinical excellence, innov-ation and nurse leadership. Key features of anNDU funded by the DoH are shown in Box 3.1.The subsequent DoH-funded evaluation study isextremely useful reading for the student as thereare many pertinent references to major policy ini-tiatives that have impacted on the nursing profes-sion over the past 10 years, not least The Patient’sCharter (DoH, 1991), which was the precursor ofthe strong user focus currently being promoted.

The background to the NDU programme iswell described by Vaughan (1998) and in the‘Master Class’ by Redfern and Murrells (1998).Theaccompanying review by Bond (1998) highlightingthe difficulties of research and audit is well worththe student’s attention. It affords a unique oppor-tunity to read open critique and response to peerreview – the true test of a professional approach.The NDU initiative has had a major impact onnursing services, and has been adapted by manyNHS trusts. At last, here was formal recognitionof specific nursing expertise.Yes, nurses could andwould break out of traditional moulds of task-oriented care and provide nursing which was opento change, centred on user perspectives, and basedon willingness to work in a culture of inquiry! Suchunits are still running in many areas and they werecertainly the forerunner of the numerous currentdiverse nursing initiatives.The recognition, stimu-lated by the NDU initiative, had a positive knock-on effect for clinical practice and a platform hasdeveloped which has established collaboration

between higher education and clinical areas. In animportant paper Read (1999) draws attention tothe importance of proper management planningand support which is needed to underpin the pro-vision of nurse-led services. Read has a record ofresearch in this field and had developed the strongimpression that nurse-led services often fail to reachtheir full potential, at least in part because of inad-equate management. As the profession becomesmore dynamic, and more complex, it is paramountthat each individual nurse understands his or her own accountability and legal responsibilities(Glover, 1999).

Future developments

So how will health care look from a nursing per-spective in the future? While a crystal ball wouldbe handy, it is not needed to recognize that thefocus, which is now on primary care, where previ-ously it has been on hospital care, makes for manychanges. Nurses working with general practitioners,currently the largest single group of nurses, aretaking over many of the tasks previously carriedout by doctors. This is not only in health promo-tion and triage, but also in running clinics, makingreferrals and prescribing. In the drive for seamlessservices hospitals are becoming less central andmore specialist services have developed, such asrheumatology clinics, pain clinics and well peoplewalk-in centres, many of which are nurse led.Although it cannot ever be economically viable tohave centres of excellence in highly technicalmedicine with costly equipment in every locality,service beds for minor and general surgery will beavailable in smaller hospitals, many of them pri-vately run. The ‘integration’ of the private sectorwith the NHS through the latter purchasing bedsand services is a key development.

A great challenge for the immediate future is theincrease in the older population, an increase thatis unlikely to change as life expectancy becomeslonger with healthier living and access to goodhealth care.As families become less and less stablethe effects on lone elders need to be carefully con-sidered in health planning for the future.This is butone of the many challenges for the future, a futurewhich will be determined by genetic engineering,advances in every area of technology, an increasing


Box 3.1 Nursing development unit

• Staff commitment to the NDU philosophy• Clinical development: striving for excellence• Evaluation of care• Clinical nurse leadership: management

support

population overall, and, as far as one is able to judgewithout the crystal ball, depleted natural resources.The challenges presented by this or any similar scen-ario can only be won by working collaboratively –not only across health disciplines, but also with thegeneral public, the users. The future of nursing liesin balancing expert knowledge with care, which issensitive to the needs of the consumer.

The joys of achieving this balance, in terms ofjob satisfaction, the ability to provide and deliverthe quality care which students are taught to give,will be more than repaid in terms of retention of staff, therapeutically enhanced patients andclients, and successful partnerships within thehealth care team. Historically, nursing has neverappeared to be better placed to take forward anew professional status that will empower itspractitioners to provide the care they are wellequipped to give, to take their rightful place insociety, at the bedside and at the policy table.Thiswill not be achieved by innovation alone, how-ever well publicized. This will only be achieved,in the long-term, by nursing continuing to showits reflective and dynamic abilities, and by soundresearch underpinning its practice.

RESEARCH AND DEVELOPMENT IN NURSINGThe importance of research and development inthe NHS presents a major challenge to nurses.Why? Because without evidence, scientificallyderived, to support nursing practice and to underpinstandards, there are no criteria for care provision,

and no substantive arguments for qualified staff.In a medically dominated arena nursing researchis at odds with the medical model and often penal-ized accordingly in terms of recognition and fund-ing. This section highlights the progress to dateand identifies the issues of particular importanceto nursing practice.This is discussed in the contextof clinical governance and clinical effectiveness.Issues specifically identified include utilization ofresearch findings, understanding research, workingfor a research degree, and the usefulness or other-wise in professional terms, of achieving this. Refer-ences are provided for further reading.

• What makes a good nurse?• What is effective nursing?

A policy versus practice dilemma: Have you evervisited a relative or friend in a hospital and, as youarrive at the entrance to the ward thought ‘Thisseems a good place’ or ‘Heavens, I wouldn’t liketo be a patient here!’? Most people of whom I askthis question know exactly what I mean. We aretalking about a therapeutic environment. A goodnurse contributes to that environment, as well aseffectively carrying out his or her work. A poornurse may still efficiently do their work but theireffectiveness is less, or maybe even detrimental.Pearson (1998) stated that effectiveness can beachieved in the absence of excellence. Our chal-lenge is to marry effectiveness and excellence.There is a plethora of initiatives to enhance nursingcare and service delivery, with a particular focuson evidence-based practice. It is the view of Maggs(1997) and one which needs some exploration,that nursing staff are being asked to measure out-comes of care rather than to record the process ofcare, i.e. the quality of nursing and health care deliv-ery. Donabedian (2003) stressed the equal import-ance of process with outcome. Much of nursing isprocess rather than an easily defined interventionso to disregard models of research, which ignore,because of the difficulty in measurement, the philo-sophical basis of nursing, is to disregard the activ-ities of the largest health care workforce.

Student nurses are not expected to rush off and ‘do research’, but developing a questioningapproach to practice, based on applying evidence,and watching and finding out what is going on isthe beginning of developing research mindedness.

Research and development in nursing 27

Summary

A brief history is provided on the developmentof nurse-led services, and some exampleshave been given. While the difficulties in thecreation of nurse-led services, which are notproperly supported managerially, have beenhighlighted, the benefits in terms of improvedpatient/client care and staff satisfactionfrom successful implementation of newnursing roles have been stressed.

The major difference between research and a ques-tioning approach is that research must always bedisciplined and attempt to control everything thataffects what is being studied. Reflective practice isa feature of the learning process and personal andprofessional development. It refers to the oppor-tunity for nurses to reflect, and perhaps react, andlearn from experiences. It is a feature of coursesfor nurses at all levels and encourages inquiry con-cerning practice, research application and analysisof nursing developments. This may lead to somemodification of the nurse’s original approach or amore advanced approach next time.

Evidence-based practiceDiCenso et al. (1998) define evidence-based prac-tice as follows:

In practising evidence-based nursing, a nursehas to decide whether the evidence is relevantfor the particular patient. The incorporation ofclinical expertise should be balanced with therisks and benefits of alternative treatment foreach patient and should take into account thepatient’s unique clinical circumstances.

Deighan and Boyd (1996) offer the definitionof a clinical learning strategy, and provide a sub-stantial background to the development of evidence-based health care in this country, highlighting thestrengths, and weaknesses of this approach to careprovision. In a publication aimed at nurses, mid-wives and health visitors, the NHS Executive high-lighted some of the benefits of clinically effectivecare such as improved consistency of care, shorterwaiting lists and increased value for money (NHSExecutive, 1998). Opponents of the evidence-based practice movement are concerned that itoffers a ‘cook book’ approach to care with poten-tial for rigidity. Whichever stance is taken in thedebate, most agree that evidence-based care has arole to play in reducing variation.The issue of howyou, the practitioner, are supposed to access all theavailable evidence for every patient or client is avital one which deserves far more attention thanis currently the case.

What is central to the nursing research agendais the generation of a body of knowledge, whichcan underpin excellence in care, no small challengegiven the limitations of available instruments! All

registered nurses have the responsibility to applyup-to-date knowledge to practice.

Bridging the theory–practice gapAs a practice discipline, nursing shares with theother practice disciplines, such as medicine andsocial work, the difficulty that so much of its fun-damental knowledge base originates from otherdisciplines, e.g. biology, chemistry, psychology.The‘gold standard’ method of collecting research datahas been considered by the scientific communitygenerally to be the randomized controlled trial.Thismethod employs a reductionist approach wherethe environment and all related variables are con-trolled. Clearly this cannot always be applied tonursing interventions. Nursing relies on patientexperiences, personal and cultural contexts andrelationships between patients and those who carefor them (Maggs, 1997). Carr-Hill (1997) lists cri-teria that should apply to all research in terms ofdata quality, theoretical adequacy and policy rele-vance, and suggests that the dichotomy betweenquantitative and qualitative data is overplayed.However, research into social processes raises anumber of dilemmas, one of which is the problemof subjectivity and its resulting bias (Mulhall et al.,1999). Nursing research does much to promoteunderstanding and clarity of practice-based issuesand to generate evidence for nurses to use, share,and explain and promote appropriate standards of care.

It is beyond the remit of this chapter to take youthrough the fundamentals of nursing research,however, some texts are recommended for read-ing at the end of the chapter. What I have hopedto do is to raise an awareness of the issues that sur-round nursing research and to offer pointers forfurther study, if you wish. All nurses, however,should be research aware, as a matter of profes-sional accountability, and to assist in this usefuladdresses are listed at the end of Chapter 9.

National Institute for Clinical ExcellenceEstablishing what constitutes ‘best practice’ issomething of a political minefield, for what isdeemed best from one perspective, or discipline,may not find agreement with another! Whenresources are limited, cost also plays a major partin any equation when defining best practice. Do


you fund rare and highly costly treatments for afew, at the expense of treating a bigger populationfor a greater number of minor illnesses? Attentionis being paid by the media to what is termed the‘postcode lottery’ of health care. This is due tosome health authorities funding more expensivetreatments than others. The National Institute forClinical Excellence (NICE) evolved in an attemptto neutralize some of these contentions and inresponse to the challenges presented to the healthcare professions, not least those establishing bestpractice and putting clinical governance into operation. However, as Freshwater (1999) pointsout, while a variety of available evidence is to beappraised, the scope of NICE is heavily weightedtowards medical interventions, pharmaceuticalpractice, diagnostic techniques and procedures. It isthus of particular importance that nursing includesitself in the work of NICE, so that the profession isa player in the drive towards clinical governance(see Chapter 9 Useful addresses, page 121). Onlynurses who have the education and confidence tocut through the jargon of health care research, tounderstand the key role that they play in healthcare provision, and be unafraid, open-minded andquestioning in their approach to research canachieve this. Hence it is the responsibility of theregistered nurse to understand research findingsand to question practice.

SUPPORT FOR CLINICAL EXCELLENCEIn this section, the drive for a quality NHS, whichmeets users’ needs, and supports staff in achievingthis, is discussed. The role of clinical supervision,which will encourage the accountable individualnurse to develop his or her potential, and whichwill encourage the sharing of skills, successes anddifficulties, is explained and its relevance to clinicalgovernance demonstrated.

Quality and standard setting

The drive for a quality framework in the NHS wasunderpinned by Maxwell (1984) who was a majorproponent in the UK of the work of Donabedian.However, whereas Donabedian focused equally onprocess, implementation and outcome, Maxwelland other proponents of ‘quality’ could be accused

of forgetting the importance of process and of con-centrating on outcome measures. For over 10 years‘outcomes’ in terms of waiting lists, and any otherindices which could be counted, have formed thebasis of audit and quality. Maxwell described howthe key elements which determined the quality ofhealth care were relevance, accessibility, effective-ness, acceptability, efficacy and equity (cited inMarinker, 1994). These six elements were adaptedfor clinical audit, and although none of the healthprofessions have a shared definition of audit (Koganand Redfern, 1995) it is broadly interpreted as themeasurement of professional activity which may bemeasured against predefined standards.

The former community health councils havenow been replaced: consumers of health careservices have their views represented at the locallevel and this relates to the NHS trusts.

Clinical supervision

The nursing professions have the responsibility of self-regulation; nurses who do not uphold thestandards laid down can be removed from theNMC professional register. Clinical supervision,properly implemented, offers that opportunity topractitioners to develop their practice. It is aboutempowerment rather than control, though theterm ‘supervision’ is off-putting to some, withconnotations of management looking over yourshoulder! This is NOT what clinical supervision isabout. Clinical supervision had been practised insome pockets of enlightened nursing (mainly inmental health) but was first formally introducedto the nursing professions in the early 1990s. Thereare many definitions of clinical supervision includ-ing the following devised at a workshop on clinicalsupervision:

Clinical supervision is a designated interactionbetween two or more practitioners, within asafe/supportive environment, which enables acontinuum of reflective, critical analysis of care to ensure quality patient services.

(Bishop, 1998a)

The components of clinical supervision aredescribed in full elsewhere (Butterworth, 1996;Bishop 1998b; Fowler 2003). Clinical supervision isclose in concept to mentorship and preceptorship,

Support for clinical excellence 29

with the key difference being that the supervisormay not necessarily be senior but a peer or equal.Clinical supervision pulls together most of the con-cepts which have been discussed in this chapter sofar. It embraces reflective practice, research andevidence-based practice, critical thinking, and isabout life-long learning. It is about setting personaland shared standards in care giving and takes you,the practitioner into the centre of focus during thatactivity.You matter. So what are the goals of clinicalsupervision? Platt-Koch (1986) describes them asthe expansion of the practitioner’s knowledge base,assisting in the development of self-autonomy andprofessional accountability. The ultimate aim, ofcourse, is to promote excellence in practice fromsupported and happy staff.

The perceived benefits of clinical supervisionare well described by Kohner (1994) who studiedfive DoH-funded NDUs that had implementedclinical supervision.The benefits included enhancedpatient care, professional growth with self-assuranceand confidence, broadened thinking and improvedrelationships between all health care professionals.

The concept of ‘clinical supervision’ is not yesterday’s notion – it is embedded in Making aDifference (DoH, 1999) and is pivotal to nursesmaking a real contribution in clinical governance.For this reason management must be committedto its success at every level. Clinical supervision isnot a cheap option: it requires, time, budget, man-power and training. Supervisors must be trained,and in the view of some senior nurses who haveimplemented clinical supervision, superviseesshould be trained as well. Certainly inductioncourses are needed, and the ethos of valuing staffpromoted. Shared skills and a culture of caringcritique will take nursing into this new millenniumwith unshakeable confidence and an ability to playits full part in the health care agenda.

Clinical governance

The concept of clinical governance was introducedThe New NHS (DoH, 1997), and in the subse-quent White Paper A First Class Service – qualityin the new NHS (DoH, 1998). It is described as aframework through which NHS organizations areaccountable for continuously improving the qualityof their services and for safeguarding high standards

of care by creating an environment in which excel-lence in clinical care will flourish. There are manynurses who are proponents of clinical governance,as it is seen to offer a unique opportunity forresearchers and practitioners to work together –particularly at the point of care delivery – to maxi-mize health care improvements (Boden and Kelly,1999). It is the aim of clinical governance to drawtogether all these excellent mechanisms already inexistence to support quality care from accountablestaff. A professorial colleague of mine is tremen-dously enthusiastic and refers to clinical governanceas ‘the glue, which holds the best together, andprovides the necessary transparency to see whereimprovements need to be made’. Scott (2001)describes clinical governance as a concept which isprocess driven not function-oriented, which putsthe processes of care and the patient experiences atthe heart of the new culture. Certainly it is clearthat the development of clinical governance offersclinical nurses the opportunity to influence the clin-ical agenda within a trust, equals within a multi-dis-ciplinary forum, which has not existed to date.Clinical governance, properly carried out, will putthe power of the NHS back into clinical activity,rather than in the creation of layers of managementand bureaucracy. Figure 3.1, taken from Scott(2001) expresses succinctly the key components ofthe clinical governance model.


Per

form

ance

man

agem

ent

Best practice Education andteaching

Risk

management

Clinical

effectiveness

EvidenceA

udit

Research

Figure 3.1 The core elements of clinical governancecreate the basis for good care pathways (redrawn bypermission of the publisher from Scott I (2001) Clinicalgovernance. In: Bishop V, Scott I (eds) Challenges inClinical Practice. Basingstoke, Palgrave Macmillan)

Commission for Health ImprovementThe Commission for Health Improvement (CHI)was established by the government to improve thequality of patient care in the NHS across Englandand Wales.The Commission has the brief to assure,monitor and improve the quality of patient carethrough clinical governance reviews.The CHI visitsevery NHS trust every four years. Its findings arebased on evidence from the work of the trusts andhow National Service Frameworks and NICEguidelines are being met at the local level.

CONCLUDING THOUGHTS: NURSINGFOR THE FUTUREIn drawing together all the issues raised in thischapter you will need to consider how best tooffer individualized patient care within a hierarchyof care needs; look into the future and considerwhat shape nursing may need to take to meet theneeds of society as a whole and nurses as a group.Questions of professionalism, elitism and pragma-tism should run around your mind – it would beso interesting to know your thoughts at the begin-ning of your career.

Nursing in the UK has the wind of change behindit. Consider, in the light of the recent history, whatpermutations are likely for skill mix in an economythat is struggling to support an increasingly elderlypopulation, and straining to keep up with theexplosions in technology. Will we develop into anall-graduate profession in England as the otherUK countries have done? What will identify the

‘expert’ nurse, and how best may the profession berepresented at the policy table? Perhaps the leadingquestion should be ‘How can the NHS provideindividualized patient care which is user centred,meets the demands of a knowledgeable and liti-gious society, in an economy which indicates littlesign of expansion?’ These are the real challengesto health care professionals.

Perhaps the contribution of nurses, who are thelargest group of professional staff in the NHS, willbe understood as the configuration of servicechange in response to users and career demands.Training and education programmes for studentnurses are already involving patients and families;patients from ethnic minorities are rightly influ-encing our services to their communities; sociallyexcluded individuals are at last beginning to beheard. This has a little to do with politics, and agreat deal to do with the confidence with whichour nursing profession is embracing such diverseagendas. The government has committed itself inMaking a Difference (DoH, 1999), the nationalstrategy for nursing in England, and has placedresearch highly in that portfolio. Whatever thenational priorities are, it must be a priority of theprofession to care for itself, to support each otherand to share our undoubted expertise. If we supporteach other and base our knowledge on sound edu-cation and research we can meet any challenge.

REFERENCESBishop V (1998a) Clinical supervision, what is it? In: Bishop V

(ed.), Clinical Supervision in Practice: some questions,answers and guidelines. Basingstoke: Macmillan.

Bishop V (1998b) What is going on? Results of a questionnaire.In: Bishop V (ed.), Clinical Supervision in Practice: somequestions, answers and guidelines. Basingstoke: Macmillan.

Bishop V (2001) Professional development and clinical practice. In: Bishop V, Scott I (eds), Challenges in ClinicalPractice: professional developments in nursing. Basing-stoke: Palgrave, p. 78.

Boden L, Kelly D (1999) Clinical governance: the route to(modern, dependable) nursing research? Nursing TimesResearch 4, 177–88.

Bond S (1998) Masterclass. Review. Nursing Times Research3, 289–90.

Briggs A (1972) Committee on Nursing. Cmnd. 5115. London:HMSO.

References 31

Summary

Mechanisms to support the provision ofquality care in the NHS are discussed in thecontext of nursing: quality frameworks,audit, clinical supervision and peer review,and clinical governance. Clinical governanceaims to underpin the existing frameworks,and is seen to offer nursing an opportunityto demonstrate more openly its major contribution to health care services.

Butterworth T (1996) Primary attempts at research-basedevaluation of clinical supervision. Nursing Times Research1, 96–101.

Calman K (chair) (1993) Hospital Doctors: training for thefuture. Report of the Working Group on specialist medicaltraining. London: DoH.

Carr-Hill R (1997) Choosing between qualitative and quan-titative approaches. Nursing Times Research 2, 185–6.

Department of Health (1991) The Patient’s Charter. London:HMSO.

Department of Health (1997) The New NHS – modern,dependable. London: The Stationery Office.

Department of Health (1998) A First Class Service – qualityin the new NHS. London: DoH.

Department of Health (1999) Making a Difference.Strengthening the nursing, midwifery and health visitingcontribution to health and health care. London: DoH.

Department of Health (2004) Agenda for Change: what willit mean to you? A guide for staff. London: DoH.

Deighan M, Boyd K (1996) Defining evidence-based healthcare: A health care learning strategy? Nursing TimesResearch 1, 332–9.

DiCenso A, Callum N, Ciliska D (1998) Implementing evidence-based nursing: some misconceptions. Evidence BasedNursing 1, 38–40.

Donabedian A (2003) An introduction to quality assurancein health care. Oxford: Oxford University Press.

Faugier J, Butterworth T (1994) Clinical supervision. A positionpaper. Manchester: Manchester University.

Fowler J (2003) Supporting practitioners in giving high qualitycare. In: Hinchliff S, Norman SE, Schober JE (eds), NursingPractice and Health Care, 4th edn. London: Arnold.

Freshwater D (1999) Conference report: Taking responsibilityfor making a difference. Nursing Times Research 4, 395.

Glover D (1999) Accountability. Nursing Times Monograph.London: Emap Publications.

Griffiths (1988) Community care: agenda for action. London:HMSO.

Jenkins-Clarke S, Carr-Hill R, Dixon P et al. (1997) Skill Mixin Primary Care. A study of the interface between thegeneral practitioner and the primary health care team.York: York University.

Kogan M, Redfern S (1995) Making Use of Clinical Audit: aguide to practice in the health professions. Buckingham:Open University Press.

Kohner N (1994) Clinical Supervision in Practice. London:King’s Fund.

Kyzer D (1992) Nursing policy; the supply and demand fornurses. In: Robinson J, Gray A, Elkan R (eds), Policy Issuesin Nursing. Milton Keynes: Open University Press.

Luker (1992) Health visiting: towards community healthnursing. Oxford: Blackwell.

Maggs C (1997) Research and the nursing agenda. Confrontingwhat we believe nursing to be. Nursing Times Research2, 321–2.

Marinker M (1994) Controversies in Health Care Policies.Challenges to practice. London: BMJ Publications.

Maxwell RJ (1984) Quality assessment in health. BMJ 288,1706–8.

Moores Y (1999) Making a Difference – the foundation for afuture ripe with opportunity. Nursing Times Research, 4.

Mulhall A, LeMay A, Alexander C (1999) Bridging theresearch – practice gap: A reflective account of researchwork. Nursing Times Research 4, 119–30.

NHS and Community Care Act 1990. London: The StationeryOffice.

NHS Executive (1998) Achieving Effective Practice. A clinicaleffectiveness and research information pack for nurses,midwives and health visitors. Leeds: NHS Executive.

NHS Management Executive (1991) Junior Doctors: The newdeal. London: NHSME.

Pearson A (1995) A history of nursing development units In:Salvage J, Wright S (eds), Nursing Development Units; A force for change. Harrow: Scutari Press.

Pearson A (1998) Excellence in care: Future dimensions foreffective nursing. Nursing Times Research 3, 25–7.

Platt-Koch LM (1986) Clinical supervision for psychiatricnurses. Journal of Psychological Nursing 16, 982–6.

Read S (1999) Nurse-led care: The importance of manage-ment support. Nursing Times Research 4, 408–21.

Redfern S, Murrells T (1998) Masterclass. Research, audit andnetworking activity in nursing developments units. NursingTimes Research 3, 275–88.

Ross F (2000) Commentary. The challenges ahead for public-health nursing. Nursing Times Research 3, 193.

Royal College of Nursing (2005) Agenda for Change. A guide to the new pay and conditions in the NHS.London: RCN.

Salmon (1966) Report of the Committee on Senior Nursingstaff structure. London: HMSO.

Scott I (2001) Clinical governance. In: Bishop V, Scott I (eds)Challenges in Clinical Practice. Basingstoke: Palgrave.

United Kingdom Central Council (1992) The Scope ofProfessional Practice. London: UKCC.

United Kingdom Central Council (1998) Paper to informdevelopments of the specialist practice framework, theassessment of competence. London: UKCC.

United Kingdom Central Council (1999) Fitness for Practice.The UKCC Commission for Nursing & MidwiferyEducation. (Chairman Sir Leonard Peach) London: UKCC.

Vaughan B (1998) The story of NDUs – How the nursing,midwifery and health visiting development unit pro-gramme began. Masterclass. Nursing Times Research 3,272–4.


FURTHER READINGBaly MA (1995) Nursing and social change, 3rd edn. London:

Routledge.Rolf G, Freshwater D, Jasper M (2001) Critical Reflection for

Nurses and Health Care Professionals: a user’s guide.Basingstoke: Palgrave.

Bishop V (ed.) Clinical Supervision in Practice. Some ques-tions, answers and guidelines. Basingstoke: Macmillan/NTresearch.

Johns C, Freshwater D (1998) Transforming Nursing throughReflective Practice. Oxford: Blackwells.

Atkinson T, Claxton G (2000) The Intuitive Practitioner.Buckinghamshire: Open University Press.

Bishop V, Scott I (eds) Challenges in Clinical Practice.Basingstoke: Palgrave.

Further reading 33


Perspectives on Adult NursingPenny Harrison

4

INTRODUCTIONThe aim of this chapter is to discuss the role of the‘adult nurse’ within health care and their con-tribution to the health of adult patients. Links withhealth studies and the other three branches of nurs-ing and the range of placements where students ofadult nursing may gain experience will be explored.Some key nursing activities that may be experi-enced by an adult patient will also be discussed.

To take a closer look at adult nursing it is neces-sary to review some key concepts that assist indefining health care and nursing. Henderson (1966)(cited in Aggleton and Chalmers, 2000) statedthat all individuals have social, spiritual, biologicaland physical needs as human beings, and theseneeds are shared by all people. Henderson alsostated that nursing is about assisting an individual,sick or well, in the performance of activities thatcontribute to health, recovery from illness or peace-ful death. These activities are performed in such away as to maximize the individual’s potential oractual level of independence.

Fatchett in 1998 stated that a new agenda is nowmaking its presence felt in nursing, and in the UKthis is linked to the modernization of the NationalHealth Service (NHS).These are challenging nurs-ing to change its traditional perspectives and moveto a professional model of organization, whichincludes:

• patients as active participants in their care• the nurse as health educator• care is patient-focused, not task-focused• appreciation of patients’ holistic needs• co-operation and collaboration with other health

care services.

Adult nurses form the largest group within profes-sional nursing as a whole, therefore these changesare likely to be far-reaching for all nurses caringfor adult patients across a variety of settings includ-ing primary care, acute care and social care.

ADULT NURSINGAs stated in the introduction, nursing may bedefined as the diagnosis and treatment of humanresponses to actual or potential health problems(Medical, Nursing and Allied Health Dictionary,2002).The nurse uses four key points of referencein the definition or underpinning framework ofnursing care. These are the phenomena of nursingitself, theories to observe for nursing interventions,planning nursing actions, delivering and evaluatingthe care relative to those activities.

Nursing adult patients requires study of a widerange of subjects related to health and health careas well as developing practical nursing skills.Theoryis usually learnt in the classroom, but is related topractical nursing and then applied to real patientsin the clinical placement settings. Naidoo andWills (2001) have suggested that these subjects arecollectively known as health studies (summarizedin Box 4.1).

Although these subjects relate to all types ofnursing, adult nursing has its own unique aspectsof care. Alexander et al. (2000) see adult nursingas assisting individuals to maintain good health,to recover from episodes of illness, to cope withaspects of chronic health or disability and to havea dignified end to life. Adulthood is usually takento start at mental and physical maturity. This canmean that boundaries between nursing adolescents

and adults can be blurred. In clinical practice, nurs-ing adults is usually taken to mean caring for indi-viduals who are aged 18 years and over. Thus anadult nurse will receive education and training inskills that will equip them to nurse adult individu-als in a variety of practice settings such as the indi-vidual’s home, community settings, day-care centres,clinics, health centres, a general practice or hospitalor specialist facilities, for example hospices.

Adult nursing offers a wide and varied choiceof career opportunities in the settings mentionedabove, within or outside of the NHS, as well as arange of work within these settings. Adult nursesmay be involved directly or indirectly in four keyareas of work (Box 4.2).

The adult nurse’s scope of practice is wide-ranging, and this is one of the strengths of adultnursing. No two days are ever the same. No twopatients have exactly the same needs. Each daybrings chances to learn new skills, practise existingskills and gain a wealth of knowledge, professionaland interpersonal qualities. The adult nursing student develops many skills including problem-solving, using evidence and research findings toenhance patient care as well as reflective skills toreview the progress made. There are many oppor-tunities to develop practice in a huge variety ofareas and specialties. These may be focused inwards, clinics or community settings.

Some adult nurses choose to become teachersof nursing.This may be within a formal setting suchas a university or may be based within the practicearea itself focusing on a range of staff from nursingauxiliaries, to qualified practitioners or studentsof nursing. Some adult nurses have a role withinformal research programmes or trials. Other nursesmay be using research skills in other roles, forexample, the ward-based nurse may also be usingresearch or evidence about practice within theirday to day work. Experienced nurses may also bemanagers of staff or teams. For some this may beas a ward sister or nurse manager.Adult nurses havemany transferable skills that lend themselves to avariety of managerial roles within nursing as wellas more widely within the NHS. Dowding andBarr (2002) suggest that qualified adult nurses usea range of management skills within their daily working lives to organize their work and those ofthe team within which they are based to assess,plan, deliver and evaluate the care for the patientswithin their charge.

Recently, there has been a range of developmentswithin nursing. Although these may also apply to

36 Perspectives on Adult Nursing

Reflective activityLook at the subjects listed in Box 4.1. Do youknow what they all mean? Reflect on why theymight contribute to the study of health care.

Box 4.2 Adult nursing: key areas

• Clinical practice• Education• Research• Management

Reflective activityReflect on your work in a previous health caresetting or currently with your clinically basedmentor. What aspects of the care that you havedelivered to your group of patients reflected oneor more of the key areas of nursing identified inBox 4.2?

Box 4.1 Subjects in health studies

• Anatomy and physiology• Epidemiology• Psychology• Sociology• Cultural studies• Social and health policy• Management studies• Health economics• Ethics• Legal aspects of care• Health promotion

Source: Naidoo and Wills (2001)

the other branches of nursing, adult nurses bydefinition of the wide group of patients they canwork with have an equally wide range of applica-tion of these new roles. Perhaps a good exampleof this is impact of the developments in telemed-icine as seen in NHS Direct. Other Departmentof Health (DoH) initiatives such as Making aDifference (1999) and The NHS Plan (2000), iden-tify how nurse-led services and leadership withinnursing can have a direct and major impact on thequality of patient care. Nurses with experienceand expertise in all key areas can become nurseconsultants within their area of specialty. This willassist with dissemination of best practice and influ-ence the unique role of nursing and its contributionto health care for the individual patient withinpractice. This may be across the whole multi-professional team as well as the nursing team.

Adult nursing has some of the best examples ofthe new roles and expanded practice of nursing.These roles may be in technical skills such as deliver-ing specialist drugs like chemotherapy or caringskills such as bereavement counselling. Binnie andTitchen (1999) suggest that nurses are well placedto practise patient-centred care. Individualizednursing is a combination of a systematic and sci-entific approach to nursing as well as acting as the‘skilled companion’ for patients as they progressthrough their illness.The importance of the nurse–patient relationship is paramount and the import-ance of all aspects of care, including the bedside,practical aspects of nursing are valued the same asare more technically difficult skills.

Links with other nursing and health care professionals

Adult nursing has strong links with the otherbranches of nursing. On pre-registration courses,students rotate between the four branches during the Common Foundation Programme. Thebranches are adult nursing, mental health nursing,child health nursing and learning disability nursing.Rotation is a formal requirement of the programmeof study as well as a European Directive (EuropeanDirectives Circular 771/1453/EEC). This is aboutmore than gaining insight and experience of theother branches of nursing. It is about recogniz-ing that the fact that the individual patient has a

learning disability or mental health problem doesnot mean they will not encounter general healthproblems. These clients are often vulnerable whenseeking nursing care within a general adult setting.Their individual and particular health needs maymake it difficult for them to communicate in astraightforward manner to ensure that they receiveeffective healthcare treatment.The impact of prob-lems with physical health may greatly influence theindividual’s usual level of coping or adaptation withtheir learning disability or mental health disorder. Inother words, just because an individual happens tohave schizophrenia or cerebral palsy does not meanthat they will not develop appendicitis. Thus adultnurses require a broad range of skills and compe-tencies that assist them to meet the needs of theirclients in any setting.

Many nurses work in teams.These may be teamsof nurses, or they may work within the wider healthcare team. In the NHS, health care teams may belarge and complex. There may also be overlapbetween the health care team and professionalsfrom social care such as social workers or othercommunity-based staff. Watson and Wilkinson(2001) state that adult nurses who are basedwithin primary care and community settings arein an area of health care that is taking on increasingimportance. Community nursing has particularemphasis on working with patients in partnership,based within their own environment. The adultnurse has a unique position within the multi-professional team that is providing care for a patientwithin the hospital or community setting. Walsh(1998) suggests that nurses are well placed tocarry out careful assessment of all patient needs.The results of these may form the basis for referralto other members of the multi-professional team(Box 4.3), and will assist with the planning ofhealth care interventions and discharge.

However, among the professional groups ofhealth care practitioners working with the patientand their families or carers, it is the nurses whoremain the constant professional health careprovider for the 24-hour period in the delivery ofpatient care. This is not to say that nurses have towork shifts of 24 hours! Rather, nurses are theonly professional group with a continual presencewith the patient.This makes nurses well placed toplay an important part in the patient’s care. This

Adult nursing 37

includes assessment of needs as well as co-ordin-ation of care, with referrals to the other membersof the multi-professional team who may be ableto assist the patient to recovery from or adaptionof their health care problems. Part of the challengefor adult nurses is developing a range of skills andstrategies to assist with the co-ordination of carefor the patient, sometimes across a wide anddiverse multi-professional team.

Adult nursing training programme

Students of adult nursing develop their practicein two ways that are closely linked to each other.The theory is usually taught within the classroom,but is then practised within a clinical setting. Theachievement of objectives of clinical placementsand the completion of academic work, assignmentsor exams complete blocks of learning. These blocksare frequently based within modules. The progres-sion through the programme of either the degreeor diploma in adult nursing requires successfulcompletion of the appropriate modules. Thesemodules would have been subject to validation bythe Nursing and Midwifery Council (NMC, 2004a)to ensure that educational and professional stand-ards are met and sustained. To achieve this theNMC regulates the broad content of nursing programmes nationally. Students are assisted todevelop their skills and competencies in four keyareas. These are as follows.

Professional and ethical practice: Students learnto manage themselves, their practice and thepractice of others, working within the NMC codeof conduct (2004b), recognizing their own limita-tions and abilities. The student also develops theirpractice within an ethical and legal framework,acknowledging the patient as a unique individual.

Care delivery: Students develop effective com-munication skills and therapeutic relationshipswith patients, their carers and the wider multi-professional team to facilitate the assessment anddelivery of nursing care and to promote the patient’shealth. Students deliver care based on best prac-tice/evidence using skills of assessment, planning,delivery of interventions, evaluation, problem-solving, critical thinking and reflection.

Care management: Students develop skills formanagement of a safe environment for patientcare by using team working, delegation and othermanagerial skills.

Personal and professional development: Studentscontinue to develop their practice after registra-tion and assist with the development and teach-ing/supervision of future health care practitioners/ students.

The competencies are achieved with 50 per centof the student’s time spent on learning within the


Reflective activityReflect on experience you have had in a previoushealth care setting or think about time you spentworking with members of staff in that environ-ment, or, in your current placement in nursing, askyour mentor about the multi-professional teamthat delivers patient care.

Ask your mentor to arrange for you to spend sometime with members of the multi-professional teamthat you are currently working with.

Think about the members of the multi-professional team listed in Box 4.3. Do you knowwhat their roles are? Do you know what theircontribution to patient care is?

Record the time you have spent working with eachmember of the team in your clinical objectivesbook. Reflect on how this will deepen your under-standing of teamwork in health care.

Box 4.3 Healthcare practitioners inmulti-professional teams

• Nurses: practice nurse/district nurse• Doctors• Pharmacists• Dieticians• Occupational therapists• Physiotherapist• Social Worker• Specialist nurses e.g. tissue viability nurse• Specialist therapist e.g. speech and language

therapist

educational setting and 50 per cent within clinicalpractice areas. During training, the student isassessed through their assignments, case studiesand exams. In clinical practice, the student isassessed by their mentor with a practice bookbeing completed to demonstrate competency.

Within clinical practice a formally nominatedmentor supports the adult nursing student. Amentor is an experienced nurse who acts as a rolemodel, guide and facilitator of learning for thestudent for the duration of their placement. Thementor would have undertaken formal training,usually with teaching in clinical-practice-basedskills and would be familiarized with the pro-gramme that is delivered by the local school ofnursing. Some mentors have taken formal teachingcourses to develop their skills in relation to teachingstudents within clinical practice.

PlacementsPlacements vary in length of time, but since the publication of the United Kingdom CentralCouncil’s (UKCC) Fitness for Practice in 1999 theemphasis has been on longer rather than shorterplacements, frequently of up to eight or 12 weeks’duration. This is to allow the students to settlewithin the area, develop their confidence and gainthe best learning opportunities from the area.Mentors spend a minimum of 40 per cent of theirtime with students. In many clinical placementareas this figure may be higher. In other areas, in theabsence of the nominated lead mentor, anotherqualified nurse or associate mentor supports thestudent.This individual will continue the work andlearning opportunities planned by the studentand lead mentor.

The benefits of working with mentors for theduration of the placement are continuity and con-sistency of the learning opportunities affordedwithin the placement. The benefit of workingwith an associate mentor for parts of the clinicalplacement allocation may include variety inlearning opportunities, as well as exposure toanother qualified nurse. In some instances theassociate mentor may be a relatively newly quali-fied nurse, though not usually within the first sixmonths of initially qualifying.The benefits of hav-ing an associate mentor who has qualifiedrecently will be that the experience of being anadult nursing student has not been forgotten.

Thus there may be common experiences andempathy to be shared between the student andassociate mentor, and sharing of the learningwhich may be two-way between the student andtheir associate mentor. This is also true of the relationship between the student and their leadmentor. Whereas the lead mentor will have expe-rience, possibly from a variety of clinical settingsover some years, the student will bring a ques-tioning approach to the clinical environment orsometimes new ideas or research findings that canbe shared. Confident mentors will harness theshared skills and experiences of the adult nursingstudent plus their own skills to develop compe-tent practice in the student as well as having thebenefit of updating and maintaining their ownpersonal and professional development.

Placement settings are varied and encompass awide range of areas. Nurses who are responsiblefor developing nurse education within practicemay also use a rotation between related areas.Examples of some placement settings are givenbelow in Box 4.4.

Adult nursing 39

Box 4.4 Examples of placement setting

A Within primary care• General practitioner surgeries• Health care centres• District nursing• Walk-in health centres• Minor injuries units• Specialist disabled or rehabilitation units• Community hospitals• Nursing homes

B Within an acute hospital• Accident and emergency departments• Assessment wards• Medical wards• Surgical wards• Rehabilitation wards• Specialist medical wards, e.g. neurological

medical ward• Specialist surgical wards, e.g. ear, nose and

throat surgical ward

Gaining the best from placementsThe new placement can seem a daunting experi-ence. The student may well have experience of arange of shifts, perhaps from a health care setting orwork experience from another environment or pro-fession.Adult nursing students of nursing can expectto work a variety of shifts/shift patterns. These mayinclude day as well as night shifts, working at week-ends and holiday periods. The variety of shifts isimmense so a summary is included here (Box 4.5).

The student can expect to be shown around andorientated to the placement area at commence-ment of the experience. This is likely to includelayout and location of emergency equipment suchas the resuscitation trolley, fire exits, etc. During

the first week of the placement the student usu-ally has the opportunity of an informal interviewwith their mentor. This is to outline the learningopportunities available and set goals and actionplans to achieve the objectives. This may also be an opportunity for the mentor to plan rotationbetween the different areas related to the place-ment setting.This will be to ensure the student seesthe patient group that they will meet throughoutall the areas available. An example of this is givenbelow in Box 4.6. Many placement areas have anurse responsible for organizing the student nurses’placements, both in terms of shifts to be completed,nomination/allocation of mentors and rotation pro-grammes. An information book may also supple-ment this. Often this is sent to students prior totheir arrival within the area.The benefit of this is toallow students to have information about theirforthcoming clinical placement area prior to arrival.


• Out-patient clinics• Specialist areas, e.g. burns/stroke units• Operating theatres and recovery rooms• Critical care areas, e.g. intensive care/

coronary care/high dependency units

C Within other areas• Hospices• Private hospitals• Specialist services, e.g. alcohol rehabilita-

tion programmes• Undertakers• NHS Direct

Box 4.5 Examples of shift times

8-Hour shifts• Morning/early shift – 07:00 to 15:00 hours• Afternoon/late shift – 14:00 to 22:00

hours• Night shifts – 21:00 to 08:00 hours12-Hour shifts• Day shift – 07:15 to 19:45 hours• Night shift – 19:15 to 07:45 hoursShift for work with a specialist nurseUsually eight hours anytime between 07:30to 19:00 hours

Box 4.6 Example of a rotation programme for an adult surgicalward

• Pre-assessment clinic• Admission to surgical ward• Following patient through from ward to

operating theatre/recovery• Working with specialist nurses during

patient’s recovery, e.g. nutrition nurse specialist

• Discharge planning• Out-patients

Reflective activityThink about the area in which you are gainingclinical experience at the moment.

What areas link or relate to the group of patientsthat you are caring for? List the related areas.Ask your mentor to arrange for you to visit orwork with the linked areas.

THE ADULT NURSE’S DAYSo how about a typical adult nurse’s day? What isthe adult nursing student nurse likely to be doingduring a day in adult nursing? Based in an acuteinpatient setting, the following example may befairly typical. It demonstrates some key areas of carethat adult nurses will be involved with. It alsodemonstrates the balance between the artistic andscientific side of nursing practice; the art beingthe caring side of nursing practice and the sciencebeing the technical skills required to supplementnursing practice.

The method by which nursing care is organizedvaries greatly from one practice setting to another.Some nurses work in teams, whereas others maywork in a more autonomous way. However, oneaspect that continues to be challenged is that ofthe focus on patient’s needs from a non-medicalperspective.This is not to under-estimate the con-tribution of medical staff to the management ofpatient care. However the focus on or managementof disease and its symptoms, rather than all of thepatient’s needs by doctors has been challenged.This is emphasized by Aggleton and Chalmers(2000) who suggest that the medical model shouldbe integrated with other professionals’ models ofcare so that they complement one another ratherthan conflict with each other. Nursing models arealso many and varied, with different models appli-cable to different patient groups in different prac-tice settings.Aggleton and Chalmers (2000) identifyten models of nursing, including a commonly usedexample: the Roper, Logan and Tierney Activities ofLiving Model.This model, in common with othershas some key concepts (Box 4.7), often referred toas the Nursing Process, that assist with the system-atic approach to the organization of patient care.

The student will be able to see how the modelof nursing care reflects in the management andorganization of nursing care during the placement.This may be reflected in the nursing records anddocuments as well as in the delivery of nursinginterventions. Part of the benefit of being activelyinvolved in the assessment, planning, delivery andevaluation of nursing care is the development ofclinical nursing skills. The adult nursing studentwill be exposed to a range of clinical skills and beable to practise these under supervision, gainingconfidence, new skills and competencies for futurepractice. Baillie (2000) suggests that nurses needto use motor and cognitive skills as well as criticalthinking skills to develop practical nursing expert-ise.These require underpinning knowledge as wellas repeated practice to gain confidence with theirdelivery.

An aspect of working on an acute ward is theimmediacy of the team that the individual isbased in. Thus before starting work there may bea short amount of time for catching up with col-leagues and friends. This is an important part ofthe reinforcement of bonds within the team andalso allows for good as well as more difficult newsabout individual practitioner’s lives to be sharedby the collective.

The start of many shifts begins with handover.This may take many forms but is a useful tool forstaff coming onto the new shift to hear about thenature of the patients and their nursing needs. Itmay be undertaken at the nursing station or at thepatient’s bedside. Skilled practitioners will be ableto share how a patient is progressing and informstaff of any changes that may have taken place onthe previous shift. It also allows for clarification ofany areas of query or difficulty. In some settingshandover is also used for teaching purposes wheremore experienced staff share their knowledgeabout certain conditions or types of nursing inter-ventions. For other areas, especially those withadult nursing students, handover may assist withthe formulation of any particular learning needsfor that particular shift. For example, it may behanded over that a patient has enteral feeding inprogress (artificial feeding). The student and theirmentor may be able to plan the care for thispatient as well as meet the student’s particularlearning needs for that shift.

The adult nurse’s day 41

Box 4.7 Key concepts of nursingmodels

• Nursing assessment/diagnosis• Planning of care• Delivery of care/nursing interventions• Evaluation of care

Source: Aggleton and Chalmers (2000)

Communication is at the heart of this activity.Communication is defined as the sending andreceiving of messages, where information is trans-ferred. Ellis and Betts (2002) suggest that nurseshave a duty to take the aspects of communicationwithin their work seriously, developing the skillsfor this competency as well as any other practicalskills. This is likely to be made up of oral commu-nication skills, the use of written nursing records,non-verbal information and increasingly the patientas a direct participant to this activity. Initially, thewords, phrases and abbreviations used at handovercan seem daunting. However, students rapidlyacquire the technical language that may be used.This in itself may form a learning objective.Studentsare encouraged to ask questions, clarify points theyhave not understood or asked for backgroundinformation.

The adult nurse then plans their work for theirgroup of patients for the duration of the shift aboutto be undertaken. For experienced nurses this mayinclude the supervision of adult nursing studentsplanning aspects of care for their group of patients.For the less experienced or newly qualified nurse,this process may take a little longer and they mayrequire support from the experienced nurse onthe shift. Support is also likely to come from thenursing auxiliaries on the ward. These staff mayhave been on the ward team for some time, possiblysome years, and are able to offer support in manyforms as well as being very familiar with the workenvironment and how to access particular typesof equipment or facilities that may be requiredfor delivery of patient care.

At some stage during a typical shift, administra-tion of medicines is likely to demand time and arange of complex skills from the adult nurse.Depending on the nature of the patient problemsand their particular medical/nursing requirements,medications will be administered. For some patientsthis will be straightforward and for others themedications will be complex. Popular images ofnurses administering medicines tend to reflectonly ‘dishing out pills’. In fact, drug administrationis one of the most complex areas of nursing inter-ventions. Although medical staff may prescribemedicines, nurses have just as much professionalresponsibility to administer them safely. Drugrounds can be bewildering. The drug trolley and

cupboards appear to contain hundreds of differentpills, capsules and syrups with strange names anddifferent, sometimes brightly coloured, packaging.The nurse will be checking for a number of pro-fessional as well as patient-focused requirementsbefore administering the medication.

Experienced nurses supervising the adult nursingstudent or newly qualified nurse with drugs willencourage the practitioner to look at the patientas complete person rather than just a disease orrange of symptoms to be managed. For example,reviewing of the patient’s observation charts assistswith the clinical decision-making process.This maybe to assess whether the medication given earlierto reduce a patient’s pyrexia (fever) has beeneffective or not. It also allows for the nurse to askthe patient how they feel and to use skills ofreassessment where necessary. This is combinedwith knowledge about the patient, their disorderor symptoms and the drugs to be given includingusual doses, side effects and any special require-ments that may be required. Clearly the nursewho is working in a particular area on a continu-ous basis becomes confident and familiar withdrugs that are used on a regular basis. Howeverthe nurse is not expected to be an expert in phar-macology or to remember every medicine everused. This is the role of the pharmacist, many ofwhom are now based within wards to work closelywith nurses and other members of the multi-professional team. The emphasis for the nurse ison safe professional practice (NMC, 2000; NMC,2004b), acknowledging limitations and seekingappropriate advice from a range of resources whena query or problem is encountered. Other profes-sional skills used in the administration of medi-cines include communication, consent from thepatient who is being given the medicines andrecord keeping. Thus what initially appears to bea simple task is complex and demanding in termsof professional practice.

The nurse will assist the patient with a range ofother nursing interventions. These are likely toinclude what is sometimes referred to as essentialaspects of nursing care (DoH, 2001).These may bewashing and dressing, eating and drinking, assistingwith toileting needs, mobilizing safely, etc.Although many patients require assistance withthese functions to a greater or lesser degree of


dependence, the term essential has been used toemphasize the importance of these aspects of care.This is set out in the document Essence of Care(DoH, 2001). This is due to their relationship ofessential aspects of care on long term health andrecovery from episodes of ill health.These essentialaspects of care are just as important as some of themore technical aspects of nursing care such as therecording of the patient’s vital signs such as bloodpressure, pulse, temperature. Binnie and Titchen(1999) suggest that such essential aspects of careare ‘practical’ nursing skills and should not be givenlightly to untrained or junior staff. This is becausethey form part of the unusually privileged access topatients and remain central to nursing’s function.

CONCLUSIONFatchett (1998) stated that nurses have developeda range of new skills that will assist them to workwithin the modernized environment that formsthe NHS today. Research/evidence-based care,quality, auditing, standard setting and bench-marking skills, health promotion/education pluscare protocols and multi-professional/collabora-tive working practices are all features of modernnursing. For adult nursing this is likely to be par-ticularly challenging. Adult nurses already workin busy, pressurized environments. Walsh (2000)suggests that there is now a shift away from thescientific and technological paradigm as the soleoption for the caring professions, and that the costof caring is more valuable to patients than thecost of giving this care to the nurse. Thus if adultnursing is to meet the challenges it will requirecombining the best of traditional nursing skills aswell as the continuing development of newerstyled skills.

GLOSSARYIn the context of this chapter the meanings of the follow-ing words are described:Anatomy and physiology Study of the structure (anatomy)

and the function (physiology) ofthe body

Best practice/evidence- Nursing practice based on evi-based practice dence to support the nursing

care/interventions. Research

may be used as evidence toshow that a particular aspect ofcare is effective for the adultpatient

Biology Study of living organisms and their products

Clinical mentor Named qualified nurse whoserole is to facilitate learning andwho assesses the student in theclinical practice setting

Clinical placement Area where a student nurseworks with their clinical mentorto learn the art and science ofnursing

Clinical skills Skills used in practice, e.g. givingan injection or dressing a wound

Cognitive skills Developing skills of reasoning,critical thinking

Diagnosis Identification of a disease orevaluation of signs and symp-toms

Dietician Qualified health care practitionerproviding assistance with themanagement of nutrition andfood

Disease Specific disease or disorder characterized by a set of recogn-izable signs and symptoms

Epidemiology Study of disease/disease eventsin populations

Ethics Study of moral values or prin-ciples

Handover Transfer of information fromone group of nurses to another

Health care Provision of services by healthcare professionals/practitioners to prevent, maintain or managea state of health

Health promotion Health education programmes/ information designed to improve, maintain or safeguardhealth for individuals or the community

Motor skills Physical skillsMulti-professional Team of qualified health careteam practitioners and support staff

working together to deliverpatient care

Nursing Nurse assisting in the care andtreatment of activities of liv-ing and/or human responses to actual or potential healthproblems

Glossary 43

Nursing interventions Acts or actions by nurses toimplement plans of care for patients

Occupational therapist Qualified health care practi-tioner who helps patients todevelop skills to cope with phys-ical, social or emotional deficits

Pharmacist Qualified health care practi-tioner who assists with the for-mulation, dispensing and adviceregarding drugs or medicationto the multi-professional healthcare team, patient or their carer

Physiotherapist Qualified health care practi-tioner concerned with the phys-ical examination, testing andtreatment of physical impair-ments through a range of techniques including exercise

Psychology Study of behaviour and the mind

Reflective practice Thoughtful review of one’s actions

Social worker Qualified health care practitionerwho deals with social, emotionaland environmental problems that may impact on a patient’shealth

Sociology Study of people and societiesSymptoms Indication of a disease or

disorder

REFERENCESAggleton P, Chalmers H (2000) Nursing Models and Nursing

Practice, 2nd edn. Hampshire: Palgrave. Alexander M, Fawcett J, Runciman P (2000) (eds) Nursing

Practice. Hospital and home: the adult, 2nd edn. Edinburgh:Churchill Livingstone.

Baillie L (2001) (ed) Developing Practical Nursing Skills.London: Arnold.

Binnie A, Titchen A (1999) Freedom to Practice: the develop-ment of patient-centred nursing. Oxford: ButterworthHeinemann

Department of Health (1999) Making a Difference. Strength-ening the nursing, midwifery and health visiting contri-bution to health and health care.London: DoH.

Department of Health (2000) The NHS Plan. London: TheStationery Office.

Department of Health (2001) Essence of Care – benchmark-ing and audit tool kit for essential aspects of care.London: The Stationary Office.

Dowding L, Barr J (2002) Managing in Healthcare: a guidefor nurses. Harlow: Prentice Hall.

Ellis R, Betts M (2002) The nurse as a communicator. In:Kenworthy N, Snowley G, Gilling C (eds) CommonFoundation Studies in Nursing, 3rd edn. Edinburgh:Churchill Livingstone.

Fatchett A (1998) Nursing in the New NHS: modern,dependable? London: Bailliere Tindall.

Henderson V (2000) In: Aggleton P, Chalmers H (2000) NursingModels and Nursing Practice, 2nd edn. Hampshire:Palgrave.

Medical, Nursing and Allied Health Dictionary, 6th edn. St. Louis: Mosby, 2002.

Naidoo J, Wills J (2001) (eds) Health Studies: an introduction.Hampshire: Palgrave.

Nursing and Midwifery Council (2000) Guidelines on Admin-istration of Medicines. London: NMC.

Nursing and Midwifery Council (2004a) Standards ofProficiency for Pre-registration Nursing Education.London: NMC.


United Kingdom Central Council (1999) Fitness for Practice.London: UKCC.

Walsh M (1998) Models and Critical Pathways in ClinicalNursing: conceptual frameworks for care planning.London: Bailliere Tindall.

Walsh M (2000) Nursing Frontiers: accountability and theboundaries of care. Oxford: Butterworth-Heinemann.

Watson N, Wilkinson C (2001) Nursing in Primary Care.Basingstoke: Palgrave.

ANNOTATED FURTHER READINGAggleton P, Chalmers H (2000) Nursing Models and Nursing

Practice, 2nd edn. Hampshire, Palgrave. An effective textthat reviews the various models of nursing used within avariety of practice settings.

Alexander M, Fawcett J, Runciman P (2000) (eds) NursingPractice. Hospital and home: the adult, 2nd edn. Edinburgh: Churchill Livingstone. A comprehensive textthat reviews the principles and practices of adult nursing.Relevant to nursing students and for the newly qualifiedpractitioner. Highly recommended.

Cormack D (2000) (ed) The Research Process in Nursing,4th edn. Oxford: Blackwell Scientific. An effective textintroducing nursing students to the research process.

Dimond B (2005) Legal Aspects of Nursing, 4th edn. London:Prentice Hall. A thorough review of legal aspects of nurs-ing and implications for clinical practice.

Dougherty L, Lister S (2004) (eds) The Royal MarsdenManual for Clinical Nursing Procedures, 6th edn.


Oxford: Blackwell Scientific. A procedure manual includ-ing care plans for many aspects of nursing care and inter-ventions. Highly recommended.

Dowding L, Barr J (2002) Managing in Healthcare: a guidefor nurses. Harlow: Prentice Hall. Principles of the man-agement of nursing care are reviewed within this text.

Hinchliff S, Norman S, Schober J (2003) (eds) Nursing Practiceand Healthcare. 4th edn. London: Arnold. A comprehensivetext reviewing principles of nursing practice.

Maslin-Prothero S (1997) (eds) Study Skills for Nurses.London: Bailliere Tindall. A text that assists students todevelop study skills for both pre-registration nursingcourses and for post-registration studies.

Medical, Nursing and Allied Health Dictionary, 6th edn. St. Louis: Mosby, 2002. Many dictionaries are available.This one is comprehensive.

Naidoo J, Wills J (2001) (eds) Health Studies: an introduc-tion. Hampshire: Palgrave. Principles of health promotionexplored within this text.

Seeley R, Stephens T, Tate P (2003) Anatomy and Physiology.6th edn. Boston, McGraw Hill. A comprehensive anatomyand physiology text that is specifically designed for nursing.Appropriate for both pre-registration and post-registrationstudents.

Smeltzer S, Bare B (2000) Brunner and Suddarth’s Textbookof Medical-Surgical Nursing, 9th edn. Philadelphia:Lippincott. A comprehensive text that reviews the prin-ciples and practices of adult nursing. Relevant to nursingstudents and for the newly qualified practitioner.

Trounce J (2004) Pharmacology for Nurses, 17th edn.Edinburgh: Churchill Livingstone. A comprehensive textthat reviews the principles of pharmacology for nursing.Relevant to nursing students and for the newly qualifiedpractitioner. Highly recommended.

Walsh M (1997) (ed.) Watson’s Clinical Nursing and Related Sciences, 5th edn. London: Bailliere Tindall. A comprehensive text that reviews the principles and prac-tices of adult nursing. Relevant to nursing students and forthe newly qualified practitioner. Highly recommended.

Watson N, Wilkinson C (2001) Nursing in Primary Care.Basingstoke, Palgrave. A text that reviews the principlesand practices of nursing adults within primary care settings. Relevant to nursing students and for the newlyqualified practitioner.

USEFUL WEBSITESNursing and Midwifery Council. www.nmc-uk.orgDepartment of Health. www.open.gov.uk/doh/dhhome.htmRoyal College of Nursing. www.rcn.org.ukNational Institute for Clinical Excellence. www.nice.org.uk

JOURNALS RECOMMENDED FURTHER READINGBritish Journal of Community NursingThis journal focuses on nursing within primarycare and the interface between acute care, primarycare and social care.

British Journal of NursingA peer-reviewed journal with a range of articlesrelevant to adult nursing within a range of clinicalsettings. This journal is particularly effective atpresenting nursing research in an understandableand accessible format.

Nursing StandardThis is published by the Royal College of Nursing.Arange of news, views and peer-reviewed articles ofinterest to adult nurses. Widely available in manyhigh street outlets.

Nursing TimesBritain’s most widely read journal that consists ofabout one-third news articles, one-third clinicalarticles, with a large recruitment/job advert section.Again, widely available throughout the UK.

Professional NurseA professional and readable journal that focuses ondeveloping nursing care and clinical practice,which reflects evidence-based care, quality initia-tives and the modernization agenda.

Nursing Times and Professional Nurse are now onejournal.

Journals recommended further reading 45

www.nmc-uk.org

www.open.gov.uk/doh/dhhome.htm

www.rcn.org.uk

www.nice.org.uk


Perspectives on Children’s NursingKevin Power

5

INTRODUCTIONThe aim of this chapter is to provide an insightinto children’s nursing. The key ideas and philoso-phies underpinning children’s nursing will beexplored to aid understanding of the world of chil-dren’s nursing. Aspects of the course content andclinical experiences will be discussed to provideguidance on how to get the most out of a course.The principal sections of this chapter are:

• Historical insights into children’s nursing• Child health policy affecting children’s nursing• An outline of children’s nursing• Why sick children need children’s nurses• Making the most of the Common Foundation

Programme• Starting in practice• How to get the most out of a placement• Essential skills in children’s nursing• Sources of knowledge and information

Children’s nursing is a popular choice of studyand many courses are oversubscribed.At the inter-view, course applicants are usually expected toshow some insight into children’s nursing. It canbe very difficult, if not impossible, to gain experi-ence in children’s nursing prior to commencing apre-registration nursing course. There are rela-tively few opportunities to become employed as ahealth care assistant (HCA) and many hospitalsapply age restrictions on anyone wishing to under-take work experience from school on a children’sward.Thus, many students embarking on the childbranch of a nursing course may have little idea ofwhat children’s nursing is like or what it involves.

This chapter therefore aims to help develop thatinsight which will help enhance any application toa children’s nursing course. It is also aimed atintroducing those who may already have secured aplace on a course to some of the main issues thatwill impact on their practice.

It is important to recognize that children aredifferent from adults and have different careneeds.As we shall see later in this chapter childrenexperience different illnesses and respond to someillnesses differently than adults. For example asimple cold in an adult could be a serious respira-tory infection for a young child. Therefore thischapter also provides an outline some of the dif-ferent needs children have in health care and theskills the nurse requires to meet these needs.

HISTORICAL INSIGHTS INTOCHILDREN’S NURSINGDr Charles West recognized that children neededspecialist care when ill and in 1852 he founded theGreat Ormond Street Hospital for Sick Childrenin London. He then established training pro-grammes specifically to prepare nurses in the careof sick children (Miles, 1986). In 1919 the NursesRegistration Act established the requirement fornurses to be entered on a national register (Parker,1996). A separate professional register was cre-ated for children’s nurses, although according toWhiting (2002) this was to prevent children’snurses masquerading as general nurses rather thanas a recognition that children need specially trainednurses to care for them.

In 1989 the first Diploma of Higher Educationand BSc (Hons) courses in nursing began andthose graduating from these courses were quali-fied in adult, mental health, learning disabilitiesor children’s nursing. The courses consisted of an18-month common foundation programme (CFP)and an 18-month branch programme, specializingin one of the four branches of nursing. Followinga review of nursing education in 1999, the formerUnited Kingdom Central Council for Nursing,Midwifery and Health Visiting (UKCC, now theNursing and Midwifery Council (NMC) maderecommendations (UKCC, 1999) that led to thecurrent situation of a one year CFP and a two-year branch programme. The four branches ofnursing remained the same as before.

Debates have taken place regarding the futureof the separate branches of nursing (UKCC, 2001;Whiting, 2002) although no definite action hasbeen taken as yet. Thus it can be seen that thechildren’s nursing education has undergone, andis likely to continue to undergo, changes thatreflect current thinking. Many of these changesare influenced by child health policies originatingfrom central government.

CHILD HEALTH POLICY AFFECTINGCHILDREN’S NURSINGThe organization of children’s health care isdetermined by policy set at government level andmany reports and studies have influenced the pol-icy changes. Laws such as the Children Act 1989,the Human Rights Act 1998 and the Protectionof Children Act 1999 also influence children’snursing practice and education. It should also benoted that although the Children Act 1989 itselfonly directly relates to those children defined as‘in need’, the principles within the Act areapplied to the care of all children. One of theseprinciples is that of Parental Responsibility. Onlythose with parental responsibility are able to giveconsent for a child to undergo examination ortreatment. Policy and law does change over timeand therefore it is important for children’s nursesto be aware of these changes when they occur. Anexample of this is a change in the legal definitionof when a father may have parental responsibility

for a child. The Adoption and Children Act 2002made an alteration to the original definition laiddown in the Children Act 1989. From December2003 fathers who were not married to the motherat the time of the birth may automatically haveparental responsibility if they are named as thefather on the birth certificate (Adoption andChildren Act 2002 (Commencement No. 4) Order2003 section 2.2 (a)).

Unfortunately, tragedies also inform policy suchas that detailed in the Victoria Climbié Inquiryreport (Laming, 2003). Additionally, the adoptionof international conventions by the UK govern-ment, such as the United Nations Convention onthe Rights of the Child (UN, 1989), also influencechildren’s nursing.The most recent initiative deter-mining child health services in the National HealthService (NHS) involved the Children’s Taskforce,set up by the Department of Health (DoH), creat-ing a national set of standards called the Children’sNational Service Framework (NSF) (Box 5.1).Thisframework sets new national standards across theNHS and social services for children.

The first part of the NSF for children was pub-lished in 2003 by the DoH and this set out thestandards for the provision of services for children

48 Perspectives on Children’s Nursing

Box 5.1 The Children’s NationalService Framework

The framework is an important way ofresponding to some of the key challenges facing children’s health and social care services,for example:

• Responding to Learning from Bristol: thereport of the public inquiry into children’sheart surgery at the Bristol Royal Infirmary1985–1995

• Mainstreaming the successes of programmessuch as Quality Protects and Sure Start

• Most importantly, the Children’s NSF willbe about putting children and young people at the centre of their care, buildingservices around their needs.

Source: DoH (2002a)

in acute hospital settings. Three key standards areset out in the NSF:

• services should be centred around the needs ofchildren

• care must be of high quality and based on goodevidence

• the hospital environment should be safe andappropriate for children.

The third key challenge identified for the NSF,and the first standard in the NSF, points to one ofthe central themes in children’s nursing: that ofseeking out and taking seriously children’s viewsregarding their care when planning care. This isalso reflected in the Children Act 1989 and theUN Convention on the Rights of the Child 1989,and is embodied in the Human Rights Act 1998.A number of other themes or ideas underpin chil-dren’s nursing practice and these will be con-sidered in more detail further on in this chapter.

AN OUTLINE OF CHILDREN’SNURSINGIf a survey of children’s nurses were to ask ‘Whatis a children’s nurse?’ there are likely to be manydifferent answers. The reason is that children’snurses practise in a wide variety of areas and specialities (Box 5.2). Therefore it is difficult topin down exactly what children’s nursing is andwhat a children’s nurse does, and a simpledescription of a children’s nurse’s work would notdo the role justice. Clearly a children’s nurse couldnot hope to practise effectively across all thesespecialities and in all areas of practice. This means

that children’s nurses may focus on a particulararea such as surgery and may then specialize intoa particular type of surgery such as ear, nose andthroat surgery. Others may work mainly withadolescents or work in the community caring forchildren with chronic or long-term illness at homeor working in a children’s hospice. What this doesreveal is the potential for a children’s nurse todevelop a career in many different and varied areasof care.

In addition to the many areas of practice that a children’s nurse might work in, increasinglyopportunities are becoming available to acquire a

An outline of children’s nursing 49

Summary

• Nurses Registration Act 1919 establisheda register for nurses with a separate register for children’s nurses.

• Ongoing debates regarding the future ofchildren’s nursing as a separate branch.

• Children’s views about their own care akey principle in children’s nursing.

• NSF recognizes a need to design servicesspecifically for children.

Box 5.2 Examples of areas of practice and specialities in children’s nursing

• Hospitals• Medical wards• Surgical wards• Orthopaedics• Ear, nose and throat• Oncology (cancer wards)• Out-patients clinics• Accident and emergency• Operating theatres• Out-reach services, e.g. specialist respiratory

nurses providing some care in the child’sown home

• Neonatal units (for premature babies)• Intensive care• Community• Child’s own home• Schools• Special schools, i.e. schools for children

with special mobility needs or a learningdisability

• Young offenders institutions• Health promotion such as advising parents

and children on healthy diets or dentalhygiene, or providing sexual health infor-mation for adolescents

• Mental health care such as helping youngpeople deal with emotional problems orsuch serious issues as anorexia and bulimia

specialist practitioner qualification that is recog-nised by the NMC. Ultimately there is the poten-tial for the children’s nurse to become a consultantnurse. Alternatively there are opportunities todevelop a career in leading nursing through man-agement or becoming a researcher. Essentially regis-tering as a children’s nurse following three years ofhard work need only be the first step in a wide andvaried career in children’s nursing.

Notwithstanding all the different areas of prac-tice the majority of what is written about chil-dren’s nursing suggests that there is an underlyingphilosophy or set of ideas about what children’snursing is. This philosophy is evident in a RoyalCollege of Nursing (RCN) statement (RCN, 1992)about the principles underpinning all their pol-icies regarding child health (Box 5.3).

It can be seen that within the RCN philosophystatement, in common with the UN Conventionon the Rights of the Child (UN, 1989) and theChildren Act 1989, that the issue of children’srights is a significant feature of children’s nursingpractice. Within the UN Convention, three mainrights underpin all the others and these must betaken into account in any decision relating to oraffecting children.

1 All the rights in the Convention apply to allchildren equally whatever their race, sex,

religion, language, disability, opinion or familybackground (Article 2)

2 When adults or organizations make decisionswhich affect children they must always thinkfirst about what would be best for the child(Article 3)

3 Children too have the right to say what theythink about anything which affects them.Whatthey say must be listened to carefully. Whencourts or other official bodies are making deci-sions which affect children they must listen towhat the children want and feel (Article 12)

These three rights are also evident within theChildren Act 1989 and firmly established withinUK law through the Human Rights Act 1998.Thus it is clear that the principles of equality, bestinterests and the right to participate in decision-making are central to the care of children.

Another key value or principle underpinningchildren’s nursing is that of family-centred care.Coleman (2002) suggests that family-centred careis an evolving concept that is influenced bychanges in society and the health care system.There are several views in the literature about howto define family-centred care and this is evidencethat it is an evolving concept. Nethercott (1993)argued that family-centred care has seven criticalcomponents. Although there are some drawbacksto viewing family-centred care using Nethercott’slist (Smith et al., 2002) each of the seven compon-ents she outlined will be explored here as they doprovide an easily digestible description of the mainelements of family-centred care.

1 The family must be viewed in its social, cul-tural and religious context.At times of stress, family members should not

be required to conform to norms that are alien tothem. This means that the care should be organ-ized as far as possible to fit the ‘normal’ pattern ofthe family. There are limits to this of course. Itwould be impossible to arrange different meal-times for each individual child in a hospital ororganize community children’s nurse visits purelyto suit individual families.

2 The roles of individual family members mustbe evaluated to help meet their physical andemotional needs and to maximize their indi-vidual roles in providing care for their child.


Box 5.3 Principles underpinningchildren’s nursing

• Recognize each child as a unique,developingindividual whose interests are paramount

• Listen to children, attempt to understandtheir perspectives, opinions and feelings,and acknowledge their right to privacy

• Consider the physical, psychological, social,cultural and spiritual needs of children andtheir families

• Respect the right of children, according totheir age and understanding, to appropri-ate information and informed participa-tion in decisions about their care

Source: RCN (1992)

It would be incorrect to assume that parents arealways the main carers for a child. Grandparentsor even older sisters or brothers may fill this rolein some families. Therefore the nurse must ascer-tain the role fulfilled by each member of the fam-ily especially in relation to the care of an ill child.

3 Information should be explicit to enable partici-pation in decision-making and the acquisitionof knowledge pertaining to their child’s illness.This means that the nurse should be giving

information to families and children in a mannerthat the lay person can understand. Much of theinformation used by professionals concerning achild’s care is expressed in jargon or technicalwords that are not part of everyday language.

4 The prime caregiver should be involved indeveloping and evaluating care plans.The prime caregiver for the child is the person

who normally cares for the child at home. Thismeans that the nurse becomes an advisor ratherthan the person who decides alone what care isgiven and when. The nurse must use his or herknowledge to guide and assist the family in mak-ing plans of care and should not merely dictatewhat they feel should be done.

5 The involvement of families in technicalaspects of care should be in accordance withtheir own perceived ability and willingness todevelop the necessary skills.The nurse may be able to teach family mem-

bers how to carry out technical aspects of thechild’s care. Care needs to be taken, however, toensure that no pressure is put on the family to beinvolved in the care of a child if they do not wishto or feel they lack confidence. Sometimes it isjust as important for the family to get a rest as itis for the child to be given care.

6 Usual childcare practices, unless detrimental tothe child’s well-being, should be continued inhospital.There may be a number of ways of caring for

children and professionals may prefer some ofthese as opposed to others. However, families haveto make their own decisions about how to carefor their children and some of these choices maynot coincide with the view of professionals. Forexample, breast milk is generally recognized as

best for infants but bottle-feeding may be thefamily’s preferred option.

7 The impact of the sick child on the familyshould be evaluated and steps taken to ensuresupport continues as needed after discharge orin the event of death.Research has shown (Callery, 1997) that having

a sick child in hospital or at home can have signifi-cant social and financial impact on families. It isimportant that any problems in these areas areidentified and alleviated as much as possible.

Some of the skills and qualities you thought ofmay be listed in Table 5.1. Do not worry if youdid not think of all of these. There will be, nodoubt, some qualities that you have thought ofthat have not been included in the table.

These are some of the essential personal skillsand qualities that a children’s nurse shoulddevelop to deliver family-centred care. Havingthought about what skills and qualities might berequired by a children’s nurse let us now considersome of the reasons why children should be caredfor by children’s nurses.

WHY SICK CHILDREN NEEDCHILDREN’S NURSESSome people believe that children are essentiallysmall adults and thus do not need nurses specif-ically educated to care for them. This is far fromthe truth, not only do children grow, their bodiesare also developing. That is to say that the waytheir bodies work is different in many respectsfrom an adult.This means that a child’s physiologychanges over time until eventually they have thesame characteristics as adults.During this time manydifferences are apparent that the children’s nurseneeds to take account of. For example, children’stotal daily fluid requirements change with age and

Why sick children need children’s nurses 51

Reflective activityHaving read Nethercott’s main or key compon-ents of family-centred care, make a list of thequalities or skills the children’s nurse shouldexhibit to make family-centred care work.

weight and thus the nurse needs knowledge ofthese changes to ensure a child is receiving suffi-cient fluids for their needs. This is especially thecase when children develop illnesses that causefluid loss, such as diarrhoea and vomiting, which isrelatively common in young children.

As a child grows, the amount of any particulardrug that they may be prescribed needs to bealtered in response to changes in the child’sweight. Children’s nurses must therefore beadept at calculating the appropriate dosage of anydrug according to the child’s weight. This willprevent over or under dosage both of which canbe detrimental to the child’s continued goodhealth.

Children’s diseases are different from adults: seeTable 5.2 for a comparison of the commonest reasons why people ring NHS Direct for healthadvice for children and adults. In addition chil-dren respond differently to the same diseases thatadults may also experience. For example, most fitadults cope relatively well with a respiratory tractinfection, such as a cold. However a young childhas much narrower air passages than an adult, andany infection that causes inflammation or swelling

in the child’s air passages will cause a more signifi-cant degree of respiratory distress. This is becausethe child has less ‘spare capacity’ in the air passagesto cope with the narrowing that occurs in response


Table 5.1 Critical attributes of a nurse enabling family-centred care

Qualities and skills Reason for children’s nurse having the quality or skill

Be an informed, flexible practitioner Able to give clear and easily understood information to familiesEvidence-based practice Ensure that any advice or information given is up to date and

the best availableAble to adapt to different care delivery Able to adapt hospital routines to fit families’ needsNot see nursing as a source of power, but If families’ needs are to be cared for they need to become equalaccept parents as partners in care partners in their child’s careNurses should be advisors but should accept Parents need to make their own decisions about what is best that advice may be ignored for their child. (There may be some exceptions to this where a

child’s health or life is threatened)Nurses need to actively listen to families Families can only become true partners in care if their views are

listened to and taken seriouslyBe able to manage without the security Set routines may be fine for the nurse but they do not fit withoffered by routines and hierarchy a family’s usual patterns of careHave mature and refined interpersonal skills Nurses must be expert communicators and these are and self-awareness essential key skills in communicationNeed to be skilled in asking the right If the right questions are not asked how can the nurse know questions, listening to answers, helping the what the family’s needs are and how best to cater for them?family to understandHave knowledge of theories related to the Essential for the understanding of different families and their family and of the processes, which influence different needsfamily functioning

Table 5.2 Ten commonest symptoms on which advicewas sought from NHS Direct in 19991 (NationalStatistics, 20002)

Children Adults

Fever Abdominal painRash HeadacheVomiting FeverDiarrhoea Chest painCough Back painAbdominal pain VomitingCold/influenza Breathing difficultyHeadache DiarrhoeaHead injury Urinary symptomsIngestion (includes overdose

and poisoning) Dizziness

1Based on information collected monthly from 13 NHS Directsites between April and September 1999.2Source: Department of Health. Crown copyright material isreproduced with the permission of the Controller of HMSO andthe Queen’s Printer for Scotland.

to the swelling. Thus an infection that may causesymptoms of a cold in an adult can lead to severebreathing problems in the young child. Indeed, thecommonest reason for admission to hospital forchildren is respiratory problems (DoH, 2002b).Children’s nurses thus need to be vigilant for signsof respiratory distress when caring for childrenwith respiratory infections. Very young childrenare also unable to tell a nurse when they are hav-ing difficulty breathing, so being able to identifythe outward signs of respiratory distress becomes aparticular skill for the children’s nurse.

Children are also still developing their ability to think, use language and understand the worldaround them. This is termed cognitive develop-ment, and this must be borne in mind when com-municating with and caring for children. Taylor et al. (1999) have outlined some of the implicationsof cognitive development on the children’s nurse:

• Under 2s can best be communicated with viatheir parents.

• Under 7s are less able to see the links betweenmedical treatment and cure and may seeunpleasant treatments as punishment for somemisdeed.

• Under 7s find it difficult to have a concept ofthe internal workings of the body.They can onlyappreciate what they can see and experience.

• Over 12s can begin to imagine the implications ofchronic illness and sinister implications of pain.

Always check a child’s level of understandingbefore embarking on giving any information. Beaware of the implications of certain words beforeusing them with children, e.g. ‘cut’, ‘destroy’,‘remove’. Children over 7 years may appreciatethe use of analogies such as ‘baddies’ for germs and‘goodies’ for body defences but children under 7 years may take these terms too literally so checktheir understanding first.

It is clear then that the needs of children changeas they develop and the children’s nurse needs tobe aware of these changes and how to adjust careactivities and communication strategies to suit. Italso needs to be recognized that adolescents haveparticular needs as they emerge from childhoodinto adulthood. The children’s nurse may need toassist the adolescent and their family to under-stand the changes that occur and the particularneeds that become apparent during this period.

Let us now consider how a student can make themost of the learning opportunities presented in thevarious parts of the pre-registration nursing courses.

MAKING THE MOST OF THECOMMON FOUNDATIONPROGRAMMEThe CFP aims to equip all students of nursing,regardless of which branch they intended to study,with the skills, knowledge and understanding thatare common to all areas of nursing.This necessarilymeans that the content is generic in nature, that isto say applicable to all clients groups. For example,effective communication skills are central to nurs-ing in all spheres and there are very many ideas andskills associated with communication that apply to the care of children as much as adults. Clearlythere may be specific skills associated with caringfor children as outlined previously. Similarly, essen-tial nursing skills such as safe moving and handlingof patients, first aid, assisting a person to bath anddress are required by all nurses. The principlesunderlying all these skills apply equally whether itis children or adults who are being cared for.

Making the most of the Common Foundation Programme 53

Summary

• Children’s nurses practise in a wide varietyof contexts.

• Children’s rights are central to children’snursing.

• Three key rights for children are: equalityof rights; best interests; listening to thechild’s views.

• Care for children should be centred on thefamily.

• Children are different from adults andhave different health care needs due totheir stage of development.

• Children respond differently to certainconditions/illnesses.

• Children understand the world in a differentway than adults.

• Children’s nurses must learn to communicate effectively with childrenfrom birth to adulthood.

Social policy and sociological concepts or ideasare often incorporated into CFP learning and thiscan seem to have little to do with children’s nurs-ing. However as can be seen from the openingsection of this chapter, government policies havea significant impact on the way children’s servicesare delivered. Thus an understanding of wherethese policies come from and how they may beformulated is very important for a children’snurse. Indeed nurses need to demonstrate thatthey are fit for purpose (NMC, 2002).This meansthat nurses must be able to respond to the chan-ging needs of the health services (NMC, 2002) anda knowledge of health and social policy is essen-tial for this responsiveness.

It is not necessarily very easy when your motiv-ation is towards children’s nursing to appreciateperspectives on care from other disciplines.This isespecially the case if you have no previous experi-ence in children’s nursing and are desperate tobegin caring for children and their families. TheCFP can seem to be a long wait for the first con-tact with your chosen area of nursing. However,the learning of caring skills and competencies isessential as a baseline for developing an under-standing of children’s nursing. Reflecting on thecontent and experiences of the CFP with otherstudents and academic staff and thinking abouthow the knowledge and skills gained can be used in caring for children is an important aspectof a student’s personal development within thecourse.

STARTING IN PRACTICEIt is a daunting prospect for most students tothink of their first few days and weeks on a chil-dren’s ward. How are you going to survive? Oneof the issues that students say they are worriedabout, for example, is being asked a question by aparent or child and answering the phone. In factmany students report that, after a period in prac-tice placements, most of the questions that par-ents ask are fairly straightforward to answer andrelate to the environment of the ward rather thantechnical questions regarding their child’s care. Itis helpful then to try to find out the answers tothe questions that might be asked and thus beprepared beforehand.

You may have thought of issues such as thelocation of the toilets, where to get a cup oftea/something to eat, how to call for assistance,can you stay with the child, can I bath/shower mychild, what are the rules about watching televi-sion. There may be a host of other practical ques-tions that are probably very similar to thequestions a student has when they first start on ahospital ward or a placement in the community.Thus if the answers to such questions are estab-lished in the first few days of placement parents’questions can be answered with more confidence.

However, there may be a myriad of other ques-tions that children and families may ask, forexample when their child can have a drink, gohome, when may they re-start school. There is noshame for the student to admit he or she does notknow the answer. It would be unreasonable toexpect anyone new to an area to be able toanswer all the questions a child and family mayask. The best response in these situations is to behonest and say ‘I don’t know, but I will find outfor you [or get a more senior member of staff tohelp].’ Even the most senior nurses may not beable to answer all the questions a family may have,therefore students should not feel that they musthave the answers. In fact being asked a questionthat one does not know the answer to can promptdiscovery of the answer and add this to one’s ownknowledge.

Community placements can also create feelingsof anxiety for students. These feelings are oftenrelated to the unfamiliarity of the environment andbeing unsure what one is allowed to do and whatnot.This is particularly so when children are visitedin their own homes. Students often report feelinginadequate or like a ‘spare part’ when accompany-ing clinical mentors in community settings. It isimportant to recognize that it is normal to feelsomewhat out of place in what for the student is an


Reflective activityImagine that you are the parent of a 5-year-oldchild who has been admitted to hospital for thefirst time. Try to think of the questions you mayhave about the admission.

unfamiliar environment. Observing the practi-tioner and noting the interactions between thechild, family and practitioner is an important partof the learning process in community placements.

HOW TO GET THE MOST OUT OF A PLACEMENTThe primary responsibility of nursing staff is tocare for the children and families. Therefore theydo not necessarily always have time to thinkthrough what a student might need to learn orexperience while in their area. This is especiallythe case since most areas will have students at dif-fering stages of the course and even on differentcourses. This can make it difficult for clinical staffto be fully aware of each individual student’sneeds in terms of clinical learning. Thus the stu-dent who is well prepared, with an understandingof the learning outcomes specified for the place-ment, and able to inform their clinical mentor ofwhat activities they wish to focus on to achievethese will be in a good position to negotiate mean-ingful clinical experiences. For example, if a learn-ing outcome for a module specifies that thestudent should be able to assist in carrying out anursing assessment, the student should mention to the clinical mentor that he or she wishes toobserve an experienced nurse carrying out such anassessment. Then the clinical mentor can informother staff that if they are admitting a child theyshould invite the student to observe. The studentfor their part can make it their business to knowwhen a child is to be admitted and seek out the admitting nurse and request permission toobserve. If there are particular clinical nursingskills that the student needs to practise then this issomething to highlight with the clinical mentor.

ESSENTIAL SKILLS IN CHILDREN’SNURSINGIt would be impossible, in this text, to list all of theclinical nursing skills that should be learnt to be fitfor practice as a staff nurse. The skills that shouldbe learnt will range from day-to-day tasks such asmaking beds and administering medicines to thecomplex skills of teaching children and familieshow to continue care following discharge. Severaltexts are available outlining the range of clinicalskills needed by children’s nurses and guidelineson the delivery of those skills (Lawrence, 1998;Barber et al., 2000; Huband and Trigg, 2000).Most children’s nursing areas/teams will also havenursing guidelines that outline a wide range ofclinical skills and the standards expected in carry-ing these skills out. These nursing skills also needto be delivered to children of all ages and stages ofdevelopment from infants to adolescents. This isbecause children of different ages and stages ofdevelopment have particular needs in relation tovarious care activities. Taking a throat swab froman infant, for example, will involve techniques dif-ferent from those required when doing the samewith a toddler or an adolescent.

However, it needs to be acknowledged that it isnot possible to learn every skill that a qualifiednurse might need in the course of clinical practice.This is partly because there may not always be theopportunity to practise every skill during a pre-registration course. Learning new skills and refresh-ing existing skills continues after registration andthroughout a professional nursing career. None-theless it is necessary to be able to demonstrate

Essential skills in children’s nursing 55

Summary

• CFP aims to equip students with skills,knowledge and understanding of nursingcommon to all areas of care.

• Students should not be afraid to admitthey do not know something.

• Practice placements provide opportunitiesfor a great deal of learning.

• Students should take responsibility fortheir own learning.

• Ask lots of questions.• Try not to accept what others say on trust,

always ask for reasons why something isbeing said.

• Set personal objectives for learning inplacements.

• Develop good relationships with the clinical mentor.

competence in those nursing skills that enable theachievement of the competencies (NMC, 2002)for entry to the register of nurses. The NMC usesthe term competence to describe ‘the skills andability to practise safely and effectively without theneed for direct supervision’ (NMC, 2002 p. 9).These competencies are designed to ensure thenurse can give and direct the safe and effectivedelivery of nursing care, including wider skills such as the ability to work effectively in a multi-disciplinary team ensuring there is seamless deliveryof care between the community and hospital teams.The children’s nurse, working with adolescents whohave chronic conditions or long-term care needs,will also require skills in facilitating a smooth transi-tion for the adolescent from children’s health careservices to adult services at the appropriate time.

Contrary to appearances most children, bothwell and ill, are cared for in their own homes by thefamily, sometimes with the support of a children’snurse or other health professional specializing inthe care of children. Generally speaking childrenare only admitted to hospital when they cannot be cared for at home. It is widely accepted in chil-dren’s nursing that children are best cared for in thefamiliar environment of their own home.Thereforeit is likely that there will be placements in thecourse with either some or all of the following:

• Health visitor• School nurse• Community children’s nurse• Children’s outreach nurse• Specialist health visitor

A significant range of skills need to be learnedin the community. The nurse may be caring for achild in their own home and be more of an advisor and guide than a direct giver of care.Communication skills are particularly importantto facilitate good quality care for the child. Beingable to listen and take seriously the wishes of thefamily in relation to how the child is cared for isan important skill. If the child and family feeltheir views are taken into account it is more likelythat they will respect the opinions of the nurseadvising them. It follows then that learning tonegotiate care effectively is an essential skill thatcan be observed in community placements.

In the community the family are likely to begiving the bulk of the care thus the opportunitiesfor delivering direct ‘hands-on’ care may be limited. However where hands-on care is given bythe nurse in the child’s home particular consider-ation needs to be given to how any task might becompleted.The environment may be less under thecontrol of the nurse as he or she is a visitor in thehome. Any supplies or equipment needed to pro-vide care must be in the home already or taken inby the nurse. It is different from being in a hospitalwhere if something is forgotten or not available onthe ward it can be found from somewhere else.Thus there is a different emphasis on what is beinglearnt during community placements and thisshould be borne in mind when negotiating learn-ing experiences with a clinical mentor in commu-nity placements.

Wherever the student is placed for learningexperiences there are always likely to be challen-ging or difficult situations to deal with. It is import-ant therefore to identify some of these and suggestways in which they may be dealt with.

Emotionally challenging situations

Fortunately death is a rare occurrence in children’snursing except in intensive care areas, and eventhen it is not an everyday occurrence. Most chil-dren who are going to die do so in their ownhome. Even those who are cared for in a hospicetend to go home to be with their family in familiarsurroundings prior to their death. It is importantto realize that it is acceptable to get upset and toeven shed a tear or two.The families will also real-ize that you are human and not an unemotionalrobot (White, 1995).There are times when a childwill die unexpectedly and these are probably themost emotionally challenging times in a nursingcareer. It is important to recognize when the grieffelt personally reduces the ability to effectivelysupport the family. If this occurs it is best to let theclinical mentor or the senior nurse present knowand withdraw from the situation. Qualified chil-dren’s nurses are acutely aware that these are verydifficult situations for students and will oftenspend as much time comforting students andhelping them to come to terms with what hashappened as they do with the family. Often the


team will meet after the event and discuss feelingsabout what happened. It is important that stu-dents join in these discussions. It is essential thatany feelings about the death of a child are sharedand not bottled up inside as this will reduce theprospect of being able to deal with a similar situ-ation in the future. In time it is possible to learnhow to develop coping mechanisms that allow thenurse to effectively care for the family and at thesame time show their own emotions withoutdetriment to the ability to care.

Similar skills need to be developed with morecommon situations such as the child admitted insevere pain or who is critically ill. The essentialdifference in these situations is that often thenurse can do something to ease the child’s pain orrelieve the symptoms. Thus, while the child inpain is a distressing sight a great deal can be doneto alleviate the pain. The critically ill child can befrightening to deal with at first but with experi-ence the confidence in one’s ability to care for thechild grows and there can be a great feeling of satis-faction from providing care.The important fact tobear in mind is that the student is not alone and aqualified nurse should be on hand to assist. Thestudent may feel they are not much help in thesesituations but it must be remembered that allqualified nurses were once in a similar situation,and with time and experience skills are developedthat enable almost any situation to be effectivelymanaged.

There are not just the emotional demands ofchildren’s nursing to consider but also the phys-ical demands. Nursing is a physically demandingjob as much of the day is spent on one’s feet andit is possible to walk several miles in the course ofa shift. This is especially the case in areas wherechildren need to be escorted to other depart-ments within a hospital. There are also the shiftpatterns to consider particularly if the student isnot used to shift work. It can be demanding com-pleting a late shift, going home and not being ableto get to sleep because one is still ‘buzzing’ withthe activity of a busy shift and then having to getup for an early shift the next day. As a result ofthis it is important to keep physically fit and lookafter oneself especially in the early days of thecourse. This is particularly important in view ofthe fact that the student is likely to be exposed to

a great variety of infectious children, especially inthe winter months.

SOURCES OF KNOWLEDGE AND INFORMATIONThroughout the course and indeed during the restof a career as a nurse there is a need to ensure themost up-to-date information is used to gain ordevelop knowledge. Journals are usually the bestsource of the latest information because they arepublished on a regular basis.A number of journalsthat carry information, articles and research relat-ing to children’s nursing are available in orthrough most nursing libraries. Some of these willbe specialist children’s nursing journals, whereasothers will be general nursing journals that havearticles on or research reports relating to chil-dren’s nursing and health care.

Specialist children’s nursing journals

Journal of Child Health CareThis is the journal of the Association of BritishPaediatric Nurses and is published four times a year.

Sources of knowledge and information 57

Summary

• A vast range of skills need to be developed as a nurse ranging from theseemingly mundane bed-making to thehighly complex teaching children newskills to enable then to care for themselves.

• Skills acquisition continues after qualification.

• The NMC set specific competences to be achieved prior to registration (seeAppendix 1).

• Different skills may be learnt in hospitaland community placements.

• Learning to cope with emotionally difficult situations is an essential skill forchildren’s nurses.

• It is important to maintain personal fitness to be able to deal with the physicaland emotional demands of the job.

It has peer-reviewed articles written in a style andlevel similar to that required for academic essays.

Journal of Neonatal NursingThis is published every two months, and it is aspecialist journal for neonatal nursing publishingresearch articles. It provides information relevantto placements in neonatal areas.

Professional Care of Mother and ChildLargely a midwifery journal but it has a good num-ber of peer-reviewed articles of interest to children’snurses.

Paediatric NursingThis is a Royal College of Nursing journal, pub-lished monthly. It has news items and peer-reviewed articles on policy and practice. There isalso a useful reference list of recent research andsome critical reviews of recent research reports.

Archives of Diseases in ChildhoodThis is a medical journal with many articles relatingto care and treatment of childhood illnesses. Manyresearch articles relate to recent medical advances.It is not an easy read for the beginner. A fetal andneonatal edition is also published.

General nursing journals

British Journal of NursingThis is a general nursing journal with regular chil-dren’s nursing supplements. It frequently has art-icles relating to professional issues such as the lawand professional conduct, and many peer-reviewedarticles.

British Journal of Community NursingDistrict nursing and health visiting are the mainfocus of this journal but regular articles on chil-dren’s issues do appear.

Community PractitionerThis is the journal of the Community Practitionersand Health Visitors Association. Similar to theabove.

Journal of Clinical NursingA general nursing journal focusing on research intoclinical care. Regular children’s nursing focusedreports are included. It has mostly-peer reviewedarticles.

Nursing StandardGeneral weekly journal published by the RoyalCollege of Nursing. It has lots of news concerningnurses, some clinical articles and a few peer-reviewed articles.

Nursing TimesThis is also a general weekly journal with lots ofnews concerning nurses. Similar to above.

Journal of Advanced NursingThis journal is published fortnightly. It has peer-reviewed research reports, some of which arerelated to children’s nursing. It also carries usefulliterature review articles. Not easy reading for thebeginner.

Although the journals listed above are likely tocontain a good deal of the information andknowledge needed throughout the course thereare many other useful journals that should not beignored. It is essential that children’s nursing stu-dents recognize that even those journals that donot have a specific focus on children’s health careare a useful resource.

CONCLUSIONIt is important to remember throughout thecourse and on qualifying that it is not possible tobe an expert nurse after three years on the course.The pre-registration nursing courses are designedto enable a qualified nurse to:

• assess a child’s needs• plan care based on those needs• give or direct the giving of that care• evaluate the effectiveness of that care and take

appropriate action.

The course should provide a broad base for anynursing career and thus a great deal has to belearnt in the first few years of practice on qualifi-cation. The message then is clear. Be realisticregarding what can be achieved as part of thecourse. It is not necessary to learn everything andno-one should expect a newly qualified nurse toknow everything. It is sufficient to be able to prac-tise safely as part of a whole team in providinggood quality care to children and their family in avariety of settings. Use every available opportunityto learn and get the most out of each placement.


Not all placements will be completely enjoyableexperiences and students cannot like or be liked byeveryone. Try to use the less than excellent experi-ences as a learning experience to identify whatcould have been done to improve the situation.

The most important aspect of children’s nursingis to enjoy the learning and the children. It will behard work at times but ultimately worthwhile. Therewards of helping children return home on theroad to recovery outweigh the hard work and unsocial hours. There is also the prospect of a longand fruitful career with many opportunities todevelop in clinical practice, education, research ormanagement that make the hard work worthwhile.

GLOSSARYIn the context of this chapter the meanings of the followingwords are described:Clinical mentor A named qualified nurse whose role

is to facilitate learning and assess thestudent in the practice setting.

Clinical skills Skills used in the practice of nursing,for example giving an injection ordressing a wound.

Cognitive Development of the ability todevelopment think, reason and understand the

world.Evidence-based Nursing practice based on evidence practice to support that practice. Research

may be used as evidence to showthat a particular nursing care iseffective for a child. Child and/orfamily preferences may also be usedto show that a particular nursingintervention should be used.

General nursing Journal that carries articles relating journal to all areas of nursing including

children’s nursing.NHS Direct A 24-hour nurse advice and health

information service for the public,providing confidential informationon: what to do if you or your familyare feeling ill; particular health con-ditions; local health care services,such as doctors, dentists or late-night-opening pharmacies, self helpand support organizations (NHSDirect, 2003).

Orthopaedics Literally means ‘straight child’. Thisterm refers to surgery to either

correct some deformity of the bonesor treatment for a break or fracturewhich may or may not involve surgery.

Peer-reviewed Articles that have been read andarticles checked for accuracy and relevance

by an ‘expert’ in the field. Thus theconclusions drawn in such articlesare likely to be better informed andmore reliable than mere opinion.

Quality Protect Three-year programme launched in1998 by the UK government that setquality targets for the provision ofchildren’s services by local authorities.

Sure Start Government initiative involvingagencies at local and national levelworking together in new ways toimprove services for young childrenunder 4 years of age from disadvan-taged areas and their families.

REFERENCESAdoption and Children Act (2002) (Commencement No. 4)

Order 2003. London: The Stationery Office.Barber J, Campbell A, Morgan L (eds) (2000) Clinical Care

Manual for Children’s Nursing. Quay: Dinton.Callery P (1997) Paying to participate: financial, social and

personal costs to parents of involvement in their chil-dren’s care in hospital. Journal of Advanced Nursing25:746–52.

Coleman V (2002) The evolving concept of family centred care.In: Smith L, Coleman V, Bradshaw M (eds) Family-CentredCare. Concept, Theory and Practice. Houndmills: Palgrave.

Department of Health (2002a) www.doh.gov.uk/nsf/children.htm (accessed 21 March 2002).

Department of Heath (2002b) www.doh.gov.uk/HPSSS/TBL_B12.HTM (accessed 10 May 2002).

Department of Health (2003) Getting the right start:National Service Framework for Children. Standard forHospital Services. London: The Stationary Office.

Huband S, Trigg E (2000) Practices in Children’s Nursing:guidelines for hospital and community. Edinburgh:Churchill Livingstone.

Lawrence C (1998) Essential skills for paediatric nurses.Paediatric Nursing 10:6–8.

Laming L (2003) The Victoria Climbié Inquiry. London. TheStationery Office.

Miles I (1986) The emergence of sick children’s nursing.Nurse Education Today 6:82–7.

National Statistics (2000) Social Trends 30. London: TheStationery Office.

Nethercott S (1993) A concept for all the family. Family-centred care: a concept analysis. Professional Nurse 8:794–7.

References 59

www.doh.gov.uk/nsf/children.htm

www.doh.gov.uk/HPSSS/TBL_B12.HTM

www.doh.gov.uk/HPSSS/TBL_B12.HTM

www.doh.gov.uk/nsf/children.htm

NHS Direct (2003) Welcome to NHS Direct Online. www.nhsdirect.nhs.uk/index.asp (accessed 22 December2003)

Nursing and Midwifery Council (2002) Requirements forPre-registration Nursing Programmes. London: NMC.

Parker E (1996) Development of paediatric nursing. In:McQuaid L, Huband S, Parker E (eds) Children’s Nursing.Edinburgh: Churchill Livingstone.

Royal College of Nursing (1992) Paediatric Nursing. APhilosophy of Care. Issues in Nursing and Health.London: RCN.

Smith L, Coleman V, Bradshaw M (2002) Family-centredcare: a practice continuum. In Smith L, Coleman V,Bradshaw M. (eds) Family-Centred Care. Concept, theoryand practice. Houndmills: Palgrave.

Taylor J, Muller D, Wattley L, Harris P (1999) Nursing chil-dren: psychology, research and practice, 3rd edn.Cheltenham: Stanley Thornes.

The Adoption and Children Act 2002. London: The StationeryOffice.

The Children Act 1989. London: HMSO.The Human Rights Act 1998. London: The Stationery Office.The Protection of Children Act 1999. London: The Stationery

Office.United Kingdom Central Council (1999) Fitness for Practice.

London: UKCC.United Kingdom Central Council (2001) Fitness for Practice

and Purpose: The Report of the UKCC’s Post-CommissionDevelopment Group. London: UKCC.

United Nations (1989) Convention on the Rights of theChild. New York: UN.

White C (1995) Life crises for children and their families. In:Carter B, Dearmun A (eds) Child Health Care Nursing:concepts, theory and practice. Oxford: Blackwell Science.

Whiting M (2002) Children’s nursing education: towardsconsensus. Paediatric Nursing 14: 26–9.

ANNOTATED FURTHER READINGCarter B, Dearmun A (eds) (1995) Child Health Care Nursing:

concepts, theory and practice. Oxford: Blackwell Science.This British book examines in some detail the key con-cepts that underpin nursing practice using examples frompractice. There are some sections examining specific dis-ease processes but the main focus is on the principles of care that can be transferred into almost any nursingsituation.

Heath S (1998) Perioperative Care of the Child. Salisbury,Mark Allen. A relatively small and easily digestible bookspecifically focusing on the care of children and familiesbefore and after surgery.

Huband S, Trigg E (2000) Practices in Children’s Nursing:guidelines for hospital and community. Edinburgh:

Churchill Livingstone. A comprehensive guide to clinicalskills in children’s nursing. This very useful British textalso includes rationale and literature sources to supportthe guidelines. Offers insights into community as well ashospital clinical skills. Useful introductory chapter on keyconcepts in children’s nursing.

Moules T, Ramsey J (1998) The Textbook of Children’s Nurs-ing. Cheltenham: Stanley Thornes. A British children’s nursing book that provides a comprehensive guide to practice.

Smith L, Coleman V, Bradshaw M (2002) (eds) Family-Centred Care. Concept, theory and practice. Houndmills:Palgrave. A useful text that explores in detail one of thekey underpinning principles in children’s nursing. Thereare a number of case scenarios and case studies to help the reader understand the issues that are being discussed.

Taylor J, Muller D, Wattley L, Harris P (1999) NursingChildren: psychology, research and practice, 3rd edn.London: Chapman and Hall. This is a useful text consider-ing in some detail the psychological and emotional devel-opment and care of children. Some very useful critiques ofcurrent theories of child development that provide help-ful material for assignments are included.

Hockenberry M, Wilson D, Winkelstein M, Kline N (eds)Wong’s Nursing Care of Infants & Children, 7th edn. St Louis: Mosby. This comprehensive American text is nowin its seventh edition. A highly respected book that cov-ers virtually all one might wish to know about children’snursing. There are two drawbacks to note regarding thisbook. First, it is American and a number of things aboutAmerican nursing practice differ from British nursing andthese need to be borne in mind. Allied to this is that thelanguage, drugs, equipment and clinical measure-ments used in the books do differ in some cases fromBritain. The second drawback is the relatively high cost ofthe book.

As with all books that one is considering pur-chasing rather than borrowing from a library it isbest to borrow first. If you feel comfortable withthe way the text is laid out, the level of sophisti-cation of the language and the scope of informa-tion offered then buy it. However it is worthremembering that books can go out of datebecause they are not able to update as rapidly as ajournal that is published on a regular basis.

USEFUL WEBSITESAssociation of British Paediatric Nurses. www.abpn.org.uk/ –

contains useful information plus references for articles


www.nhsdirect.nhs.uk/index.asp

www.abpn.org.uk/

from back issues of the Journal of Child Health. There isalso a link to the electronic version of the journal.

Action for Sick Children. www.actionforsickchildren.org/ –action for Sick Children is the UK’s leading children’shealth care charity, specially formed to ensure that sickchildren always receive the highest standard of care possible.

www.internurse.com/ – this is an extensive internet resourcefor nursing with links to many articles references andscholarly papers plus news on the current debates innursing.

http://nmap.ac.uk/ – this internet resource for nursing pro-vides searching facilities for finding a wide range ofinformation on all nursing topics.

www.jiscmail.ac.uk – this internet discussion group can offerstimulating debate on current issues in children’s nursingand a resource for information. Two forums are particu-larly worth joining: Paediatric Nursing Forum and ChildHealth.

Royal College of Nursing. www.rcn.org.uk/index.php – theRCN website provides access to a wide range of informa-tion, resources and the students discussion forums. Thereis also a range of paediatric nursing forums at the RCNalthough membership of the RCN is required to accessthese.

USEFUL ADDRESSESAction for Sick ChildrenC/O National Children Bureau8 Wakley StreetLondon EC1V 7QETel: 020 7843 6444

Association of British Paediatric NursesNorman Long Membership Secretaryc/o School of Nursing and MidwiferyDe Montfort University266 London RoadLeicester LE2 1RQ

Royal College of NursingRCN Headquarters20 Cavendish SquareLondon W1M 0ABTel: 020 7409 3333Fax: 020 7647 3425

RCN Welsh BoardTy Maeth King George V Drive EastCardiff CF14 4XZTel: 029 2075 1373Fax: 029 2068 0726E-mail: [email protected]

RCN Northern Ireland Board17 Windsor AvenueBelfast BT9 6EETel: 02890 668236Fax: 02890 382188E-mail: [email protected]

NHS Careerswww.nhscareers.nhs.uk/index.htmlTel: 0845 60 60 655

Useful addresses 61

www.actionforsickchildren.org/

www.internurse.com/

http://nmap.ac.uk/

www.jiscmail.ac.uk

www.rcn.org.uk/index.php

www.nhscareers.nhs.uk/index.html


Perspectives on Mental HealthNursingBen Thomas and Robert Tunmore

6

INTRODUCTIONThe purpose of this chapter is to introduce stu-dents to contemporary mental health nursing as acareer option. The incidence of mental illness willbe described with emphasis on the extent anddiversity of its associated problems. Mental healthcare represents a continuum from primary care to highly specialized services. The multi-facetednature of mental illness and the range of servicesavailable to provide help, care and treatment areused to explore the roles and responsibilities ofmental health nurses. The emphasis throughoutthe chapter will be on the values and principleswhich underpin good mental health practice.These include the involvement of service usersand their carers, working in partnership, socialinclusion, equality, teamwork and clinical effect-iveness. The core of the chapter will discuss theattitudes, knowledge and skills required by men-tal health nurses, particularly in the developmentof an effective, therapeutic nurse–patient rela-tionship and the delivery of evidence-based inter-ventions.The educational pathway and preparationwill be discussed in relation to the acquisition ofskills and knowledge for mental health nursingtraining and the need for continuing educationand life-long learning. The chapter will concludeby highlighting future trends, recent policy initia-tives, advances in treatment and legislative reform,all of which impact on the future of mental healthnursing.

SCENE SETTINGAchievements within mental health nursing

The past 50 years have seen enormous changes formental health nurses both in their clinical practiceand the way they are prepared for their role.Fifty years ago there was little effective treatment.People with a mental illness were sent to large asy-lums. At the time physical treatments predomi-nated and mental health nurses were required tohave medical and surgical skills to assist withinsulin shock treatment, psychosurgery and elec-troconvulsive therapy. The 1960s brought in thewidespread use of pharmaceutical interventionsand a substantial increase in the understandingand management of mental illness. The resultingprovision of community care and the closure ofpsychiatric hospitals provided mental healthnurses with many opportunities and challenges.Despite the sometimes harmful and unwantedside-effects of prescribed medications there is nodenying that they have relieved and reduced someof the major symptoms and distress associatedwith mental illness, including hallucinationsand delusions. Pharmaceutical interventions havealso enabled a much more multi-dimensionalapproach to treatments, such as group therapy,psychosocial interventions, cognitive behaviouraltherapy and family interventions. These positiveadvances together with a movement towards a

more comprehensive range of care settings haveenabled mental health nurses to respond to theneeds of people with mental health problems witha range of evidence-based interventions that theycan apply in a variety of service settings includingprimary care, acute inpatient care and highly spe-cialized psychiatric units.

THE EXTENT AND INCIDENCE OFMENTAL ILLNESSIn the UK, mental health is one of the govern-ment’s four priority areas for the modernizationprogramme of the National Health Service (NHS)with one adult in six (13 million people) experi-encing one or other form of mental illness (Depart-ment of Health (DoH), 1999a). Mental healthconsumes 9 per cent of the NHS budget. In add-ition mental illness accounts for £32 billion of thehealth economy per year with £12 billion attrib-uted to lost employment and £8 billion in benefitspayments. Just as there are many different types ofphysical illness, mental illness is also multi-faceted.Mental illnesses range from the more commonconditions such as depression to the more complexcomplaints such as schizophrenia. Unfortunately,

due to a number of reasons, mental illness does notreceive the profile it deserves. This often results inmisunderstanding, stigma and variation in services.People with mental illness are often sociallyexcluded, have reduced opportunities for educationand employment and a lack of supportive networks.

As part of its modernization programme thegovernment is set to reverse this trend andlaunched a strategy and way forward for modernmental health services (DoH, 1998). The vision isto provide safe, sound and supportive services forpatients and users. Among the proposals is arequirement for the NHS and social services towork together to provide a seamless and inte-grated service. Mental health has been given amuch higher priority by the government with itsinclusion among its programmes of NationalService Frameworks (NSFs). The National ServiceFramework for Mental Health (Box 6.1) laysdown models of treatment and care that people can expect wherever they live. It spells outnational standards for mental health, which arefounded on sound available evidence, what isachievable, how they should be developed anddelivered and the ways performance will be meas-ured in every part of the country.

64 Perspectives on Mental Health Nursing

Box 6.1 The National Service Framework Standards

Standard One

Health and social services should:

• promote mental health for all, working with individuals and communities• combat discrimination against individuals and groups with mental health problems and pro-

mote their social inclusion

Standard Two

Any service user who contacts their primary care team with a common mental health problem should:

• have their mental health needs identified and assessed• be offered effective treatments, including referral to specialist services for further assessment,

treatment and care if they require it

Standard Three

Any individual with a common mental health problem should:

• be able to make contact round the clock with local services necessary to meet their needs andreceive adequate care

The extent and incidence of mental illness 65

• be able to use NHS Direct, as it develops, for first-level advice and referral on to specialisthelplines or to local services

Standard Four

All mental health service users on the Care Programme Approach (CPA) should:

• receive care which optimizes engagement, prevents or anticipates crisis, and reduces risk• have a copy of a written care plan which (i) includes the action to be taken in a crisis by service

users, their carers, and their care co-ordinators, (ii) advises the general practitioner how theyshould respond if the service user needs additional help and (iii) is regularly reviewed by thecare co-ordinator

• be able to access services 24 hours a day, 365 days a year

Standard Five

Each service user who is assessed as requiring a period of care away from their home should have:

• timely access to an appropriate hospital bed or alternative bed or place, which is (i) in the leastrestrictive environment consistent with the need to protect them and the public and (ii) asclose to home as possible

• a copy of a written after care plan agreed on discharge, which sets out the care and rehabilitationto be provided, identifies the care co-ordinator, and specifies the action to be taken in a crisis

Standard Six

All individuals who provide regular and substantial care for a person on CPA should:

• have an assessment of their caring, physical and mental health needs, repeated on at least anannual basis

• have their own written care plan, which is given to them and implemented in discussion with them

Standard Seven

Local health and social care communities should prevent suicides by:

• promoting mental health for all, working with individuals and communities (Standard One)• delivering high quality primary mental health care (Standard Two)• ensuring that anyone with a mental health problem can contact local services via an accident

and emergency department (Standard Three)• ensuring that individuals with severe and enduring mental illness have a care plan which meets

their specific needs, including access to services round the clock (Standard Four)• providing safe hospital accommodation for individuals who need it (Standard Five)• enabling individuals caring for someone with severe mental illness to receive the support which

they need to continue to care (Standard Six)

and

• supporting local prison staff in preventing suicides among prisoners• ensuring that staff are competent to assess the risk of suicide among individuals at greatest risk• developing local systems for suicide audit to learn lessons and take any necessary action

Source: Department of Health (1999b)

The government acknowledges that implemen-tation of the standards specified in the NSF willrequire additional staff, including nurses who aretrained and supported. To ensure the creation ofsuch a workforce the government has developed anaction plan to address the following:

• workforce planning• education and training• recruitment and retention• developing and supporting leadership.

In addition the action team provides nationalleadership in developing and taking forward theworkforce plan. Following an assessment of theworkforce implications of the NSF the WorkforceAction Team proposed a mixture of practical, short-term initiatives to support the NSF and longer-term, more radical thinking which are meant tochallenge some of the ways in which mental healthworkforce issues have been addressed previously.Included in the recommendations is the expect-ation that every region will map current educationand training provision against the core competen-cies required to deliver the NSF (Brooker et al.,2000). The Workforce Action Team also recom-mends the exploration of recruiting more profes-sionally non-affiliated people and providing themwith appropriate training. For example graduatemental health workers, support time recoveryworkers and gateway workers.

In parallel with these developments the DoHcommissioned the Sainsbury Centre of MentalHealth to establish a single agreed set of the com-petencies required to deliver each of the NSF stand-ards. In October 2000 the Sainsbury Centre forMental Health produced the Capability Frameworkand the list of practitioner capabilities required toimplement the NSF. The report defines ‘capability’by the following dimensions:

• a performance component which identifieswhat people need to possess and what theyneed to achieve in the workplace

• an ethical component that is concerned withintegrating a knowledge of culture, values andsocial awareness into professional practice

• a component that emphasizes reflective practice

• the ability to effectively implement evidence-based interventions in the service configur-ations of a modern mental health system

• a commitment to working with new models ofprofessional practice and responsibility for life-long learning.

The capabilities in the new framework are notspecific to any profession and combine the notionsof the effective practitioner with that of the reflect-ive practitioner.The Capability Framework consistsof values, attitudes and knowledge in addition tocompetencies along with an ability to apply these inpractice across a range of clinical contexts. TheFramework for Capable Practice produced by theSainsbury Centre for Mental Health is shown inAppendix 4 on page 147.

Mental health nursing has often been threatenedby the ambiguity expressed over the role of themental health nurse in the multi-disciplinary set-ting and the calls for more blurring of professionalroles.The recommendations for core competenciesfor all mental health staff and the suggestion formore professionally non-affiliated people to workin mental health may also be seen as a threat to theprofessional status of mental health nurses. Beforeexploring why the mental health nurses are essen-tial members of the multi-disciplinary team it isworth reiterating one of the main findings of theSainsbury report Pulling Together: the future rolesand training of mental health staff (1997):

the review found little evidence or support forradical reconfigurations of current professionalboundaries. There is great value in diversity andeach of the current mental health professionshas strengths and skills to offer for the servicesof the future.

Why do we need mental health nurses?

‘Making a difference’ how mental healthnurses are different and why they need to beFifty years ago the General Nursing Council(GNC) syllabus (GNC, 1957) reflected the beliefthat psychiatric nursing was very similar to generalnursing (Thomas, 1992). A number of reportssince have examined the roles and functions ofmental health nurses. In 1968 a major review by


the Ministry of Health highlighted the importanceof counselling and psychotherapeutic skills. Thereport recognized that mental health nurses wererequired to play a much more active therapeuticrole and should be prepared accordingly. In add-ition to preparing nurses for advanced clinicalroles, such as psychological treatments includingbehaviour therapy, the importance of the thera-peutic relationship was recognized. The thera-peutic relationship is seen as central to effectivecare and much research has been carried out toidentify the components of forming a good workingrelationship and its helpful, beneficial elements(Altschul, 1972; Cormack, 1983).

Despite the potential for mental health nurses toexpand their therapeutic role, progress in generalwas slow, particularly on acute wards and recentlythe nature of the nursing work has begun revertingback to a custodial role. The introduction of thetheory-orientated Project 2000 (UKCC, 2000) curriculum with its 18-month common foundationprogramme (CFP) also left many mental healthnurses feeling inadequately prepared for their rolesand lacking in practical skills. It was against thisbackground that another ministerial review ofmental health nursing took place.The review team,under the chairmanship of Professor Butterworth,were asked to ‘Identify the future requirements forskilled nursing care in the light of developments in the provision of services for people with mentalillness’.

The Mental Health Nursing Review Team’sreport (DoH, 1994) concluded that mental healthnurses should focus on people with serious andenduring mental illness. In addition when address-ing the individual needs of patients wherever pos-sible the patient or service user should be fullyinvolved in the care process including the devel-opment of care plans. The report clearly identifiedthe core skills of mental health nurses but remainedcritical of the lack of post-registration courses andexpressed concern over recruitment to mentalhealth nursing. Working in Partnership (DoH, 1994)captured the essence and the principles under-lying user involvement and user empowerment.The report recommended that:

Mental health nursing should re-examine everyaspect of its policy and practice in the light of

the needs of the people who use services.Nursing services should be designed and developed to meet the needs of service usersand people should not be expected to conformto the convenience of the service.

Working in Partnership set a major challenge formental health nurses. It questioned accepted prac-tice and enabled mental health nurses to becomethe forerunners at facilitating user involvementand treating people who use mental health servicesmore as equal partners rather than passive recipi-ents. Most recently, the Chief Nursing Officer’sReview of Mental Health Nursing, due to be pub-lished early in 2006, is likely to include changesand improvements for pre-registration trainingprovided in both academic and practice settings(DoH, 2005).

Users’ rights and user involvement

The mental health service user movement has along history, however, it is only since the mid-1980s that the cause has gained momentum in theUK. Since that time many improvements broughtabout in mental health services have occurredbecause of listening to and working with the people who use the services.The first of 10 guidingvalues and principles underpinning the NationalService Framework for Mental Health (DoH,1999b) clearly identifies the expectation that ser-vices will involve service users and their carers in the planning and delivery of care. A range ofmodels have developed all seeking to integratemore genuine participation of service users andcarers. These include patient satisfaction surveys,newsletters, user and carer support groups, advo-cacy projects, patients’ councils and user-focusedmonitoring of services (Rose et al., 1998).

It has been suggested that on occasions mentalhealth nurses will act as advocates for patients toempower them to make informed choices. Actingas the patient’s advocate is often claimed as anintegral part of the mental health nurse’s role. TheRoyal College of Nursing (RCN, 1991) definesadvocacy as ‘a process of acting for and on behalf ofsomeone who is unable to function themselves’.The principle of advocacy has been included in theInternational Council of Nurses’ Code since the

The extent and incidence of mental illness 67

early 1970s.The RCN included advocacy as a prac-tice function in its document The Nature and Scopeof Professional Practice (RCN, 1991). Howeverdespite official endorsements from internationaland national nursing bodies, advocacy in nursinghas not been universally understood, accepted oradopted. The reasons for this are multi-faceted. Ina review of the literature Mallik (1997) found thatdespite a considerable increase in the claims bynurses to undertake the patient advocacy role, inthe past 20 years confusion still exists about thecomplexities and potential problems inherent inthe role of advocate.

In describing the history of advocacy in mentalhealth David and Toby Brandon (2000) raise thethorny issue of professionals acting as patient advo-cates. Although the nurse–patient relationshipremains pivotal to mental health nursing, the advo-cacy role is increasingly undertaken by independentagencies. Currently a range of advocacy agenciesexist well outside of conventional mental healthservices where independence is the fundamentalprinciple. These advocates offer a range of servicesincluding advice, information giving, befriending,support and practical assistance.Although there is anew legitimacy and availability of advocacy serv-ices, Kerr (1997) suggests that the keys to successfuladvocacy are accountability, focus and support. Heproposes that advocates must be answerable notonly to their clients and potential clients, but also totheir funders and the professionals with whom theywork. Advocates must seek to engage with all par-ties on a basis of trust and co-operation according to Kerr. Finally he suggests that there is nationalneed to evaluate advocacy services and for greatersharing and learning between projects.

The NHS Plan (DoH, 2000) emphasizes theimportance of putting the patient at the centre ofthe NHS. The resulting publication of the Healthand Social Care Bill (House of Commons, 2000)addresses these arrangements and covers thedevelopments in the planning of a more robustsystem of patient and public involvement.The newarrangements offer a broader scope of involvementincluding:

• all NHS organizations have a statutory duty to consult and involve patients and the public

• there will be a patient’s forum for each NHStrust and each primary care trust (PCT)

• patients’ fora will be independent statutorybodies, whose primary function is the monitor-ing and review of health services from thepatient’s perspective.

WHAT CAN BE ACHIEVED THROUGHEFFECTIVE MENTAL HEALTH NURSING?Evidence of value of mental health nursing

As well as putting the service user first, contem-porary mental health nursing seeks to providecare in accordance with the best available evi-dence. Rather than nursing care being based upontraditional custom and practice, nurses areexpected to know the available evidence whichsupports the interventions of their choice. Theavailable evidence should also be integrated withindividual clinical experience and service userchoice (Geddes et al., 1999). However, there aremany mental health nursing interventions whereinformation is imperfect and there is a shortage ofevidence. Even when evidence is available, it isbased on a small number of studies which oftenlack scientific rigour. Also there is the practicalproblem of accessing the necessary information.There are, however, a number of ways to accessup-to-date good quality research findings andclinical guidelines. Generally, there are five mainlevels of evidence:

• randomized control trials• systematic reviews• non-randomized experimental studies• non-experimental studies• expert opinion.

Accepted methods of accessing such evidenceinclude searching databases, journals and bul-letins such as Evidence-Based Mental Health (seeUseful websites at the end of this chapter).

Evidence-based practice

Like other professional groups mental health nurseshave found it difficult to implement research findings into clinical practice (McKenna, 1995;Yonge et al., 1997). However, more recently a num-ber of research-validated interventions, although


not widely disseminated, have become more estab-lished in nursing practice. These include psychoso-cial interventions which are normally divided intothree main categories according to their generalaims and clinical procedures (Tarrier et al., 1998)These are:

• Family interventions• Cognitive–behavioural therapy (CBT)• Early sign monitoring and early interventions

Family interventionsFamily interventions arose primarily from researchon expressed emotion (EE). Rigorous studies haveconsistently shown that service users who returnedhome to live with relatives and who rated high onEE were much more likely to relapse than thosewho went back to live with relatives having lowEE (Kavanagh, 1992). In the belief that changingthe behaviour of relatives with high EE wouldreduce the risk of relapse, a number of interven-tions have been designed to lower stress in thehome situation. Common features among theseinterventions includes an educational, information-giving aspect, a problem-solving approach andassisting the family to develop coping strategies.Tarrier et al. (1998) suggest that methodologicallysound clinical research has consistently found thatfamily intervention in conjunction with prophy-lactic medication reduces relapse rates in peoplewith schizophrenia, at least in the short andmedium term. However, despite these findings thenumbers of mental health nurses who carry outfamily interventions remain low.

Cognitive–behavioural therapy for psychotic symptomsSince the 1990s research is showing increasinglythat psychotic and affective symptoms can bereduced using CBT.These interventions consist ofa number of different treatments including prob-lem solving, coping strategy enhancement andmanagement of auditory hallucinations.Althoughthe results are encouraging most of the researchso far has been single case design (Fowler et al.,1995). Controlled trials will add to our body ofknowledge about the effectiveness of CBT in thetreatment of psychotic symptoms. Many mentalhealth nurses have now been trained in CBT.

Early interventionEarly intervention in psychosis usually involvesthree main areas:

• services based in primary care• intensive treatment at onset• detection of prodromal signs in people prone

to relapse.

Hirsch and Jolley (1989) found that 70 per centof service users who relapsed complained of ‘a fear of going crazy’.This led them to believe thatservice users can usually tell when they are becom-ing unwell but can not always articulate or definethese feelings. Birchwood and Shepherd (1992)demonstrate that early intervention at the first signsof relapse including stress reduction and a review ofmedication are effective in preventing relapse.Mental health nurses have a key role to play helpingservice users and their carers identify and monitorthese early signs and seek appropriate treatmentsooner. For a fuller review of the latest evidence inthese approaches see Wykes et al. (1998).

As previously mentioned a number of studieshave examined the impact of psychosocial inter-vention training on routine nursing practice.Unfortunately implementation remains problem-atic for a number of reasons. These include out-dated teaching methods, organizational barriers,resistance to change and lack of clinically compe-tent supervisors.

The Report by the Standing Nursing andMidwifery Advisory Committee (SNMAC), (DoH,1999c) suggests that in recent years the focus ofeducation, training, status and career opportun-ities have all shifted from acute in-patient care tothe community and specialist services. Despite theincreasingly demanding nature of in-patient care itis not seen as an attractive area to work in and doesnot attract the required expertise. The SNMACsub-committee found a number of skill deficits inmental health nurses working in acute in-patientsincluding evidence-based cognitive, behaviouraland family interventions.

Many of the new mental health nurse trainingprogrammes are addressing these deficits. Forexample the Thorn Programme aims to equipnurses with skills in a range of interventions tomeet the needs of people with psychotic symp-toms and their families. Students are taught casemanagement, CBT and family interventions.

What can be acheived through effective mental health nursing? 69

Unfortunately, as previously mentioned good-quality evidence is not available in all areas andwhere it is lacking it is important to seek outestablished clinical principles, procedures, poli-cies and guidelines from professional organiza-tions, for example Practice Guidance: safe andsupportive observation of patients at risk (SNMAC,1999).

The drive for evidence-based care is long over-due. Most mental health nurses have been taughtto avoid doing harm while trying to help peoplewith mental health problems on the road torecovery. Unfortunately, even today few of theinterventions used have been found by scientificresearch to be of established benefit. This paucityof knowledge is not just peculiar to mental healthnursing but persists throughout the profession.While, at last, some headway has been made inthe identification of useful interventions, for theforeseeable future, mental health nurses will con-tinue to provide care without knowing if what weare doing is effective.The balance between poten-tial benefit and risk has to be assessed in every situation.

CLINICAL GOVERNANCE, CLINICALEFFECTIVENESS AND RISKMANAGEMENTClinical governance is the umbrella term for allthose activities aimed at improving patient care.Some of these have already been described in theprevious sections. In addition clinical governanceinvolves clinical effectiveness; the setting, deliver-ing and monitoring of standards; clinical audit;creating an open learning culture and sharinginformation. Clinical governance is underpinnedby leadership, continuing professional develop-ment and professional self-regulation. All of theseconcepts are central to current health reforms.

Clinical effectiveness is about doing the rightthing in the right way for the right patient.

(RCN, 1996)

In addition to making sure the care provided isbased on sound research evidence and informedservice user preference, clinical effectiveness involvesa consistent approach. It is important that men-talhealth nurses are able to think about and questiontheir practice. To do so they need to work within aculture that encourages open and frank discussions;a culture where reflection and learning from experi-ence is part of day-to-day practice. This includesacknowledging what is effective and works, learningfrom mistakes and what is ineffective. In order toencourage such learning, there must be a blame-freeculture rather than one that is punitive and wherestandard practice is to take disciplinary action.

KNOWLEDGE AND SKILLS OF MENTAL HEALTH NURSESWorking in Partnership (DoH, 1994), the report of the mental health nursing review team, identi-fied the skills of the mental health nurse in relationto the phases of the nursing process; assessment,planning, implementation and evaluation. A widerange of specific skills are identified under broadheadings related to each phase. Box 6.2 provides afew examples from the whole range. It is these coreskills, based on the therapeutic use of self in thenurse–patient relationship, in conjunction with aclient-centred philosophy, values and practice that


Summary

The emphasis in mental health care ischanging towards evidence-based practice.However, it is not enough for interventionsto have proved therapeutic effectiveness.They must be acceptable to service users andbe delivered sensitively, otherwise they willbe regarded as ineffective. It is thereforeimportant to gather evidence through theuse of patient feedback. Service users canprovide valuable feedback on the quality ofcare they receive. For example a number ofstudies have investigated what service usershave found helpful about the care providedby mental health nurses (Beech and Norman,1995; Cutcliffe and Bassett, 1997). Thisgrowing body of evidence suggests that service users find nursing interventionsbased in human relationships, includingempathy, respect and dignity, and good communication skills most helpful.

Knowledge and skills of mental health nurses 71

Box 6.2 Working in Partnership: skills of the mental health nurse

Assessment

• Self-awareness, e.g. awareness of one’s own degree of attention to others• Observing, e.g. how others react to the individual• Data collection, e.g. awareness of sources of data – individual, family and significant others

including other professionals• Interviewing, e.g. listening and attending• Identifying needs and diagnosing problems, e.g. recognizing issues amenable to nursing inter-

vention and identifying those which need to be referred to others• Recording and disseminating information, e.g. organizing, documenting, charting, processing

and assembling information

Planning

• Identifying solutions, e.g. using problem-solving skills to generate creative solutions• Setting goals, e.g. setting short-term and long-term objectives of nursing care, taking account of

the policies of the organization• Formulating plans, e.g. setting the criteria of evaluation for measuring the achievement of

objectives• Communicating, e.g. negotiating the care plan with the individual and the care team• Producing the plan, e.g. writing a clearly expressed unique nursing care plan which can be

understood by all grades of the multi-disciplinary team

Implementation

• Planned intervention, e.g. modifying objectives in the light of further information• Motivating, e.g. using positive incentives, persuasion, suggestion, appropriate rewards• Teaching, e.g. identifying and agreeing learning needs• Managing, e.g. maintaining a positive attitude• Meeting personal care needs, e.g. promotion of independence• Organization, e.g. effective organization of the environment

Evaluation

• Defining results, e.g. identifying methods of evaluation• Obtaining feedback, e.g. discriminating between what is valid and invalid• Assessing results, e.g. assessing the validity and reliability of data of the evaluation• Identifying process changes required, e.g. using the results of evaluation to reconsider nursing

care plans• Creating opportunities, e.g. identifying realistic short- and long-term goals for change• Reviewing overall performance, e.g. reviewing with the team the results achieved• Managing success/failure in achieving goals, e.g. identifying what was effective and ineffective

within the constraints• Recording and communicating, e.g. documenting the progress achieved against

criteria

Source: DoH (1994)

is responsive to individual need that provides theunique experience of mental health nursing.

While it is important to identify and articulateclearly core skills, values and knowledge – theunique contribution of mental health nursing – it isimportant to see the relationships between theseattributes and those that are common to the nurs-ing profession as a whole and to other professionaland occupational groups.The Sainsbury Centre forMental Health has addressed the future roles and

training of mental health staff. Pulling Together(1997) identifies the skills, knowledge and attitudesrequired in mental health services across differentprofessional groups. The report sets out core com-petencies for working with adults with severemental illness (Box 6.3) as the basis for a trainingframework providing ‘fitness for purpose’ of staffworking with people with severe mental illness.The unique and various skills of the different discip-lines may be built around such a framework.


Box 6.3 Core skills, knowledge and attitudes for mental health workers

Management and administration

• Knowledge of current systems of care and the policy background (CPA, supervision registers,community care and care management procedures, functions and organization of primary care)

• Understanding of mental health law and related legislation, especially in relation to users’ civilrights and powers of compulsion and detention

• Understanding the roles of the various disciplines and agencies involved in the provision ofmental health care and the range of settings within which care and treatment take place

• Awareness of the role and contribution of non-specialist and support staff, and the ability tosupervise and provide support to those staff

Assessment

• Skill in conducting a collaborative needs-based assessment• Ability to develop a treatment and care plan based on a thorough and comprehensive assess-

ment of the client, family and social system• Apply knowledge of the issues and skill in the assessment and management of the combined

problem of drug and alcohol abuse and mental illness• Skills in the assessment of users’ needs and requirements of housing, occupation and income• Apply knowledge and skill in risk assessment and the management of violence and aggression• Apply knowledge of factors related to the development of ‘chronic crises’ and skill in assess-

ment and management strategies

Treatment and care management

• Knowledge of the priority target group, their needs, characteristics and clinical symptomatology• Knowledge of crisis intervention, theory and practice• Effective understanding of current medical interventions and possible side-effects• Knowledge of basic current cognitive–behavioural strategies to assist users, carers and family

networks to contain and manage a severe and enduring mental illness• Understanding of the issues in the evaluation and treatment of service users at risk of self-harm

or suicidal behaviour• Knowledge and skill in effective interpersonal communication• Awareness of cultural and gender issues in mental illness and an awareness of the principles and

practices of anti-discriminatory and anti-racist practice

The United Kingdom Central Council forNursing Midwifery and Health Visiting (NMC,2004; DoH 2001, 2004) have identified fourdomains common to all areas of nursing alongwith competencies required for entry to the regis-ter. These competencies – common to all areas ofnursing – are the starting point of a career in nurs-ing (see also Appendix 2). Specific competenciesor benchmarks for mental health nursing to beachieved on completion of the mental healthbranch programme have also been identified andcross referenced with the UKCC competenciesand domains (The Northern Centre for MentalHealth and The Northern and Yorkshire RegionalEducation and Workforce Development Subgroupfor Mental Health, 2000). This marks a newdevelopment in the pre-registration programmefor preparation and registration as a mental healthnurse. The next section addresses nurse trainingand education.

MENTAL HEALTH NURSINGEDUCATION AND TRAININGThe ENB (2000) and the UKCC (1999) identifybroad guiding principles that underpin require-ments for programmes leading to registration on

the professional register as a qualified nurse.Theseguiding principles are related to competencies andoutcomes that need to be achieved during theperiod of training and preparation and provide thefoundation for outcome-based competencies.

In September 2000 a new model of trainingstarted in 16 university pilot sites across the UK.This new outcomes competency-based model had its roots in the government’s White PaperMaking A Difference (DoH, 1999d). This calledfor a common approach to definition of outcomes for programmes leading to registration to ensurethat newly qualified nurses and midwives are fit topractise.

A Commission for Education was establishedby the UKCC in 1999 to address plans to improvenurse education and training. Priorities included:

• more flexible career pathways into and withinnursing and midwifery education

• develop a training system that is more respon-sive to the modern NHS

• stronger practical orientation to pre-registrationtraining.

Fitness for Practice, the report of theCommission for Education (UKCC, 1999) (alsoreferred to as The Peach Report after Sir Leonard

Mental health nursing education and training 73

• Knowledge and skill in creating therapeutic co-operation and developing an alliance with theservice user

• Awareness of the needs, characteristics and principles of care for homeless people with mentalillness

• Knowledge and skill in the provision of assertive outreach and long-term continuing care• Awareness of the needs, characteristics and principles of care for forensic patients• Awareness of user perspectives on the provision of treatment and continuing care• Knowledge of care management principles

Collaborative working

• Awareness of the need to work in partnership with carers and social networks• Ability to work effectively as a member of a multi-disciplinary mental health team through

clarity about the role and purpose of the team and its individual members• Understanding of sources of conflict and development of basic teamwork skills including

negotiation and conflict resolution• Comprehension of the need for and willingness to participate effectively in multi-disciplinary

teams

Source: Sainsbury Centre for Mental Health (1997)

Peach, Chair of the Commission) reviewed evalu-ations of Project 2000, established in the 1980s asthe means of preparing nurses and midwives, identi-fying its achievements and deficits. Identifyingkey drivers for change, the report of the Commis-sion established a new approach to training,building and maintaining a workforce for theNHS. This new model of health-needs-led educa-tion would focus on:

• the contemporary and anticipated needs ofhealth care

• an outcome-based competency approach tofitness for practice

• sound assessment of practice and its integra-tion with theory.

This new approach would provide:

• A consistent, standardized approach to nurseeducation

• Wider access to nurse training• Strengthening links between vocational train-

ing and pre-registration education• Vocational pathways into nurse training• More part-time training opportunities• Fast-track nurse training• Recognition of life experiences as preparation

to be a carer• Students to feel part of the NHS• NHS employers recognize their obligation to

students.

OUTCOMES-BASED COMPETENCEFOR NURSE EDUCATIONCommon Foundation Programme

A 1-year CFP prepares students to a common levelof competence for entry into the branch pro-gramme. Standards for entry to the CFP and thebranch programmes have become more flexible.National Vocational Qualifications (NVQs), accessprogrammes,Accreditation of Prior Learning (APL)and Accreditation of Prior (Experiential) Learning(AP(E)L) are increasingly recognized for entry intonurse training. Both diploma and degree-level path-ways to mental health nursing are available.

Widening access and flexibility may be moreattractive to health care assistants, nurse cadets

and support workers necessary for the workforceof the modern health service. Training shouldallow breaks in studies at specified points – allowingyou to work in the health service – with recogni-tion and reward for your achievement and experi-ence to date. Those students who wish to leavethe training programme at the end of year 1/CFPwill be awarded both academic and practicecredit according to their experience relating tothe appropriate credit framework, e.g. creditstowards NVQs/SVQs.

During year 1, the CFP and throughout thebranch programme students are introduced to and experience a range of different approaches toteaching and learning. While this involves the pro-vision and acquisition of information and knowledgethrough lectures and tutorials, an increasingamount of training and education involves morelearner-centred approaches. The emphasis of theseapproaches is on output and outcomes – the iden-tification and provision of evidence to validatecompetence.

Being competent involves more than being ableto demonstrate an ability to carry out certain tasks.Competence is defined in Fit for Practice as ‘theskills and ability to practise safely and effectivelywithout direct supervision’ (UKCC, 1999). Theincreased emphasis on practise-based learninghighlights the importance of learning that takesplace in the practice setting as an important part ofthe academic award.

Outcomes-based education is student-centred and facilitative – an approach which acknowledgesthat learning takes place in a practice setting is as valuable as that taking place in an academic insti-tution. Outcome-based standards address compe-tence in both theory and practice. In the CFP thereis early emphasis on practice skills and learningfrom clinical experience gained in clinical place-ments. Learning outcomes are achieved throughthe development of knowledge and understandingfacilitated through group work and work-basedlearning. Experiential and problem-based learningskills laboratories and information technology areeducational approaches that may be used to facili-tate learning during practice placements.

Educational progression is monitored throughthe use of evidence-based practice portfolios, self-assessment and reflective accounts of learning from


clinical experience. These portfolios are used toprovide evidence of rational decision-making andclinical judgement demonstrating a student’s fit-ness for practice. During periods of clinical experi-ence your practice will be assessed by a trainedassessor against specific performance criteria rele-vant to the stage of the programme. The practiceportfolio is used to keep a record of observationsrelated to these performance criteria. These countas evidence, measures of progress and experiencetoward the outcomes of the programme.

What is the mental health branch?

The mental health branch, normally two years induration, is the route to professional registrationas a mental health nurse. Mental health nurses usethe relationship they develop with an individualwho has mental health problems to help themcome to terms with, gain an understanding of andcope with their experience. To achieve this stu-dents undertaking the mental health branch needa sound understanding of social interaction andsocial relationships, positive and negative effectsof responding to and managing stress, crisis andchange among individuals and groups. They alsoneed to know what they bring to their relation-ships with others, an awareness of their own per-sonal attributes and characteristics and the effectof these on their relationships with others.

This may seem a tall order to achieve in a life-time let alone a 2-year branch programme. How-ever, these attitudes and values are central tomental health nursing and are developed throughthe branch programme. Like most occupationsand professions, mental health nursing has its ownshare of stereotypes and clichés – some negative,some positive – for example:

• ‘They just sit around drinking cups of tea’• ‘Laid back’• ‘Wanting to psychoanalyse everybody’• ‘In it to sort themselves out’• ‘Able to “simply” be with someone when they

are distressed and having a bad time – it actu-ally takes great personal strength’

• ‘Totally non-judgemental’• ‘Well-grounded individuals’• ‘Treating each individual as unique’

• ‘They are really good listeners – they engageand involve people who would otherwise beexcluded’

• ‘They see the whole picture – where the indi-vidual is on their own life journey’.

An interest in and sense of the way peoplerelate to each other, how they feel about them-selves and about others, developing and usingself-awareness, self-confidence and self-esteem ineveryday interactions are important qualities thatcan be further developed as a mental health nurse.The ability to be with someone, simply andcalmly, for them, while they are acutely distressed –rather than try to make things better, explain why,or change the subject – things most people do to make themselves feel more comfortable aboutsomeone else’s distress – is an important qualityamong nurses and carers, but particularly so amongmental health nurses. The expression ‘Don’t justdo something – sit there!’ is rather apt.

Supervised practice and preceptorship

Towards the end of the mental health branch allstudents undertake a period of supervised clinicalpractice where they consolidate their educationand competence in practice. This period, nor-mally at least 3 months in duration, is a transi-tional period with clearly specified role-relatedoutcomes that is managed by a specifically pre-pared registered nurse.

Following registration, and on commencementof employment as a mental health nurse all newlyqualified practitioners undergo a period of pre-ceptorship. This involves a planned and organizedinduction programme with the support they willneed to assume the role and responsibilities of aqualified practitioner who is accountable for hisor her own clinical practice.

CLINICAL EXPERIENCEThe outcomes-based competency curriculummarks the most recent change in the preparationand training of nurses, a change that shifts theemphasis onto the clinical practice setting for thedevelopment of the necessary skills, knowledge

Clinical experience 75

and understanding. Currently student nurses areexpected to spend 50 per cent of their training inclinical placements.

In the past, the quality of the learning environ-ment and practice experiences have varied con-siderably from one placement to the next. One of the main aims of the outcomes-based compe-tency curriculum is to improve the overall qualityof learning from clinical experience. This involveslonger placements and initiatives that make clin-ical placements a better, more supportive learningenvironment for the student. These includeincreased teacher support for students on place-ment and increasing the number of staff involvedin supporting students who have joint appoint-ments between universities, NHS trusts, socialcare and other service organizations, for examplelecturer practitioners and practice educators.

Longer practice placements allow students todevelop a range of skills, including interpersonalskills with individuals experiencing mental healthproblems and working with groups of clients overa period of time. Longer placements will also allowstudents to experience how the organization ofnursing work, i.e. day and night shifts covering 24-hour periods seven days a week, out-reach, liai-son and consultation impact on the care of clientsin different settings. They will gain a better under-standing of working practices in the health careenvironment.

Placements should reflect service delivery andare likely to involve services for the elderly men-tally ill, acute in-patient units, community servicesand community mental health teams. The devel-opment of mental health promotion strategies in line with the NSF for mental health emphasizeliaison and consultation with primary care servicesand general practices and will provide new typesof clinical experience and different opportunitiesfor a range of practice experiences. Some place-ments may be with new and developing servicessuch as general hospital accident and emergencydepartments providing liaison psychiatric nursingservices for people who self-harm. They may alsoinvolve user groups, rehabilitation and employment-focused services and support, services for childrenwith mental health problems, family work, peoplewith dependency problems associated with theuse of drugs and alcohol.

THE NEXT STEPSLife-long learning and continuousprofessional development

As highlighted in the section on clinical govern-ance there is a clear expectation that mentalhealth nurses will be committed to continuingprofessional development (CPD) and life-longlearning. Ideally every nurse should have a per-sonal development plan linked to performanceappraisal and organizational objectives. The gov-ernment’s strategic intentions for nurses outlinedin Making a Difference (DoH, 1999d) suggests thatin planning or providing CPD organizations shouldensure that it contains the requirements listed inTable 5 of the document (p. 29). Continuing professional development, complemented by aknowledge and skills framework is key to the gov-ernment’s proposals for a new pay system Agendafor Change (DoH, 1999a).

In addition to meeting the personal and pro-fessional development needs of nurses CPD pro-grammes need to meet local service needs. As localservices set about implementing the standards con-tained in the NSF much of their successful deliverywill depend on the skills and ability of mentalhealth nurses. There are enormous opportunitiesfor nurses to work with a range of disciplines andcontribute to these new developments. Thesedevelopments include:

• assertive out-reach• early intervention in psychosis• mental health promotion strategies• strengthening primary mental health care• accident and emergency mental health liaison

services• crisis resolution, home treatment and crisis

management.

Specialist practice

Mental health nurses work in a variety of settingsand with a range of specific service user groups.Many of these have become highly specializedareas of practice and have their own particular post-registration training. These include:

• Substance misuse• Forensic mental health nursing


• Child and adolescent mental health• Eating disorders• Older people and mental health.

A full description of the services available forthese particular groups and the latest approachesto their nursing care is beyond the scope of thischapter. For a concise educational tour of special-ist mental health nursing see Stuart and Sundeen’sMental Health Nursing: Principles and practice(Thomas et al., 1997).

SUMMARY AND CONCLUSIONSA vision for the future

So what of the future of mental health nursing?We know that mental illness is likely to increaseand that there will be greater numbers of mentallydisordered offenders. To address these increasesthe UK government has produced a range of keyunderpinning programmes and an investment ofan extra £700 million over the next 3 years inmental health services. This will fund an increasein the number of medium secure beds, more out-reach services including crisis teams and 24-hourcare. All of these modern services call for anincrease both in the numbers, knowledge andskills of mental health nurses.

Occupational standards, capabilities and competencies

The outcomes-based competency curriculum,developed through nursing programmes in highereducation institutions, draws together occupa-tional and academic standards in a new approachto professional preparation. This together withthe government’s 10-year strategy for reformingmental health services with an emphasis on multi-agency and multi-disciplinary working, with part-nerships between health and social care sets thefuture agenda.

It appears that the various approaches to iden-tifying core attributes and characteristics of men-tal health workers, for example the skills of themental health nurse identified in Working inPartnership and the core competencies identifiedin Pulling Together, will be consolidated in terms

of the way they relate to both criteria for profes-sional and national occupational standards. Mappinggeneric competencies and capabilities for mentalhealth work against the outcomes for the mentalhealth branch programme for nurses and, simi-larly, the preparation of other professional groupswill lead to a standardization of training and edu-cational preparation of individuals working in thisfield. The identification of core and specific char-acteristics among mental health professionals willimpact upon traditional boundaries of professionalroles and professional identity. This will clarifythe specific contribution of different professionaland occupational groups and increase awareness ofthe importance of collaborative multi-disciplinaryteamwork.

The Department of Health is also supportingthe development of national occupational standardsfor mental health. Healthwork UK, the healthcare national training organization has set out keyareas and key roles for those involved in providingmental health care. Each of the key areas identifiedin the list below is associated with key roles andfunctions.

1 Work in partnership with individuals, groupsand agencies to promote mental health and com-bat discrimination against those with mentalhealth needs.

2 Assess mental health needs, diagnose mental ill-ness, plan, implement and review programmesof treatment and care in the broader context ofindividual lives.

3 Plan, provide, implement and review interven-tions to address the individual’s mental healthneeds and provide ongoing support, rehabilita-tion and continuing care.

4 Develop and maintain safe, stimulating andsecure environments for individuals who havemental health needs.

5 Manage the risk to the public of offendingbehaviour by individuals with mental healthneeds and develop, implement and review pro-grammes and interventions to address individ-uals’ offending behaviour.

6 Develop, maintain and improve ethical,evidence-based practice which promotes com-munication and relationships with individuals,their careers and other agencies.

Summary and conclusions 77

7 Develop strategies, policies and services forimproving mental health and addressing men-tal illness, and manage people, resources andinformation.

Mental health nurses have a major role to playin each of these key areas. The chapter has high-lighted the numerous initiatives aimed at achiev-ing a workforce that is fit for the purpose ofdelivering a modern mental health service. Theseinitiatives together with new service configur-ations and developments have major implicationsfor the education and training of mental healthnurses.There has never been a more exciting timeto undertake mental health nurse training. For thefirst time there is an opportunity to have a systemof education and training reflecting service needand workforce requirements that have a growingevidence base; all of which will be underpinnedby the views of service users, those who supportthem, and provide them with more purposefulnursing care and a mental health service thatmeets their needs and expectations.

GLOSSARYIn the context of this chapter the meanings of the followingwords are described:

Advocacy Organizations or groups that provide agencies support to or campaign on behalf of

people with mental health problemsClinical audit Comparison of existing clinical practice

against agreed professional standardsbased on reliable evidence and patientoutcomes

Delusion False belief strongly held in spite ofinvalidating evidence, especially as asymptom of mental illness, e.g. delusionsof persecution

Electroconvulsive Administration of electric current to therapy (ECT) the brain through electrodes placed on

the head, usually near the temples to induce unconsciousness and brief con-vulsions. Used in the treatment of certainmental disorders, especially acutedepression

Evidence-based Actions that aim to improve the healthinterventions and well-being of individuals, families

and populations planned and delivered

with due weight accorded to all valid, relevant information

Prodromal Early or premonitory symptom of a diseaseProphylactic Acting to defend against or prevent some-

thing, especially disease, e.g. protectivedrug or vaccine

Psychosurgery Brain surgery used to treat severe, intrac-table mental or behavioural disorders

Psychosis Severe mental disorder, with or with-outorganic damage, characterized byderangement of personality and loss ofcontact with reality and causing deterio-ration of normal social functioning

Psychotic Of, relating to or affected by psychosisSchizophrenia Psychotic disorder characterized by loss

of contact with the environment, with-drawal from reality with noticeable deterioration in the level of functioningin everyday life, and by disintegration ofpersonality expressed as disorder of feel-ing, thought (as in hallucinations anddelusions), and conduct

Service users People with mental health problems ormental illness who use mental healthservices

Social inclusion Achieved when individuals or populationsdo not suffer from the negative aspectsof unemployment, poor skills, low income,poor housing, crime, bad health, familyproblems, limited access to services andrurality, e.g. remoteness, sparsity, isolationand high costs

Therapeutic Having or exhibiting healing properties

REFERENCESAltschul AT (1972) Nurse–patient Interaction: a study of

interaction patterns in acute psychiatric wards.Edinburgh: Churchill Livingstone.

Beech P, Norman I (1995) Patents’ perceptions of quality of psychiatric nursing care: findings from a small scaledescriptive study. Journal of Clinical Nursing 4: 117–23.

Birchwood M, Shepherd G (1992) Controversies and growingpoints in cognitive-behavioural interventions for peoplewith schizophrenias. Behavioural Psychotherapy 20:305–42.

Brandon D, Brandon T (2000) The history of advocacy inmental health. Mental Health Practice 3:6–8.

Brooker C, Gournay K, O’Halloran P, Bailey D (2000) Mappingtraining to support the implementation of the nationalservice framework for Mental Health. ScHarr: Universityof Sheffield, Sheffield.


Cormack D (1983) Psychiatric Nursing Described.Edinburgh: Churchill Livingstone.

Cutcliffe J, Bassett C (1997) Introducing change in nursing:the case of research. Journal of Nursing Management 5:241–7.

Department of Health (1994) Working in Partnership: A col-laborative approach to care. London: DoH.

Department of Health (1998) Modernising Mental HealthServices. London: DoH.

Department of Health (1999a) Agenda for Change: mod-ernising the NHS pay system. London: DoH.

Department of Health (1999b) The National Service Frame-work for Mental Health: Modern standards and servicemodels. London: DoH.

Department of Health (1999c) Mental Health Nursing:Addressing acute concerns. Report by the StandingNursing and Midwifery Advisory Committee.London: DoH.

Department of Health (1999d) Making a Difference. Strength-ening the nursing, midwifery and health visiting contri-bution to health and health care. London: DoH.

Department of Health (2000) The NHS Plan: a plan forinvestment, a plan for reform. London: DoH.

Department of Health (2001) Chief Executive Bulletin, Issue94, 23–29 November, National Occupational Standards inMental Health.

Department of Health (2004) The Ten Essential SharedCapabilities – a framework for the whole of the mentalhealth workforce. London: DoH.

Department of Health (2005) Chief Nursing Officer’s Reviewof Mental Health Nursing. London: DoH.

Fowler D, Garety PA, Kuipers L (1995) Cognitive BehaviourTherapy for People with Psychosis. Chichester: JohnWiley and Sons.

Geddes J, Tomlin A, Price J (1999) Practising Evidence-basedMental Health. Oxford: Radcliffe Medical Press.

General Nursing Council (1957) Guide to the Training Schemefor Nurses for Mental Diseases. London: General NursingCouncil for England and Wales.

Hirsch S, Jolley A (1989) The dysphoric syndrome in schizo-phrenia and its implications for relapse. British Journal ofPsychiatry (suppl 5):46–50.

House of Commons (2000) Health and Social Care Bill (Bill 9). London: HMSO.

Kavanagh D (1992) Recent developments in expressed emotion and schizophrenia. British Journal of Psychiatry160:601–20.

Kerr G (1997) Advocating advocacy. Open Mind 84:12.Mallik M (1997) Advocacy in nursing: perceptions and

attitudes of the nursing elite in the United Kingdom.Journal of Advanced Nursing 28:1001–11.

McKenna HP (1995) Dissemination and application of men-tal health. Nursing Research 4:1257–63.

Ministry of Health (1968) Psychiatric Nursing Today andTomorrow. London: Mental Health Nursing AdvisoryCommittee.

Northern Centre for Mental Health and the Northern andYorkshire Regional Education and WorkforceDevelopment sub-group for mental health (2000) ACompetence-Based ‘Exit Profile’ for Pre-RegistrationMental Health Nursing. Durham: Northern Centre forMental Health.

Rose D, Ford R, Lindley P, Gawith G and the KCW MentalHealth Monitoring Users’ Group (1998) In Our Experience:User-focused monitoring of mental health services in Kensington and Chelsea and Westminster HealthAuthority. London: Sainsbury Centre for Mental Health.

Royal College of Nursing (1991) The Nature and Scope ofProfessional Practice. London: RCN.

Royal College of Nursing (1996) Doing the Right Thing:Clinical effectiveness for nurses. London: RCN.

Sainsbury Centre for Mental Health (2000) The CapablePractitioner: A framework and list of the practitionercapabilities required to implement the National ServiceFramework for Mental Health. London: Sainsbury Centrefor Mental Health.

Sainsbury Centre for Mental Health (1997) Pulling Together:the future roles and training of mental health staff.London: Sainsbury Centre for Mental Health.

Standing Nursing and Midwifery Advisory Committee (1999)Practice Guidance: safe and supportive observation ofpatients at risk. London: DoH.

Tarrier N, Hadock G, Barrowclough C (1998) Training anddissemination: research to practice in innovative psycho-logical treatments for schizophrenia. In: Wylkes T, Tarrier N,Lewis S (eds) Outcome and Innovation in PsychologicalTreatment of Schizophrenia. Chichester: John Wiley & Sons.

Thomas B (1992) Education. In: Brooking J, Ritter S, Thomas B(eds) A Textbook for Psychiatric and Mental HealthNursing. Edinburgh: Churchill Livingstone.

Thomas B, Hardy S, Cutting P (1997) Stuart and Sundeen’sPrinciples and Practice of Mental Health Nursing.Edinburgh: Mosby-Wolfe.

UKCC (1986) Project 2000: A new preparation for practice.London: UKCC.

United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1999) Fitness for Practice: The UKCCCommission for Nursing and Midwifery Education.London: UKCC.

Wykes T, Tarrier N, Lewis S (1998) Outcome and Innovationin Psychological Treatment of Schzophrenia. Chichester:John Wiley & Sons.

Yonge I, Austin W, Zhou Qiuping P et al. (1997) A systematicreview of the psychiatric/mental health nursing researchliterature 1982–1992. Journal of Psychiatric MentalHealth Nursing 4:171–7.

References 79

ANNOTATED FURTHER READINGThomson T, Mathias P (eds) (2003) Lyttle’s Mental Health

and Disorder, 3rd edn. London: Bailliere Tindall, RCN. Thisis a useful textbook for mental health nursing studentsincluding a broad range of contents under four main head-ings – Understanding mental health and illness, Inter-ventions in mental health practice, Challenges for servicedelivery and Issues for practitioners. These four sectionsinclude a range of relevant topics, the nature of mentalhealth, language and classification, emotion, behaviourand cognition, interventions including mental healthpromotion, social and psychological interventions, socialinclusion, suicide and self-harm, substance use, andaggression management. The final section includes chap-ters on the development of high standards, supportingpractitioners as they develop their knowledge and skills.The book includes a glossary of common mental healthterms that students may find helpful.

Thomas B, Hardy S, Cutting P (1997) Stuart and Sundeen’sMental Health Nursing: Principles and Practice. Mosby-Wolfe. This is the British version of a classic Americantextbook. As its title suggests the book focuses on theprinciples and practice of mental health nursing careincluding chapters on concepts of mental health, modelsand theories, the therapeutic nurse–patient relationship,and service user perspectives. It also addresses the psy-chological, sociocultural, biological and legal and ethicalcontext of mental health nursing, quality standards andsupervision in professional practice. Chapters on healthpromotion, crisis theory and intervention, in-patientmental health care, liaison and consultation, and care forlong-term clients are covered in the section on the prin-ciples of organizing care. The longest section of the bookis all about applying the principles of mental health tonursing practice and includes many of the challenges thatpeople with mental health problems are likely to experi-ence with case studies and clear pointers on how mentalhealth nurses can provide them with a high standard of

care. Chapters include understanding suicidal behaviour,interventions with acutely ill patients, management ofviolence, drug and alcohol nursing, eating disorders, sex-ual health, child and adolescent and family mentalhealth, care of older people, care of survivors of trauma,and forensic psychiatric nursing. Chapters on therapeuticapproaches cover psychopharmacology, complementarytherapies, behavioural psychotherapy, group work, schiz-ophrenia family work. All the contributors are mentalhealth nurses and experts in their field of practice. They provide a comprehensive textbook that will complementmany training programmes and be a useful resource for students.

USEFUL WEBSITESCentre for Evidence Based Mental Health – http://

www.cebmh.com Promoting and supporting the teaching and practice ofevidence-based mental health care.

Chief Nursing Officer, Department of Health – www. dh.gov.uk/AboutUs/HeadsOfProfession/ChiefNursingOfficer/Links to current information of interest to nurses.

KnowledgeShare – http://www.knowledgeshare.nhs.uk/index.htmNHS information for evidence-based practice.

National Institute for Mental Health in England –http://www.nimhe.org.ukNIMHE is responsible for supporting the implementationof positive change in mental health and mental healthservices.

Sainsbury Centre for Mental Health – http://www.scmh. org.ukThe Sainsbury Centre for Mental Health (SCMH) is a charity that works to improve the quality of life for people with severe mental health problems. It carries outresearch, development and training work to influencepolicy and practice in health and social care.


http://www.cebmh.com

http://www.cebmh.com

www.dh.gov.uk/AboutUs/HeadsOfProfession/ChiefNursingOfficer/

http://www.knowledgeshare.nhs.uk/index.htm

http://www.knowledgeshare.nhs.uk/index.htm

http://www.nimhe.org.uk

http://www.scmh.org.uk

www.dh.gov.uk/AboutUs/HeadsOfProfession/ChiefNursingOfficer/

Perspectives on LearningDisability NursingMaureen Turner

7

INTRODUCTIONThis chapter is intended as an introduction tolearning disability nursing as a viable and crediblecareer within the nursing profession. Learning dis-ability nursing did not become part of the nursingprofession until 1959 and is the least known of thefour branches of nursing.This chapter will provideinsight into how this branch of nursing hasdeveloped within the profession and how philoso-phies of care for people with learning disabilitieshave evolved and developed due to medical,social and political influences that have drivennurse education and practice. This chapter willprovide insight into the contemporary knowledge,competencies and skills required by the learningdisability nurse as stated by the Nursing andMidwifery Council (NMC) to meet the complexneeds of people with learning disabilities. Thusthe following areas will be considered:

• The medical, social and political influencesthat have governed care practice

• The development of learning disability nursingas a profession

• Public attitudes towards people with learningdisability and their influence on care practice

• Changing care provision and nurse education• Contemporary care practice and provision• Skills attitudes and competencies required by

the learning disability nurse• The terminology used to describe people with

learning disabilities

BACKGROUND TO THE DEVELOPMENTOF CONTEMPORARY CAREPRACTICESTo understand current practice, it is important togain insight into the development of learning dis-ability nursing as this will enable the reader tounderstand the changes that have led to contem-porary practice within this branch of nursing.Throughout history, politicians, professionals fromthe fields of medicine, psychology, nursing andsocial work, as well as the general public throughvarious pressure groups have debated the ways inwhich people with learning disabilities should becared for. These opinions have influenced bothservice provision and care delivery.

Historically, people with learning disabilities wereviewed negatively and often with suspicion by othermembers of society. Thus it is not surprising thatpeople with a learning disability have acquired anegative image as words now considered deroga-tory in the English language have been used legisla-tively to describe people with learning disabilities.The Mental Deficiency Act (1913) used the terms‘idiot’ and ‘imbecile’ to describe and define thosewho had a learning disability to distinguish themfrom those who had a mental health problem.Otherterminology that would be considered equallyderogatory, such as ‘moral defective’, has also beenused legislatively and academically to describe thenature of a person’s learning disability.

The Mental Health Act (1959) saw a change inthe legislative language used to define the variousclassifications of learning disability and replacedwords such as ‘idiot’ with ‘subnormal’, ‘severelysubnormal’ or ‘educationally subnormal’. At thetime this was an attempt to remove the previouslyused derogatory labels, although the 1959 Act wasnot just about people with learning disabilities orchanging labels. As attitudes changed the termin-ology in this act proved over time to be unhelpfuland equally devaluing. In addition, learning dis-ability nursing did not become part of the nursingprofession until 1959 and was a direct result ofthe Act. Before this people with learning disabili-ties had been cared for in institutions by mainlyunqualified staff who had no professional account-ability, which implies devaluing care. These estab-lishments eventually became hospitals managedby the National Health Service (NHS) with carebeing delivered by doctors and nurses.

Terminology also continued to change andeventually hospitals for the ‘mentally subnormal’became known as hospitals for the ‘mentallyhandicapped’. However, the aim of hospital carewas to provide residential care and treatment; thecare received in these overcrowded hospitalsincluded en bloc treatment which was the onlyway that the basic needs could be met. Hospitalstaff could not realistically provide standards ofcare that upheld the privacy, dignity and individu-ality of the client, all of which are underpinningphilosophies of contemporary practice.

The labelling of people with learning disabil-ities has changed consistently since the MentalDeficiency Act (1913) and Mental Health Act(1959) to meet the changing care philosophies,service provision, public perceptions of peoplewith learning disabilities and more importantly, inacknowledgement of the voice of people withlearning disabilities. It was their voice that madethe decision to be collectively known as people(first) with learning disabilities (second).

By 1972, public, government and professionalsattitudes were beginning to change towards thecare of people with learning disabilities and thiswas followed by scrutiny of care practice by theDepartment of Health (DoH) which resulted inthe publication of Better Services for the Mentally

Handicapped (1971) and the Jay Report (1979),both of which advocated care in the communityfor people with learning disabilities.These reportsinfluenced and underpinned contemporary ser-vice provision, supporting people with learningdisabilities to live in ordinary housing and live asnormal a life as possible.

The change in service provision also changedthe role of the learning disability nurse from oneof providing little more than custodial care toenabling people with learning disabilities to liveas independent a life as possible.This should be inan environment that maintains the privacy anddignity of each individual and provides supportthat enables each person to reach their maximumpotential in all areas of their life. This change in care philosophy and practice was not onlyinfluenced by government reports and recom-mendations but also by the field of psychology.The publication of Wolfensberger’s theories onnormalization (1982) and social role valoriza-tion (1994), which also supported communityliving, had enormous impact on contemporaryattitudes and practice. In addition, these theoriesdescribed care philosophies that should underpincare delivery that promotes valuing people withlearning disabilities and facilitates their value asindividuals within society and the community inwhich they live. Contemporary practice is stillbased on the ideologies and philosophies of nor-malization and social role valorization.

The advent of registration for learning disabilitynurses held nurses accountable for their practice,and this had some influence on standards of care inthe old hospitals for the ‘mentally handicapped’,but greater change was needed and this has evolvedwith the implementation of care in the community.Throughout history, practice has been influencednot only by government policy and society’s viewsand the professions of medicine and psychology butalso by the other branches of nursing.

Nursing models, which are theoretical frame-works on which to base care delivery, have beenadapted and altered to meet the needs of thisclient group. Contemporary practice has led tolearning disability nurses to develop special mod-els and frameworks of care to meet the complexneeds of people with learning disabilities.

82 Perspectives on Learning Disability Nursing

THE DEVELOPMENT OF THEQUALIFIED PRACTITIONERThe current term applied to a person with alearning disability receiving professional supportis client and no longer patient, as the word patientimplies a person who is sick. People with learningdisabilities are not considered to be sick. Hence,the term client will be used throughout this chap-ter when describing contemporary practice. Therecognition of the need for knowledgeable andskilled staff to deliver appropriate care to thisclient group equally has undergone many changesand has been influenced by the changing views ofboth government and society.

Attracting students into this branch of nursinghas always been difficult and incentives in terms

of pension have been used to encourage interest.There are several reasons why recruitment mayhave been difficult over the years. It is perhaps theleast publicly known of the four branches of nurs-ing and historically those with learning disabilitiesand their carers have had a negative image amongthe general public. This has perhaps been due to a lack of information generally being made avail-able about the needs of people who have a learn-ing disability and the role of the learning disabilitynurse in caring for this client group. Part of therole of the learning disability nurse is to encour-age a positive image of people with a learning dis-ability to promote their successful integration intonormal community life.

The influence resulting from the use of labels hasnot only come from government legislation but alsofrom the field of psychology and pressure groups insociety.After the introduction of the Mental HealthAct (1959) attitudes were already changing towardspeople with learning disabilities and their care.Theidea that people with learning disabilities couldbenefit from an ordinary life has been gainingmomentum since the days of the Better Services forthe Mentally Handicapped Report (1971), TheNational Development Group Report (1978), theJay Report (1979) and Wolfensberger’s publica-tions on normalization theory (1982) and mediacoverage by pressure groups in society.

INFLUENCES DRIVING THE LEARNINGDISABILITY NURSING CURRICULUMThe influences discussed above led to the changein the pre-registration nursing syllabus in 1982,which ceased to use the term subnormal andseverely subnormal and instead encompassed thenotion of this client group as people first andhandicapped second. Consequently a qualifyingnurse registered as an RNMH (Registered Nursefor the Mentally Handicapped) and not RNMS.Currently, a qualifying nurse registers as an RNLD.

The Mental Health Act 1983 equally changedthe terminology in keeping with the changing viewsof society, the fields of psychology, nursing andmedicine. This point demonstrates that care phil-osophy and provision have not been static and that the influence for change has not been purely

Influences driving the learning disability nursing curriculum 83

Summary

• Many people with learning disabilitiesnow living in the community lived ininstitutions and received little more thancustodial care.

• Historically people with learning disabilities were viewed with suspicionand government acts such as the MentalDeficiency Act (1913) and the MentalHealth Act (1959) assisted in segregatingpeople with learning disabilities fromsociety.

• People with learning disabilities wereoften feared.

• The care that they received was devaluingand degrading.

Reflective activityThink of yourself as a person with a learningdisability living in a hospital in an overcrowdedward. Write down all of the things that you takefor granted that would not be available to youin one of these institutions.

Now write down how you might feel.

government-directed but has changed with theviews of other professions and society.

Although professional registration for learningdisability nurses was not introduced until 1959 a syllabus for caring for ‘mental defectives’ was developed in 1923. This saw the beginning of theseparation between those with mental ill health andthose with learning disabilities. However, the sep-aration of these two patient groups was formalizedwith the introduction of the National Assistance Act1948 and the development of the NHS. Specialisthospitals cared for people with a wide range oflearning disabilities and, as stated above, were oftenbuildings that had previously been workhouses.

CHANGES IN NURSE EDUCATIONThe Briggs report on nurse education (1972) firstquestioned the need for carers of people withlearning disabilities to be nurses as these people

are not sick. This report recommended that thisbranch of nursing should no longer be part of thenursing profession and that another kind of carercould provide the care required by people withlearning disabilities. The report was produced atthe same time as the government commissioned areport known as Better Services for the MentallyHandicapped, which was published in 1971.

The main recommendations of the 1971 reportwere to prevent people with a learning disabilitybeing cared for in hospital but for adequate andappropriate support services to be provided in thecommunity to enable the person with a learningdisability to be cared for in their own home. Italso recommended that local authority take leadresponsibility for assessing appropriate care andproviding adequate services.

In 1978 the Department of Health commis-sioned the National Development Group to inves-tigate the standards of care in hospitals. Thisreport also advocated people with learning disabil-ities being cared for in much smaller groups andwhere possible in normal housing. It also recom-mended that children with a learning disabilityshould not be cared for in long-stay institutions.The Jay Report (1979) quickly followed and alsorecommended that people with a learning disabil-ity should be cared for in the community, butadded that people with learning disabilities didnot require registered nurses to care for them.

Each of these reports influenced the closure ofthe large hospitals for people with learning dis-abilities and provision of more appropriate care inthe community. These reports collectively havedriven learning disability nursing to cross theboundaries of health and social care, and, in part,influenced the 1982 syllabus, which had greaterfocus on meeting the social care needs of peoplewith learning disabilities. Hence another changein terminology: people with learning disabilitiesbecame increasingly referred to as clients ratherthan patients.The curriculum for learning disabil-ity nurses changed from a medical model of careto a model of social care that focused on promot-ing independence by teaching clients self-helpskills and social skills. This included accessingcommunity facilities, interacting with others inthe community and acquiring the skills of dailyliving that ordinary people take for granted.


Summary

There has been radical change in care deliveryfor people with learning disabilities andlearning disability practice has changed fromproviding custodial care to:

• enabling people with learning disabilitiesto live in the community

• promoting the independence of peoplewith learning disabilities

• teaching people with learning disabilitiesthe skills of ordinary living

• promoting a positive image of people withlearning disabilities.

Reflective activityWrite down the skills that you think a personwith a learning disability will need to be taughtto live as independently as possible in the com-munity. Use your previous list to consider all ofthe things that you take for granted. This willenable you to think of how learning disabilitynurses plan care interventions.

The continued evolvement of the curriculum intoProject 2000 (United Kingdom Central Council forNursing, Midwifery and Health Visiting (UKCC))has more clearly identified the role of the learn-ing disability nurse within current health carefacilitation.

Moves towards improvement

Although hospital care for many years hadfocused on meeting the basic physical needs ofpatients, attempts had been made to teach peoplewith learning disabilities self-help skills in additionto changes in behaviour that would be consideredchallenging.The introduction of behavioural inter-vention techniques, which is reinforcing behaviourthat is desirable (based on Skinner’s theories of oper-ant conditioning (cited in Glassman, 2003), meantthat nurses could make a difference to the lives ofpeople with a learning disability.

Behavioural psychology had been the major influ-ence on clinical practice at this time and knowledgeof behavioural psychology, although modified, con-tinues to have an influence in both skill teaching andin attempting to change the challenging behaviourof people with learning disabilities. Promoting theirindependence through the development of self-helpand social skills, as well as changing behaviour thatmay be considered challenging, can change the des-tiny for many people with learning disabilities andgive them hope of returning to normal communityliving.

As with any profession, change is not immedi-ate and as it evolves the implications of change andthe need for frameworks and guidelines becomeapparent. Although at this time behaviouralintervention therapy was viewed by the profes-sion as a radical move towards promoting the inde-pendence and individuality of the client it appearsthat nurses and other professionals were doingthings to the client rather than with the client.

The role of the learning disability nurse in con-temporary practice is much more about workingwith the client and their carers in partnership, toprovide choice and empower the person with alearning disability to have control over their ownlives and destiny while working within the NMC’scode of conduct (see Appendix 2).

Contemporary practice

This evolving role of the learning disability nursehas been influenced by changing ideology thatquestioned not only the practice of learning dis-ability nurse but also the very nature of serviceprovision. It created radical change in both theliving environments of people with learning dis-abilities and the philosophy of care underpinningthe practice delivered by the registered nurse.Thenormalization theory states that people withlearning disabilities should:

• lead as a normal life as possible• live in ordinary housing• have access to social and leisure facilities

enjoyed by the general public• have access to normal health care facilities

enjoyed by the general public• gain access to employment• develop meaningful relationships.

In conclusion, having greater choice and controlover their lives.

Changes in nurse education 85

Summary

Learning disability nursing skill base haschanged to:

• teaching people with learning disabilitiesself-help skills based on behavioural theory

• teaching people with learning disabilitiessocial skills

• enabling people with learning disabilitiesto access normal community facilities

• enabling people with learning disabilitiesto live as independently as possible.

Reflective activityWrite down one self-help skill like washing ordressing yourself and break this down intosmall steps to be able to teach a person with alearning disability that skill. Look at theNMC’s competencies and match these skills tothose outcomes.

This change in care philosophy created the needfor clinical leaders, service providers and registeredlearning disability nurses to reflect on their prac-tice and return control of people’s lives to the indi-vidual by working in partnership with clients andtheir families. The change in care philosophy wasintroduced gradually: as with any system of radicalchange one regimen does not automaticallyreplace another. Consequently the influence ofbehavioural therapy continues to coexist alongsidecontemporary care ideologies in varying degrees ofmodification, particularly in relation to teachingskills and promoting independence.

The notion of positive reinforcement is still evi-dent in contemporary practice although this isencompassed into care plans far more as a shareddecision with clients than as the notion of manipu-lating clients by the use of reinforcement.However, it must be noted that enabling peoplewith learning disabilities to be more independentis viewed by the profession as a prerequisite tocommunity living. The coexistence of these twoprinciples of care, although on the surface twoextremes, was implemented to achieve the onedesired goal of community living. This radicalchange in thought and attitudes towards the careof people with learning disabilities has been con-tinuously driven by the notion that people withlearning disabilities could benefit from living asordinary a life as possible with the same expect-ations as all others in society.

Consequently, normalization and social role val-orization have become the foundation of thelearning disability pre-registration nursing curricu-lum. Practitioners are able to demonstrate throughappropriate care delivery that people with a learn-ing disability are people first and disabled second.Both service providers and registered nurses havea responsibility to develop individualized plans andpackages of care to meet the total needs of the clientby providing a seamless service.

WORKING WITH OTHERPROFESSIONALSCaring for people with learning disabilities livingin the community requires a registered nurse to

acquire skills to work autonomously as a safe andcompetent practitioner and also as an effectivepractitioner working as part of a multi-professionalteam. Learning disability nurses are held account-able for their professional conduct and compe-tency by the NMC. Due to the multi-professionalnature of care delivery it is difficult to measurequantitatively the contribution the learning dis-ability nurse makes to client care. However, thelearning disability nurse has a key role in ensuringthat the contribution of each professional meetsthe total needs of the client.

The Continuing the Commitment Report (DoH,1995) supported multi-professional working and recognized the need for learning disabilitynurses to work in partnership with other profes-sionals, agencies and carers. This is particularlyimportant since the introduction of normaliza-tion, social role valorization and the move tocommunity living as the care of people with learn-ing disabilities has become the responsibility of adiversity of agencies. It has meant that the regis-tered learning disability nurse is required to main-tain the unique skills of caring directly for theclient while working in partnership with the per-son, family, other professionals and care workersto provide care that meets the total needs of theindividual.

Multi-professional care is a necessity if clientsare to receive the level of support that is requiredfor them to gain maximum independence andquality of life from community living. This meansworking with social services, educators of peoplewith special needs, doctors, physiotherapists,occupational therapists, speech and languagetherapists, psychologists and the independent sec-tor providing residential care.These working part-nerships facilitate the provision of a seamlessservice intended to meet the total and complexneeds of people with learning disabilities. Thelearning disability nurse has a key role to play inboth co-ordinating and delivering care.

In order to fulfil the nurse’s role in a new andevolving service the new pre-registration nursingcurriculum incorporates biology, psychology, soci-ology, information technology and nursing practiceto equip newly qualified staff to appropriately meetthe complex health and social care needs of the


person with learning disabilities. The knowledgeand skills of the learning disability nurse include(see Appendix 1):

• communication with people who are not ableto communicate verbally

• empowering people with learning disabilitiesto be self-advocating

• enabling people with learning disabilities todevelop meaningful relationships

• promoting the health and well-being of people with complex health and social careneeds

• managing and changing difficult behaviour• promoting independence to the maximum

potential of the individual• ensuring that the education and training needs

of the individual are met• assessing need and planning care to promote

quality of life for the individual• ensuring that care delivery meets both the

health and social care needs of the individualclient.

According to Cullen (cited in Continuing theCommitment Report, DoH, 1995) application ofconcepts such as normalization, social role val-orization, community care and empowerment havebecome so much part of best practice for learningdisability nurses as well as other professionals thatthey may be considered dominant ideologies.

Learning disability nursing is not only aboutunderpinning practice with the recognized ideolo-gies and philosophies, it is also about the attain-ment of skills. To practice effectively, a wide rangeof clinical, behavioural and attitudinal skills arerequired. Having the knowledge and skill to teachand develop the communication skills of the indi-vidual to enable them to make their needs knowncan make a huge difference to their lives, promot-ing their self-esteem and self-worth.

Thus communication and interpersonal skillsare a major focus of the learning disability curricu-lum and nurses who have difficulties with bothcommunication and interpersonal skills are notgoing to interact effectively with clients who havea learning disability, their family or other carers.

MAINTAINING MAXIMUM HEALTHAND WELL-BEINGThe learning disability nurse working in today’sservice has a key role in the total health facilitationof the individual with learning disabilities, by pro-moting the maximum health and well-being of thatindividual. Maximum health and well-being is notjust concerned with the physical health of the indi-vidual but also the mental well-being of the person.

Mental health

According to Raghavan et al. (2004) prevalenceof mental ill health is higher among people with

Maintaining maximum health and well-being 87

Summary

Learning disability nurses need to be able to:

• empower people with learning disabilities toadvocate for themselves and make choices

• work across the boundaries of health careand social care

• develop communication skills to workeffectively with the clients, their carersand their families

• use a range of therapeutic interventionsthat promote the independence, healthand well-being of the individual withlearning disabilities

• facilitate the opportunity for people withlearning disabilities to develop social networks

• provide the opportunity for people withlearning disabilities to develop andmaintain meaningful relationships.

These competencies are required by the NMC(Appendix 1).

Reflective activityWrite down the skills you feel that you alreadyhave to achieve the above and then list the onesthat you feel you need to develop.

learning disabilities than in the normal popula-tion and have an increased likelihood of havingdepression because their lifestyle is much morelikely to result in lowered self-esteem and self-worth.

The skill and knowledge of the learning disabil-ity nurse enables them not only to recognizemental ill health and intervene appropriately butalso to prevent mental health problems. This isachieved in part by increasing the autonomy andcontrol an individual has over their own life asthese increase the individual’s own self-value andself-worth. The greater one’s independence theless likely a person is to become depressed. It isequally important that nurses understand the the-ories of institutionalization and the effects thatdepersonalization may have had in contributingto the wide range of mental disorders in peoplewith learning disabilities.

People with a learning disability have the right toaccess the same treatment as the wider generalpopulation. It is not solely recognition of the illnessand care that is the duty of the registered learningdisability nurse, but it is also necessary for theresponsible nurse to evaluate the effectiveness ofany treatment given and provide support for theclient during the illness. For registered nurses to beconfident and competent to be able to do this stu-dent nurses need to acquire an academic under-standing of the theories of psychology and mentalill health. This theoretical understanding is rein-forced through experience in a range of practicesettings that care for those people with learningdisabilities who also have mental health problems.

The aim of specialist care for those people withlearning disabilities who also have mental healthproblems is to provide treatment and rehabilita-tion so that they may return to an ordinary life inthe community. This may mean that the commu-nity learning disability nurse continues to supportthe client after discharge to prevent further re-admissions.

Challenging behaviourSome people with learning disabilities exhibit highlevels of challenging behaviour and it is the role ofthe learning disability nurse to understand andmanage that behaviour. According to Repp et al.(1989) challenging behaviour is most effectively

managed when treatment is based on the hypoth-esis of its cause.The learning disability nurse work-ing in contemporary practice in this muchspecialized area is required to have a sound know-ledge of the biological, psychological and socio-logical theories that underpin the motivation forchallenging behaviour to understand, manage andtreat challenging behaviour effectively.

Excellent communication skills are of paramountimportance when interacting with clients who chal-lenge their carers and the service. The care phil-osophy underpinning practice when working withthis group of people is still to value the individualand promote a positive image of this client groupin the community in which they live. The skillbase of the registered learning disability nurse iscomplex as in addition to recognizing and man-aging an individual’s mental health problems andchallenging behaviour they are also required tohave the knowledge and skill to meet the com-plex physical needs of the person with a learningdisability.

Physical health care needsAccording to Tait and Genders (2002) peoplewith learning disabilities have more complexphysical needs than the normal population. Thosepeople with profound learning and physical dis-abilities may require the intervention of specialistclinical skills. For example, due to their profoundphysical disability a few clients have eating diffi-culties that require mechanical aids such as percu-taneous endoscopic gastrostomy (PEG) feeding. Itis necessary that staff undertaking such proceduresare competent and confident to always maintainthe safety and well-being of the client. Thisrequires greater skill than just being able to gothrough the motions of being able to perform thetask. There is equally a need for the practitioner,who is accountable, to acquire a wider knowledgeof the implications of such procedures and to beable to act in accordance with the policies andframeworks that govern practice to always ensurethe client’s safety and well-being.

Clients who do have complex health and socialcare needs are extremely vulnerable and are oftentotally dependent on their carers to recognizewhen their physical or mental state of health haschanged.The ability to observe and interpret each


individual’s state of wellness requires a specialistskill, especially as many clients with multiple needsare often unable to articulate their desires, needsand feelings verbally. Caring for this client groupis developed through a continuum of knowledgeand skills that encompass both the tasks and theart of nursing.

ASSESSING, PLANNING ANDIMPLEMENTING CAREIndividual needs are not identified on the basis ofassumption but on accurate assessment. This isnot merely a check list of problems, it is informa-tion about all internal and external influencesthat may have affected an individual’s life.

The learning disability nurse working in today’sservice has a key role in the total health facilita-tion of the individual with learning disabilities. Itis the specific role of the learning disability nurse

to collect accurate information and analyse the datacollected during the assessment that will use thisinformation to plan effective care. It is throughaccurate observation and interpretation of theinformation collected that the knowledge and skillof the learning disability nurse facilitates thedevelopment of appropriate care plans to meet thecomplex health and social care needs of the clientand improve quality of life for the individual.

Nurses carrying out assessments and developingcare plans have to remember that all informationconcerning the client is relevant. In addition tocollecting information relating to the physical andmental health state of the client other factors suchas age, gender, previous life experiences and thecause of the person’s learning disability are import-ant. For example, Cosgrave et al. (1999) clearlyinform us that there is an association betweenDown’s syndrome and Alzheimer’s disease; there-fore it is important that consideration is given tothis fact if an elderly client with Down’s syndromepresents with an altered health state. Equally it isimportant that all care interventions are ageappropriate as it is demeaning and devaluing totreat an adult as a child. This is not an exhaustivelist and the skill of the learning disability nurse isto be able consider each area of a person’s life thatwill impact on their current health status.

The ability to synthesize the information col-lected during the assessment process and makeaccurate judgement relies on the knowledge ofthe nurse carrying out the assessment. The pre-registration nursing curriculum includes a rangeof academic subjects that provide students withthe appropriate knowledge which will enablethem to consider the relationship between a per-son’s environment, lifestyle, skills, and physical andmental well-being.This same knowledge ultimatelyprovides the competent practitioner with the infor-mation required to develop appropriate careplans to overcome any barriers to maximum healthand well-being.

Planning care

This approach to care planning – considering allaspects of a person’s life rather than a list of problems – prevents care from being delivered in acompartmentalized fashion which may mean that

Assessing, planning and implementing care 89

Summary

To manage, treat and meet the mental healthneeds, challenging behaviour and physicalhealth needs of people with learning disabilities the learning disability nurserequires a knowledge of:

• theories of biology, psychology, sociologyand the aetiology of learning disability

• effective and appropriate care interventions• clinical nursing skills• the roles of other professionals in meeting

the complex health care needs of peoplewith learning disabilities.

Reflective activityThe learning disability nurse requires knowledgeas well as skills. Write down the topics that youthink you will be required to study at diplomalevel to underpin practice with sound evidence.

some of the client’s individual needs may be omit-ted. Equally, nurses need to have a self-awarenessof their own limitations in terms of both skills andknowledge to guarantee that clients benefit fromthe diversity of knowledge possessed by the careteam during the care planning process.

In addition to gaining knowledge and skills incommunication, care planning and the promotionof advocacy it is essential that the curriculumaddresses the ethical issues involved in caring forsuch a vulnerable group of people. The learningdisability pre-registration curriculum includes avariety of challenging topics that enable the prac-titioner to consider the ethical implications oftheir practice. Consequently, any care interven-tion designed to change any area of a client’s lifethat may be considered intrusive has to be care-fully analysed in terms of the ethical implications.

Practitioners should be able to justify how thechange may improve the client’s quality of lifeand enable the person to become more independ-ent. Any form of treatment or care interventiondesigned to promote independence invariablynecessitates some form of intimate interactionwith the person; therefore consideration has to begiven to the client’s wishes and desires. However,gaining consent for such interaction can be diffi-cult when caring for people who may have littleor no verbal communication. The responsibilityfor ensuring that the client is consenting relies onthe skill of the registered practitioner and theirknowledge of the client to interpret that consenthas been given.

The learning disability nurse is constantly facedwith a wide range of ethical dilemmas thatrequire the expertise to make decisions in relationto care practice that are genuinely in the client’sbest interest.

PHILOSOPHIES OF CARECare philosophies informing practice have for someconsiderable time emphasized the need for peoplewith learning disabilities to receive individualizedcare. The competent practitioner will always haveto reflect on their interactions with clients and theirfamilies to be sure that they have taken into accountthe ethical, cultural and spiritual needs of theclient and their family, even if this means the mostfavourable care intervention cannot be imple-mented without causing offence. Practitioners can-not claim competence and expertise from thelength of time spent in clinical practice but need tobe able to justify their practice from a sound evi-dence base. This means that registered nurses havean obligation to remain up to date in terms of con-temporary research and published evidence.

Pre-registration student nurses are taughtthroughout the programme to critique and analyseresearch and judge the value of specific researchstudies as being valid and credible to underpinclinical practice. Care intervention based onsound evidence and research provides registerednurses with an academic justification for caredelivery that is open to question and scrutiny. It isequally important for learning disability nurses tobe able to undertake research to ensure that con-temporary practice continues to develop andevolve. Consequently all pre-registration nursing


Summary

The competencies required by the learningdisability nurse are to be able to:

• assess, plan and implement care to meetthe total needs of clients

• work in partnership with clients and theircarers to develop care plans that encom-pass the client’s choices

• consider the ethical implications of careinterventions.

Reflective activityConsider a variety of ways that you couldinvolve a person with learning disabilities intheir care without using verbal communication.Also consider what you think some of the ethicalissues surrounding learning disability practicemight be.

programmes include the research process andmethodology within the curriculum.

Evidence-based practice

There is a need to research and analyse clinicalpractice and care delivery carried out by learningdisability nurses to augment the credibility andviability of learning disability practitioners. It isthrough the articulation of research developedfrom within the profession that the unique con-tribution that learning disability nurses make tothe care of their clients becomes evident. It hasbeen of benefit to people with learning disabil-ities and the profession to have been so closelyscrutinized and questioned prior to the advent ofcommunity care. There is equally a need for caredelivery to be less influenced by other profession-als than it has been historically and for learningdisability nurses to publicize evidence and moreclearly demonstrate the diversity of their role inmeeting the total needs of the clients.

It is evident from this chapter that the care ofpeople with learning disabilities and the profes-sion of learning disability nursing have undergoneradical change over the past 30 years. Thescrutiny into clinical practice has constantly

provided the medium for individual clinicians toreflect on their own practice as well as for man-agers and nurse educators to consider care fromthe point of view of the organization, which hasto be a positive step rather than a negative one.

LEARNING DISABILITY NURSING IN THE FUTUREThe latest government report Valuing People(DoH, 2001) undoubtedly acknowledges that therights of people with learning disabilities are thesame as for any other member of society andinclude the right to employment, housing, educa-tion and general health care. The report equallyacknowledges that people with learning disabil-ities have perhaps not enjoyed the same standardsof general health care as the normal population.The future role of the learning disability nursemay well be in facilitating access to general healthcare services with a view to this client group gain-ing quality of life through maximum health andwell-being. This will require student nurses fol-lowing all four nursing pathways to gain insightinto the lives of people with learning disabilitiesso that they may care for them appropriately ingeneral health care settings.

Student nurses following the learning disabilitybranch programme will need to be provided withthe knowledge and skills that prepare them towork in flexible and changing health and socialcare arenas to meet the individual needs of peoplewith learning disabilities. It is through rigorousacademic and practice assessments, which meas-ure if the learning outcomes of the programmehave been met, that students will develop thepersonal and professional competence they needto demonstrate their fitness for practice.

The curriculum’s learning outcomes will alsoneed to be constantly evaluated to ensure thatnew government proposals and contemporaryissues are incorporated to prepare student nursesto be competent practitioners in tomorrow’s wide-ranging care settings and support services.The future for learning disability nurses appearsto be focused on meeting the health care needs ofpeople with learning disabilities and ensuring thatall of their health care needs are met. This will

Learning disability nursing in the future 91

Summary

The learning disability nurse needs to plancare:

• based on sound evidence from a widerange of literature

• based on contemporary philosophies.

Reflective activityBecause learning disability nursing practice hasbeen influenced by other professions and clinicalpractice is centred around multi-professionalworking, consider the various sources of litera-ture that you could access to help you to developa sound knowledge base.

require learning disability nurses to be far morecommunity based and they will need to continueto work with a wide range of professionals. Nurseswill also be required to undertake programmes inhigher education at post-registration level to con-tinue to lead the profession in meeting the chan-ging service demands.

CONCLUSIONThe skills and competencies of the registered learn-ing disability nurse cannot always be articulated interms of tasks but are expressed in a wide range ofcomplex skills that are both behavioural and attitu-dinal. The future of the learning disability nursecontinues to be to work across professional bound-aries facilitating maximum health and well-beingof people with learning disabilities, supporting this client group to be their own advocates and live a quality of life that is expected by others insociety.

GLOSSARYIn the context of this chapter the meanings of thefollowing words are described:Advocate Person who acts on their own behalf,

or if a person with a learning dis-ability has an advocate, this personwould intercede on their behalf

Behavioural Understanding and changing behav-psychology iour by observing environmental rein-

forcementsDown’s Chromosomal abnormality resultingsyndrome in varying degrees of learning dis-

ability. The risk of this disorderincreases with maternal age

Eugenics Study of improving the human raceNormalization Means being treated in a way that

an individual is happy to accept andis not about being ‘made normal’(Chisholm, cited in Shanley E andStarrs T (eds) (1993) Learning Dis-ability: a handbook of care.Edinburgh, Churchill Livingstone p. 41)

Social role Universal principle on which servicesvalorization for those with learning disabilities

are based

REFERENCESBriggs Report (1972) Report of the Committee on Nursing.

London: HMSO.Cosgrave MP, Tyrell J, Carron M, Gill BA, Lawlar (1999) Age

at onset of dementia and age of menopause in womenwith Down’s syndrome. Journal of Intellectual DisabilityResearch 43:446–65.

Department of Health and Social Security (1971) Better Services for the Mentally Handicapped. London:HMSO.

Department of Health (1995) Continuing the CommitmentReport. London: HMSO.

Department of Health (2001) Valuing People. A new strategyfor learning disability for the 21st century. London:HMSO.

Glassman W (2003) Approaches to Psychology, 3rd edn.Buckinghamshire: Open University Press, p. 120.

Jay Report (1979) Report of the committee of enquiry intomental handicap and nursing care. London: HMSO.

Mental Deficiency Act (1913) Cited in: Morris P (1969) PutAway. A social study for the mentally retarded. London:Routledge and Kegan Paul, pp. 22–3.

Mental Health Act 1959. London: HMSO.Mental Health Act 1983. London: HMSO.National Assistance Act (1948) Cited in: Morris P (1969) Put

Away. A social study for the mentally retarded. London:Routledge and Kegan Paul, p. 257.

National Development Group report (1978) London: HMSO.

Raghavan R, Marshall M, Lockwood A, Duggan L (2004)Assessing the needs of people with learning disability andmental illness: development of the learning disability ver-sion of the Cardinal Needs Schedule. Journal of IntellectualDisability Research 48:25–36.

Registered Nurse for the Mentally Handicapped syllabus(1982) UKCC.

Repp A, Felce C, Barton E, Lyle D (1989) Basing the treatmentof stereotypic and self injurious behaviour on thehypotheses of their cause. Journal of Applied BehaviouralAnalysis 21:281–9.

Tait T, Genders N (2002) Caring for People with LearningDisabilities. London: Arnold pp. 55–60.

United Kingdom Central Council for Nursing, Midwifery andHealth Visiting. Project 2000 A new preparation for prac-tice. London: UKCC.

Wolfensberger W (1982) Social role valorisation. A proposedterm for the principle of normalisation. MentalRetardation 21:234–9.

Wolfensberger W (1994) An analysis of the client role from asocial role valorisation perspective. The InternationalSocial Role Valorization Journal 1(1):3–8.


ANNOTATED FURTHER READINGTait T, Genders N (2002) Caring for People with Learning

Disabilities. London: Arnold. This is an extremely usefulbook for students on the foundations of learning disabil-ity practice.

Gates B (1997) Learning Disabilities, 3rd edn. Edinburgh:Churchill Livingstone. This book covers many issues relatedto contemporary practice.

Jukes M, Bollard M (2003) Contemporary Learning Disability.Dinton Quay: Health Care Limited. This book includes awide range of issues surrounding contemporary practicefor nurses working in learning disabilities including inter-professional working, valuing people and the complexhealth needs of people with learning disabilities.

Recommended journals

Journal of Learning Disabilities for Nursing Health andSocial Care

Nursing TimesLearning Disability Practice.

USEFUL WEBSITESBritish Institute of Learning Disabilities. www.bild.org.ukwww.Dh.gov.uk/PolicyAndGuidance/HealthandSocialcare

Topics/Learning Disabilities/fs/enLearning Disability Practice. www.learningdisabilitypractice.

co.uk

Useful websites 93

www.bild.org.uk

www.Dh.gov.uk/PolicyAndGuidance/HealthandSocialcareTopics/LearningDisabilities/fs/en

www.learningdisabilitypractice.co.uk

www.Dh.gov.uk/PolicyAndGuidance/HealthandSocialcareTopics/LearningDisabilities/fs/en

www.learningdisabilitypractice.co.uk


Support Systems for StudentNursesNick Salter

8

INTRODUCTIONThis chapter aims to enlighten you about the per-sonal challenges that you may face during a courseof study. Support can offer the chance to cope bet-ter with those challenges. The nature of supportwill be explained and the importance of supportsystems and the possible benefits will be discussed.It is hoped that when armed with this information,you will feel more able to solve problems and willlook forward to the changes and challenges that lieahead.

Many people give support in different situationsand it takes place in both formal and informalstyles. Various types of support are needed at dif-ferent times but sometimes support does not hap-pen. This may be due to a feeling of weakness orfailure or simply not knowing what help is on offerand from whom it can be sought. There is a rangeof support systems that are an essential part of stu-dent experience. Then there is additional supportavailable if other problems occur, for example,homesickness, debt or problems with accommoda-tion. As a result of reading this chapter it is hopedthat you will understand what can be achieved andto whom you might turn for help. At the end ofthis chapter you will find a list of useful websites.These will help you to answer these questions.

When contemplating a university-based courseof study there are so many choices and decisionsto make:

• Which course?• Which university do I choose?

• Do I want to leave home and live inde-pendently?

• What kind of accommodation will I look for?• Can I afford to live independently?• Will I have to gain paid employment to sup-

plement my bursary?• Will I have to buy lots of expensive books?

There are many more questions to ask anddecisions to make and you might be able toanswer them more easily with some help.

Perceptions of student support

Your perceptions of the benefits of support atuniversity may have developed from your ownexperiences at school or from experiences that

Reflective activityThis first activity aims to start you thinkingabout yourself. As caring people, we so often putothers’ needs first and forget ourselves. Underthe following headings, make a list of your ideasabout these new situations you will have to getused to when you start your course:

Getting to know your way aroundAdjusting to working in practice placementsFitting into new groups or teamsManaging your study timeManaging your finances

your peers have shared with you, either recentlyor in the distant past. Positive experiences with,for example school teachers, could induce a beliefthat future relationships with lecturers will bebeneficial. However, previous negative experi-ences could work against a possible successfulstudent–lecturer relationship. When at school weoften saw the teachers if things went wrong. Asummons to ‘the office’ created doubt and fear.We might have thought ‘Why me?’ or ‘What doeshe want me for?’ Lecturers though, like teachers,are well able to dispense praise; they like nothingmore. They enjoy helping students solve prob-lems, guiding them and rewarding good work.

Actually, as a lecturer, it is very easy to becomeenthusiastic about the outcome of support. Thewhole object of support is to help students. Supportshould ease your development and passage throughthe educational experience. A lecturer might helpsimply by listening to what you have to say. Advicecould take the form of a direction, or a course ofaction that you could take. You may need persua-sion or help towards making a decision. A lecturermight support a decision or your behaviour as beingacceptable, praise you for your achievements andreassure you to help maintain your effort.

Outcomes of support

Students can achieve a level of re-assurance (as anoutcome) (Teasdale, 1989) by simply knowingthat support is available; that there is someone orsomething to turn to. Feelings of success are verypositive motivators and these can come fromfeedback from assignments, placement reports,tutorials and exam successes. Motivation is a greatdriving force. Sometimes students need encour-agement to seek feedback and advice from lectur-ers and this can also come from peers. Oftenstudents learn together from shared experiencesand the feeling of partnership can strengthen thedesire to do well for each other and learning thattakes place together can seem more valuable.

Personal support can help maintain positivebehaviour and therefore learning. It can encour-age the development of both personal and profes-sional skills. So often, support attempts toenthuse students into action or decision-making.At times, when a student becomes unhappy or

depressed, clarity of vision is lost. Support willattempt to re-orientate the student to reality.Thisprocess can be a difficult one and students mayneed many sources of support. The student maybe seeking some sort of consolation or comfortduring times of trouble. Symptoms of sufferingare often difficult to alleviate and are often easierto spot in someone else rather than oneself.

Supporters also help by enlivening the mind andcreating a sense of cheer; feelings that create hopeand purpose in the mind. These positive statescan help, when for example, study behaviour mayneed adapting to meet new situations, a change inthe level of assessment, a new placement for prac-tical experiences or when reactions to eventsrequires new preparations for the future. Plansand arrangements for future experiences mayneed careful consideration and timely, effectivesupport may make some positive difference.

One outcome of support is the creation ofindependence. There would be nothing gained bysupporters who wish to make students dependentupon their advice. It should be obvious then, thata significant amount of responsibility for self-determination depends on willpower. As theNursing and Midwifery Council code of conduct(NMC, 2002; see Appendix 2) indicates in section6 you will, as a registered nurse, be responsible foryour own development, so during your course youwill need to develop your ability to be responsiblefor your own actions. As a student, you will workunder the supervision of registered nurses.However,your aim should be to practise safely and effec-tively without direct supervision and maintain yourown knowledge and the skills required whereveryou practice.

96 Support Systems for Student Nurses

Summary

This discussion has described support in ageneral sense with the aim to enthuse you to view support in a positive manner. The following sections discuss some of the common reasons why students might seek support or to put it another way, some of themany needs students may experience duringtraining. A further section discusses possiblesources of support.

POSSIBLE CHALLENGES TO CONSIDERChanges to accommodation

Leaving home can be an upheaval, leaving afamiliar environment, routine, people with whomyou live and friends. The need to learn how toperform domestic activities might be a major newexperience that could seem daunting. On theother hand, changes might be preferable to pre-sent arrangements and new experiences may bethose that have been looked forward to for sometime. Many students, especially mature students,choose to stay at home. This can produce savingson expenses as well as reducing the need forchange. As the need to study changes and thetime that you will spend at home changes, someallowances need to be made by you and all wholive with you. Often, students talk about thenotion that their families and friends go throughthe course with them so even your family andfriends could be making some sacrifices.

Arranging accommodation itself might be anew experience and advice is available from, e.g.university accommodation officers, housing agen-cies and students’ unions. You will want to live insecure, safe and comfortable housing and someuniversities actually guarantee accommodationfor your first year of study especially if you arefrom overseas. When you receive you final offerfrom your chosen university, you will receive a formP76. This is your Accommodation PreferenceForm and it must be returned within seven days if you are from the UK.

Living in university halls of residence is anexperience some students relish whereas othersprefer to avoid it. It is a matter of taste and no twohalls are the same. Try to visit prospective hallsand talk to resident students for their views, thenmake up your mind. The quality of accommoda-tion worries a lot of students and their parentswhen, for example, there has been no prior view-ing. There is a tendency to make friendshipgroups quickly and often, small groups move hallsto be with each other. Some leave halls and rentaccommodation together to give them a greatersense of independence. Private accommodation isusually available and the local advice centre,accommodation officer or the student union are

all available to give advice. Many students enjoyliving with other student nurses because they gaina lot of peer support regarding course issues evenif they are living with students in another yeargroup or branch speciality.

There are some very useful internet sites thatoffer sound advice.Try www.merlinhelpsstudents.com – this site offers advice about accommoda-tion, advice on renting in the private sector, safetyissues, contracts, types of tenancy, deposits, uni-versity lodgings and the benefits of staying athome. It may be worth approaching an accom-modation agency. Look at local papers and theirwebsites, notice boards and perhaps actually lookat the student housing on offer. This is often anoption on university open days. Another helpfulinternet site is www.connexions-direct.com – thissite displays advice about housing, i.e. studentaccommodation, housing benefits, moving out/leaving home, and more.

Inventories of contents should always be checkedupon entering the accommodation for the first time.This should include an inspection of any damagealready present and although accommodationshould be in an acceptable condition, what con-stitutes acceptable is open to debate. If you needto make a complaint try to be objective and fairand be prepared to compromise at least until yousettle in. Over time, you will discover alternativesand avenues to getting changes made.

One of the fears for some students, especiallythose who have not lived away from home before,is homelessness. Occasionally accommodation isarranged too late for the agency or accommoda-tion officer to give any advanced notice of loca-tion. It is something to keep a wary eye on. Checkthe location and type of accommodation on offerat the interview stage and make a note to enquireabout its availability if information does not arrivewhen you expect it.

Mature students may need to adapt their life-style to meet their need to study effectively. Thismay mean simply that furniture is moved aroundor a desk brought into the house. This may affecthow the house or a particular room is used.A din-ing room may become a temporary office. Thefamily will experience the changes and may notenjoy the encroachment into their space. The way changes are made and rationalized may be

Possible challenges to consider 97

www.merlinhelpsstudents.com

www.merlinhelpsstudents.com

www.connexions-direct.com

more important than the physical alterationsthemselves.

Managing your finances

Most students find it difficult to spend moneywisely.The lack of money might occur due to poorbudgeting. You may not have had much experi-ence of handling money for food, clothing, accom-modation and study expenses, paying bills, feesand living on a limited budget. Bank managers,student services departments, student loan depart-ments, parents and spouses are there to give help ifnecessary so do not think that you are on yourown if you get into difficulties. Financial problemsare best managed as soon as they become apparentrather than when debt has become uncontrolled.

The amount of money student nurses gain fromtheir bursary is easily spent. Many students are indebt to banks or building societies. Many feelindebted to their parents or supporters and thiscan produce an intense feeling of guilt. However,more students these days accept that debt is justanother consequence of being a university stu-dent. The issue here is that you may experiencethe need to seek employment to supplement yourincome (see section on working while you are astudent). This might be to fund loan repaymentsor to help pay for basic requirements such as foodand accommodation expenses or childcare fees.Christmas and holiday times produce specialdemands on finances especially for students whomay be parents or carers, and mature studentswho may have family-related commitments thatyounger students do not experience. These mightbe related to partners’ unemployment or business-related expenses.

New students may not fully appreciate theimportant issue of travelling expenses. While atschool or college, the institution, parents andfriends often arrange transport. It may have beensubsidized by the institution or your parents.However, when at university, you may bear thecost of transport for the first time. The burden ofresponsibility may also be an unknown quantity.The expense, time and frustrations of car break-downs, missing buses or trains may add to themounting stresses. Try to make yourself aware ofthe chance for previous travel reimbursements or

the presence of any university student hardshipfunds and how you can access them. Many internetsites offer advice on bursary issues, finance andcounselling services; see the NMC website (www.nmc-uk.org). Have a look at websites for cheapertravel offers. Check also with your university ifuniforms are provided. Some branches of nursingdo not require uniforms, for example, learning dis-abilities and fewer uniforms may be issued duringthe common foundation programme.

Being in control of personal finances reducesthe deleterious effects of financial hardship. Thisfacilitates a greater focus on study and the positiveeffects of employment and personal managementthat can help improve a sense of self-esteem.

Managing your learning

The start of any course or even a module of studyproduces a plethora of new information to beunderstood and integrated into new routines.Most peers will be in a similar position so talkwith them to see what sense they make of it alland to facilitate awareness that you are not alonein your feelings and thoughts.

Using your initiative for organizing your timemight be a novel experience. You will need toaccept that you are responsible for your learning.Lecturers have a responsibility to teach but theycannot learn for you. In practice, it means prepar-ing for lectures, for example, gaining insights andmotivation from the lecturers and reading aroundthe subject thus gaining further information tohelp you form opinions and alter your thinkingabout what has been heard and seen.

There are some potential difficulties in relationto resources. Obtaining books and journal articlescan take a long time and can cost money.There willprobably be insufficient books in most libraries forall students to be able to borrow copies of thesame book at the same time; so use the short loanand recall systems. Photocopying costs money andthis is an expense that needs to be anticipated. Tryto plan around the times when there will be heavydemand on certain key texts. You could requestand save book tokens from birthdays, for example.Only buy a book that you have looked throughand that seems essential, for example a dictionary,anatomy and physiology book, key psychology and


www.nmc-uk.org

www.nmc-uk.org

sociology texts might be recommended. The useof the internet has expanded greatly and you maybe experienced in its use. There may be IT skillssessions arranged for you if you wish to becomemore proficient. Gain some experience in the useof various search engines, databases and electronicjournals; library support staff will be useful.Always remember to share information andresources with peers as this can save time andmoney, and it will nurture symbiotic relationships.

Meeting deadlines, handing in assignments andgetting behind with work often causes stress. Timemanagement can be a skill that takes years of prac-tise. Setting goals by working back from assessmentdeadlines is essential. Remember that lecturers,peers and students who are more experienced canoffer advice and encouragement so discuss any dif-ficulties you have with them. If all else fails lectur-ers could agree to give extensions to assignmentdeadlines when there have been difficulties, e.g.illness that prevents proper completion of work.Do not be reluctant to negotiate an extension ifyou have experienced unforeseen difficulties.

Working while you are a student

Learning takes place as much from experiencesgained in practice as from learning from reading,thinking and writing.As a student, you will be work-ing as part of the course but not as an employee.Your course is unlike so many other universitycourses because your ultimate professional regis-tration depends on the practical work you per-form. So whereas other university students usetheir non-contact time (i.e. time away from lec-turers) to study and socialize, much of your non-contact time is spent practising in care estab-lishments, studying and socializing or perhapsrunning a household, family, etc. This means thatyour actual free time for yourself is limited andneeds to be managed differently from the way youmanaged it before you started the course.

If you need to work to earn money, as discussedearlier, this will produce its own set of stresses.Taking time from social activities, study and oftensleep can have effects on wakefulness, concentra-tion and morale. Holding down a job that helpsfund studies might be relatively easy at the beginning of a course but some students find that

the need to concentrate on studies when the aca-demic level increases puts a strain on their abilityto work in the latter part of the course. Paid orunpaid employment reduces the time available forstudy. Some students seem able to compile assign-ments within a few weeks, others need all the timeallowable and some ask for extensions to deadlines.This results in a tension between the need to earnmoney and the need to study; the outcome is oftenfurther stress. Disappointment can occur becauseassessment results are lower than anticipated orfinancial hardship may follow.The amount of timethat is devoted to reading and reflection on, andassimilation of that reading is often related to aca-demic results so this is another issue that is relatedto work time, leisure time and time off for illness.

Some students enjoy the experience of workoutside their course and gain positive well-beingfrom it. Working as a health care assistant or simi-lar can help students gain practical experience andinteractional skills. Furthermore, the experienceswill help nurture a caring attitude and approach toothers. However, there is a word of warning here.Some students feel compromised when they workas a bank health care assistant. They may even dosuch work on a ward where they have worked inthe role of student nurse. Students in this situationobviously possess skills gained and practised as astudent but there is a tension when they are notable to use these skills as a health care assistant. Inboth roles, the student is responsible to the samemanager but different tasks and interactions areexpected in the differing roles. Students often feelrestricted when in the assistant role and shouldremember the boundaries to the role and theexpectations made of them.

Many students continue the work that theyenjoyed before starting university. Any job meansthat transferable skills are learned and these are veryvaluable to a student of nursing. Interpersonalskills, responsibility, autonomy, independence andteam working are just some of them. However,some jobs are low paid and this leads to some stu-dents taking on several different jobs. A reversesituation exists because some students leave paidemployment to join a course.They may lose statusand other benefits of employment. The change inrole, control and perceived competence can be aninitial worry.


Other non-paid work may involve students usingtheir time away from study and placement experi-ences to help others, in a caring role for example, orto support a partner or spouse’s employment. Oneof my students needed to be at home to supporther husband’s business by performing an accoun-tant’s role; he had just become self-employed andcould not afford to employ another person to help.

Well-being is a critical factor forsuccess

The effects on available time for study and recreation, and the effects on well-being are criti-cal issues. However, physical manifestations oftiredness and frustration can affect behaviour andfriends and associates might be the first people torecognize the results of getting the balance wrong.For this reason you may find yourself helping afriend to realize what is happening to them becausethe student who gets the balance wrong may notbe the first to realize it.

Any physical or psychological work takesenergy.A study day can be as draining, if not more

so than physical work. Routine academic studymay lead to under-stimulation during the day,which may fail to induce sleep later at night.Physical work can produce more deep sleep,which can create the sense of recuperation thefollowing day. An interesting day’s activities filledwith variety and novelty helps to induce sleepmore rapidly and provides more deep sleep.However, extra work of any kind produces a senseof weariness after an extended time. If insomniaoccurs it can lead to ill health, reduced work per-formance, absenteeism and accidents. If this hap-pens, try to increase exercise and interest duringthe waking hours. If you are interested in sleep, agood book to read is Morgan and Closs (1999).

Students should not expect absence from workor study to be condoned and they can attractresponses from placements and or the universitythat prove to be stressful. Each university coursehas regulations about minimum attendance; theymight relate differently to practice and theory.These will probably be reinforced during induc-tion. So the message is: talk to your lecturer aboutyour need to work outside your course. Genuinesickness is usually not a cause for debate butabsence levels are cause for concern during pro-fessional courses and lecturers are there to helpduring times of difficulty. Student welfare officersor occupational health departments can help.They can help with advice about health-relatedissues, counselling, finance and employment issues.Considering all these factors, there appears to be avicious circle that could operate (Fig. 8.1).

Cause and effect of poor well-beingIt is obvious that students may need support atany stage of this cycle of events to protect theirwell-being. Over time we build up strategies tocope with stress. McInnes (1999) comments thatalthough these strategies might have helped inthe past, that might not be the case presently in anew situation. Nursing courses help students tobe more assertive and this is one skill that shouldhelp students to challenge their stressful encoun-ters. The following is a possible stress-relievingprocess (after McInnes, 1999):

• Look at what is causing the stress and try to dowhat you can to alter it: you could try to tackle


Reflective activityThis is a good place to encourage you to thinkabout your commitment to others. Have a lookat the following questions:

If you are currently employed, will the nature of your employment change as a result of your course?

Will you need to start a job to finance yourcourse?

If there are people who are dependent on you fortheir well-being what will have to changewhen you start your course?

Will you be able to alter any volunteer workwhile on your course?

If you have any regular sporting interests, willyou need to make any changes to your routines?

While thinking of the possible answers youmight like to involve others in discussion toarrive at an action plan so you can control thechanges that may have to be made.

bits of the problem at a time, break it down tomanageable chunks.

• If that can not be done try to change your per-ception of it, think about trying to see it as ifsomeone else has the problem and what theymight do about it.

• Try not to worry about stress. Some stress is pos-itive and can be a motivational force for positivechange and we should not strive to erase allstress in our lives – in any case that would beimpossible.

Physical and emotional changes will occur dur-ing the course. One guarantee is that at the end of the course every student will be a different person: not only because of experiences but alsobecause maturity adds insight and a changed self-awareness. The knowledge that we as adults canbe vulnerable, wrong, unskilled and unappreci-ated can come as a surprise. Support is oftenrequired to help explain and accept personal andattitudinal changes. Disenchantment with place-ments, colleagues, lecturers and results can lead toapathy, lack of motivation and does occasionallylead to students withdrawing from courses.Problems are much better aired before they affectyou, let alone other people you are close to.

Illness can happen at any time, a fact that allnurses quickly learn to appreciate. A little know-ledge may make you suspect the worse about per-sonal illness. Furthermore, nursing ill people canmake you think that patients’ symptoms could besimilar to your own. This can lead to needlessworry or even hypochondriasis. Personal illnessmust be taken seriously, as you need to be fit andwell to be able to nurse patients.

Struggling into work when ill could lead othersto question your professionalism and motives.Colds and ‘flu’, for example, are debilitating andcontagious and as such are best isolated from staffand patients, so stay at home. Occasionally courseshave to be customized or interrupted because ofillness.This obviously is unfortunate but not a signof personal weakness or failure. Further advicemay need to be sought regarding maximum allow-able sick leave and of course, it is vital to followany health and safety advice, policies and pro-cedures relating to working while ill or recovering.


Need to workoutside the course

Lack of timeto study

Poor results

Poor well-being

Extra studyrequirements

Time offsick

Figure 8.1 The cause and effect of poor well-being

Reflective activityThe following exercise refers to questions thatwill help you to focus further on your needs for

How relationships might be affected

When you start the course, it might involve anelement of sacrifice, a trade of a comfortable exist-ence for an uncertain future as borne out byEarwaker (1992). You should look to the coursefor re-assurance that your decision was justified.You may need to ask questions to test whetherthe curriculum will or will not satisfy your needs.This could be a continuous affair of challenge foryou and your lecturers but during the course, youshould continue this process of checking yourdecisions so that you re-affirm your commitmentto the course and desire to succeed.

Leaving family and friends to join a course canbe stressful. This of course will probably be tem-porary. However, for some who travel from over-seas this separation might be for many months ora year or so. It is important to maintain contactbecause family and friends can be a tower of strongsupport at times when motivation decreases andthey will want to know how you are progressing,especially about your successes and excitements.Try to remain in contact through any means youcan, by phone, e-mail, text, letter, etc. Travellingwill incur greater cost and it is probably sensibleto budget wisely for trips home.As students settledown into shift patterns and blocks of study, theytend to reduce their trips home, etc. However, itshould be borne in mind that homesickness canbecome a serious issue. You or your friends mayneed to help others to adjust to being away fromthose on whom they have significant dependence.Again, talk to tutors, friends, and welfare officersif you need to. If homesickness is a worry have a

look at these websites that offer useful tips tohelp you through homesickness now or in thefuture:

• www.uwec.edu/counsel/pubs/homesick.htm• www.counselling.cam.ac.uk/hsick.html

Family problems and home life might not bedisrupted and may in fact provide substantial sup-port (Earwaker, 1992). Some problems mighteven be solved by changes that the course pro-duces. However, occasionally, changes can causeproblems. Separations, financial hardship, loneli-ness, changes to roles or an unco-operative spouseare just a few. When the student is a lone parentand siblings require care, this can produce enor-mous difficulties. Childminding, escorts to andfrom school, planning and provision of meals,especially when shift work is involved can all bestressful.A lot of discipline may be required whentrying to study at home surrounded by dependantchildren and spouse.Timing and time managementwould be essential. It would also be important togive something back to the family in the way ofquality time; time that is devoted to others as theirreward for the allowances they make towardsyou. Problems like these are surmountable andsometimes help from others is the key. Here aresome suggestions (Counselling Services, 2004):

• Admit that there is a problem – talk about itwith a family member or friend. Peer groupsdo work very well if there is a willingness toshare feelings, emotions, etc. You will probablyfeel stronger for having shared your feelings.

• Make new friends.• Think about what you want to gain or how

you would like to change.• Writing about your thoughts can help. When

you see your ideas on paper, they can look dif-ferent as if they are someone else’s. You couldimagine your friend has the problem, howwould you advise them? Then try taking yourown advice.

• Don’t just complain, think what you want tochange or achieve out of a situation but makeyour expectations achievable and realistic.

• Importantly, do something. Buried problemsrear their ugly heads later when you might beless able to deal with them.


support and relate to some of the issues discussedabove. If you have yet to commence a course:

What changes will occur for which you willhave to make adjustments? They may be thesame or similar to those identified above.

What support might you use when you are atuniversity?

How do you think your needs for support mightchange when you commence a university course?

www.uwec.edu/counsel/pubs/homesick.htm

www.counselling.cam.ac.uk/hsick.html

Relationships with peers are dynamic. Meetingfellow students for the first time and making andbreaking ties with peers brings a different set of uncertainties, doubts or pressures. In addition,peer pressure still exists within groups of studentnurses. For example, you may experience pres-sure to take up smoking or to give up smoking.Some students are enticed to join or leave groups.However, on a positive note some are encouraged tolead groups or be an official group representative.These activities might not be your initial choice, butsurreptitious pressure might bring positive rewards.Remember your personal right to express yourown thoughts and to make up your own mind(Townend, 1991).

It is possible to discover new interests at uni-versity. Find out details about sports activities atand around the campus. There are probably inter-est groups and the student union will have lots ofinformation about their activities, which are oftenthe centre of university life.

Most other university course students have morefree time at their disposal than students of nursing.Other students may seem to be ‘getting off lightly’when they seem to be out all the time or enjoyingmore freedom to choose whether to attend lec-tures. It can be frustrating if you are not expectingthis. Sharing accommodation with other univer-sity students can bring a unique set of pressures.While others may be out ‘clubbing’, it is studentnurses who have to work in placements, even duringthe night. Other students do not always appreci-ate the need for quiet and the understanding thatmid-week days off replace weekends and socialtime might not often coincide so some mixingwith others might be constrained.

Challenges for mature students

Balancing domestic responsibilities with studycan be a new venture. Remember that at schoolor college, time had to be shared between respon-sibilities and to some degree you must have beensuccessful. It has to be said that increasing agedoes bring with it different and often more signifi-cant responsibilities and occasionally a reduceddesire to change. However, change is somethingthat you will have committed yourself to for at leastthe next three years and coping with unforeseen

difficulties will probably depend on planning tocope with the known difficulties now. Good prepar-ation is the key to a feeling of being in control andthat is the key to coping so if you have doubts, askpeople questions, find sources of information, lis-ten to advice and be prepared to make difficultdecisions. When difficulties are shared, they canseem to be easier to deal with. Making new friendscan help in this process and remember thatstrangers might be simply friends that you havenot yet met.

Some students need to continue to supporttheir partner, for example, financially, emotion-ally, in a health care capacity or in business. Thistakes time, effort and commitment. It also takesunderstanding and tolerance from the partner.Compromises may have to be made on both sidesand this might only happen after lengthy debateand heart searching.Again understanding and com-promise is needed and assertiveness on both sidesis a key to overall success, and the likelihood thatchanges will eventually change again needs to beunderstood so decisions will not necessarily belife-long.

For many, the challenge of re-entering educationafter time out causes unease. Some students havenot studied for many years; they may have raiseda family or for other reasons now have reduceddemands from dependants.There are many reasonswhy some students feel that when they start acourse they are in some way disadvantaged. How-ever, mature students bring with them life experi-ences that others cannot possess and youngerstudents can be very grateful for the learning thatthey achieve from mixing with mature students.Although the lack of recent study can be seen as adisadvantage, skills such as time management canbe easily learned. The commitment to learningthat mature students possess is possibly strongerthan it is in some students who have just left schoolor college. Effective learning is often born fromcommitment and motivation so these should beseen as gifts that should not be underestimated.

Information and communication technology(ICT) is a part of efficient learning and certainly,the ability to use a word processor would be anadvantage. Recording notes and references on acomputer can easily be transformed into a pre-sentable assignment. Time is saved which is an


advantage and connection to the internet meanscommunication with the university. Couple thiswith the ability to access literature on the worldwide web and university libraries together withelectronic journals and it is an advantage for studythat should be a major consideration for students.Universities have computerized study facilitiesand courses include the use and teaching of ICTso a lack of experience or a perceived lack of skillwill be overcome with practise.

Coping as a student from overseas

Adapting to a new place of study, new accom-modation or a new town can be stressful enoughbut what about a new country and culture?Students may be fearful of encountering hostilityor alienation from fellow students or neighboursbecause of where they come from, how theyspeak or what they look like. English might be astudent’s second language and it might be diffi-cult to cope with translations and the speed ofdelivery of lectures. If in doubt students shouldseek advice to find out if there are any English-language courses run by the university. Some infact commence before official course start datesto give students a bit of a head start. Universitiesusually cater for students from overseas throughthe operation of a support group or student sup-port services or a dedicated overseas student officethat might arrange seminars, visits or meetings.

One of the inherent difficulties faced by over-seas students is the physical separation fromknown and trusted friends and family. The peoplewho used to surround you are no longer near andthe isolation felt can be enormous. Obviously, thiscan be minimized. Telephone conversations donot have to be very expensive, e-mail facilitiesmight be useful and letters are still valued eventhough it is often termed ‘snail mail’.

Actual visits home might be few but will begreatly valued. The possibilities, not taking intoaccount the financial issues, must be checked wellin advance as it might be very difficult to re-arrangeplacements and taught classes, for example, whichare usually planned before you start the course.So, check for when the planned annual leave isarranged.

SYSTEMS OF SUPPORT DURING THE COURSEAs Phillips (1994) suggested the main thrust ofsupport is probably of an academic nature; pas-toral care is also an essential element. Most con-tacts initiated because of an academic need includesome discussion related to the student’s feelingsabout themselves or others. Interactions on place-ments, in university, conflicting demands on stu-dents’ time are common discussion topics. One aimof study is to prepare students to accept responsi-bility for their own actions and their own learning.Learning through lectures and group sessionsalone will not achieve this; personal tutorials can,through individualized advice, direction, problem-solving and reflection when they are aimed at anindividual student’s needs. Students will optimizethe level of self-awareness if they avail themselvesof this facility.

The role of personal tutor

It is not the sole province of one supporter, butthe effective combination of all the available sup-port systems available to students, that will opti-mize the educational experience. A lecturer whohas responsibility for co-ordinating the support ofstudents may be termed a personal tutor.


Summary

This section has discussed some of the common reasons why you might seek supportduring training. They are numerous and thelist is by no means exhaustive. It is hoped thatyou will now imagine that although you mayhave many needs as a result of possible oractual changes to your lifestyle, you will, however, be able to cope. Knowing what to doabout a problem is only half the battle; theother half is to do something to improve yourability to cope. Coping alone can succeed, butit might be advantageous to share experiences,because coping together with others can leadto unexpected ideas for enhancing your abilityto tackle present and future challenges.

Individual students have different needs whenentering university compared with their needswhen leaving university, and the dynamics of thestudent–tutor relationship reflects this. At first,there will be a sense of dependence on the sup-port structures in general. New relationships canbe fraught with doubt and anxiety. However, trynot to delay or put off meeting with a tutor. Gen-erally, all students have an equal right to gain helpfrom lecturers. You should try to maintain regularmeetings to improve rapport, which will help youto learn more about your abilities, strengths andweaknesses. Self-awareness is a life-long process ofdevelopment and it is often not possible to becomeaware of what others think of you unless you askor they tell you.

Writing in a diary can help students to recordtheir thoughts, feelings and experiences. In somecourses, this can be a formal part of the curricu-lum. ‘Reflection … is a generic term for thoseintellectual and affective activities in which indi-viduals engage to explore their experiences in orderto lead to new understandings and appreciations’(Boud et al., 1985 p. 19). Reflection involves think-ing about all that a person does, feels and thinksabout situations or events. Learning from reflec-tion is helped in part by keeping a reflective diaryor portfolio, used to recall items for discussion,during tutorials; it can be used as a very powerfultool to reflect on changes in knowledge base andimportantly attitudinal changes (Heath, 1998).Reflection on action (see Schon, 1983) can con-tribute to growth of professional attitudes, andwriting about experiences, thoughts and feelingswill lead to improved self-awareness. Read alsoPalmer et al. (1994) to discover more about howreflection can help your professional development.

Some tutor–student relationships will be for-malized. This means the tutor initiates the inter-actions and sets the intervals of meetings.Anotherapproach is the very informal management of thescheme whereby students initiate meetings as andwhen required. This informal system often occursalongside a more official system. The reason forthis is that although students and tutors areassigned to each other, students may also have somuch incidental contact with another lecturerthat they decide to interact for all other supportrequirements with that lecturer. This should not

present many problems to the organization butyou may need to inform your personal tutorabout how you are operating.While all concernedmay not find difficulties, this could lead to somestudents finding their tutors unavailable due tothem being in demand. Line managers may as aresult rationalize the support structure and for-malize the system to produce a more equitableworkload among all lecturers. Phillips (1994)advocated a formally planned framework of sup-port to be included in curricula for this reason.

Some tutors are able to organize their time tosee students in a flexible manner. When studentsmake a request, tutors may simply make an appoint-ment in a diary to their mutual benefit. Alterna-tively, some tutors have so many demands ontheir time that they set certain times within theirworking week as surgery times when they wouldbe available for students to drop in when they can.Of course, these two contrasting arrangementswill not benefit all people at all times and ad hocarrangements will always operate. Suffice to saythat while it is accepted that students have a rightto see their tutors, the process is dissimilar to feel-ing thirsty, going to a vending machine and obtain-ing a drink on demand.You will need to appreciatethat tutors have needs, demands on their time andthe need and right to coffee and lunch breaks.This should be borne in mind when knocking ona door and expecting to be seen there and then.

The variety of qualifications held by studentsand their individual life experiences indicate thatstudents will experience differing levels of satisfac-tion from lectures and seminars. Further explana-tion and advice can be gained from the lecturingstaff after sessions or even before sessions if they areconcurrent. This of course may not occur directlyafter all sessions. Staff may not be available or youmay be moving on to another session. For this rea-son you could note down the questions you have.You might like to wait for your next meeting withthe lecturer but you could refer to texts on readinglists and other sources used in libraries. Your ques-tions might also be answered by friends.The powerof belief is very strong so try to believe in what youwant to say or ask and do not feel reluctant to askjust because you think you might be wrong. Beinga student means that you are allowed to make mis-takes, often – that is how we learn.

Systems of support during the course 105

Bramley (1977) advocated a model of friendshipfor the student–tutor relationship. Students shouldbe able to expect their personal tutor to be friendlybut not their best friend. If the lecturer is requiredto discuss poor progress or academic failure or mis-demeanours with students, a personal relationshipmay make the exchange difficult at the least andhard for students to accept. Therefore, althoughyou should expect a lecturer to be friendly, youshould be aware that lecturers would attempt toprotect you both from over-familiarity.

Friendship is not essential to the central role ofsupport, and the personal tutor may in fact notactually teach the students. Some personal tutorsmay have a relationship with students for thewhole of the course or for only part of it. Differentinstitutions will have produced their list of roleresponsibilities from different origins. This will bedemonstrated through the operation of the role.

Support by placement mentors

A network of qualified nurses and experiencedstaff provide support for students in placements.These nurses should be appropriately qualifiedand experienced in their speciality and will haveattended training sessions to familiarize them-selves with curricula content and assessment strate-gies relevant to their practice setting and courserequirements. Students often say that the qualityof the placement experience hinges on the qualityof the relationship between them and their place-ment mentors. The role of the placement mentoris therefore a crucial one. Some mentors will bejunior staff who have been in their role for lessthan a year. Relatively new mentors can be veryuseful to students because their training will havebeen recent and fresh in their mind. The stressorspresent for students might be identifiable by thementor so there is a possibility of a usefulempathic relationship developing.

Mentors who have many years’ experience inthe speciality and of supporting students are oftenseen as oracles of knowledge. Their confidence inapproaching students and knowing how to facilitatelearning through contemplation and encouragingnew experiences is acknowledged by students asbeing invaluable and often a reason for requests tore-visit a placement at a later date.

Support in placements by lecturers

Students will also be supported in placements bylecturers who undertake key aspects of prepar-ation.Visits will afford students the chance to dis-cuss academic and practical developments togetherwith discussing the theoretical underpinnings ofpractice. The morale of staff in placements willhave an effect on your attitude and motivation.Be prepared to discuss this with your visiting lec-turer who will be able to highlight issues that youmay not be aware of and possibly influence thesupport from other people or resources duringthe experience. Discussions in class of course pro-vide opportunities to explore experiences. Espe-cially important is the need to debrief afterexperiences that were emotionally significant orincidents that were of a critical nature. Occasionallyexplanations are not given close to events andworries and questions that are left unanswered canaffect morale and taint beliefs that otherwisewould not be a problem. Lecturers might refer youback to practice staff but it is still important toalert lecturers to what you are experiencing eitherverbally or through your diary or portfolio.

Peer support

Students are a great support to each other and somebelieve that they only survived on a course becauseof their friends. Even during the preparation ofassignments, it is important to share, perhaps revieweach other’s work. Of course, several students whoregularly share will be helping each other, whichwill be reinforcing their team spirit, and thusstrengthening their confidence and group strength.This will help in the future when new challengesoccur. Sometimes even competition can be veryhealthy as it can produce new insights and risk-taking. A group identity, though, provides secu-rity and camaraderie that is actioned often whenrequired by an individual. For example, if a student needs to relocate accommodation, itwould be friends who will probably help with thearrangements.

Help with language was mentioned earlier, andmixing with peers can be valuable as a ‘safe’ situ-ation to practise speaking and reviewing theirwriting skills. This would provide help towards


success in studies and practice. Some skills can bedeveloped with the help of peers. These mightinclude word processing and the use of math-ematics, for example, which would prove usefulfor both studies and practice. Knowledge aboutpractise is also shared together with advice abouthow to react in certain practise situations.

There is the possibility of learning practise-related skills from students from other groups.Students from different groups often mix in prac-tice areas. These groups are often from differentstages of various courses. Familiarity between juniorand more senior students often results in learningthat otherwise would not take place. Assertive-ness and confidence, together with learning howto become part of the team are all very valuabledevelopments that take place.

A buddy system

In some universities, there is a formal arrangementbetween senior and junior students and it might bemaintained for the length of the course. New stu-dents might want to discuss issues related to leavinghome, moving to a new area, or even a new coun-try. Their senior buddy might have experiencedsomething similar and might be able to share expe-riences and help in that way. As the course pro-gresses advice about modular content, assignmenttips or on academic style might be welcomed.When in the final year, advice on application forjobs, interviews and the culture shock associatedwith becoming a new staff nurse and the attendantresponsibility for example, might be useful, as theirbuddy would have experienced this transition.

Benefits of this approach to student support• Lecturers do not have to be aware of commu-

nications between the students.• The senior student will have experienced simi-

lar feelings and experiences to the junior stu-dent thus facilitating an empathic relationship.

• It is peer support, which means that lecturers/personal tutors are not involved so they can bethe subjects of discussion outwith the officialuniversity support structure.

• Students relating with each other do so withsimilar perceptions, lecturers do not have sucha similar view of the education experience.

• Many students feel a sense of security andcamaraderie with their buddies. Friendshipsthat exist between group members can pro-duce a sense of identity within the faculty. Thedevelopment of group support between yeargroups is an added bonus of an individualizedsupport system of this kind and it demon-strates clearly the notion that just as nursescare for patients so too can students care foreach other. Thus, the care ethic begins, beforelife as a nurse begins, which ultimately trans-fers to behaviour after qualification.

Supporting students with special needs

Special needs are usually well catered for withinuniversities. Dyslexia, for example, presents itselfin a variety of ways and occasionally is not evenproperly assessed until a student presents withdifficulties when preparing work for assessment.Many lecturers are skilled at assessing dyslexicdifficulties and routinely refer students to appro-priate sources of help that can result in extra timefor examinations and possibly several thousandsof pounds towards computer equipment and sup-plemented tutorial support. Students with hear-ing or sight difficulties can also be catered for solong as staff are made aware of a student’s diffi-culty. An important point here is that often,people who have learning difficulties have beenlabelled as slow learners and have been disadvan-taged. Students who have special needs often donot know that specific help can be effectively tar-geted if proper assessments are carried out.

Dyslexic students are able to access a free edu-cational psychologist assessment so their needscan be properly assessed so that access to financialsupport would be possible and studies wouldbecome easier. Fear of being labelled should in thefuture be reduced. Indeed, it is hoped that thepositive aspects of dyslexia will be heralded,and the lessons learned through helping dyslexicstudent nurses should be used to help other students.

The Special Educational Needs and DisabilityAct (2001), places responsibility on institutionsin respect of providing support irrespective offunding arrangements. The Act removed educa-tion’s previous exemption from the Disability

Systems of support during the course 107

Discrimination Act (1995). This meant that itbecame unlawful for educational establishmentsto discriminate against students who have dyslexia,for example it is unlawful to turn away a studentfrom a course if they have dyslexia. However,there are levels of dyslexia that would prevent aperson from working as a staff nurse so it isunlikely that a university would accept a studentonto a course if their dyslexia were so profound asto preclude them from such work. This profes-sional exception would be lawful.

GLOSSARYIn the context of this chapter the meanings of the followingwords are described:

Academic Study of theory/rationale for practiceBuddy A supportive and educative relationship

with a senior or junior student with whoma student has been paired during acourse or just for a placement

Course Programme of study on which the stu-dent has enrolled

Education Scheme of planned and unplanned expe-riences that facilitates learning that pro-duces a change in attitude, knowledge orbehaviour of the student. This does notnecessarily occur as part of the course

Institution The university and all its structuresincluding the staff

Mentor Member of practice staff entrusted withthe supervision or assessment of a stu-dent’s performance in practice

Nurse Qualified and registered practitionerPeer An equal, friend, and colleague/

companion on the coursePersonal tutor Member of the teaching staff who has

responsibility for pastoral support. Thisperson may also be referred to as a per-sonal lecturer


Summary

Challenges that you as a student mightexperience have been discussed. What iswritten here is not an exhaustive list. Thenature of support and where it can comefrom have been outlined. This chapter has setout to encourage you to believe that you arenot undertaking your chosen course on yourown. It is likely that you will gain support atdifferent times and need it for different reasons than your peers; that is perfectlynormal. The curriculum and the environmentthat you find yourself immersed in might notalways be conducive to health, wealth andhappiness. Staff in the university and inpractice areas are there to help you to succeed. Try to find comfort in these people,show willing, and they will be more likely toinvest their time in you. The way you acttowards others will affect the way they acttowards you and remember that your job willbe to make others feel better about their situation, feelings and thoughts. Carers carefor each other so do not be afraid to ask for it.

Your previous experiences, attitudes andbeliefs might be a significant influence onyour achievement on the course and yourdevelopment as a student and as a nurse, butimportantly on your personal development.You will change but you will also benefit ifyou are satisfied with that change. How others see you can be significant. People who know you well can be the best guardiansof what makes you who you are. When youneed someone, it is good to know to whom

you can turn. Remember your friends andfamily and if you have moved away fromthem, keep in touch, use their advice, and donot forget to be interested in what is goingon in their lives.

There may be times when a member ofyour church could help with your difficulties.Your family doctor might need to be contacted for help. Parents, extended familymembers or neighbours might be the oneswhom you approach for help. Keep your contact with your supporters and they aremore likely to be there for you if you needthem. This relates also to your relationshipwith your lecturers and especially with yourpersonal tutor. Relationships need to beworked on and will develop as a result ofinteractions. Share your good times and ifthere are any bad times then they too will be easier to share. Good luck.

Placement Any area where care takes place or wherelearning experiences relevant to thecourse is scheduled

Student Person enrolled on a nurse training courseStudy Exercise of non-experiential learning,

the process of cognitive learningTraining Process of becoming a qualified nurse,

this involves university-based educationand learning from experiences gainedduring planned allocations to practicalplacements.

REFERENCESBoud D, Keogh R, Walker D (eds) (1985) Reflection: turning

experience into learning. London: Kogan Page, p. 19.Bramley W (1977) Personal Tutoring in Higher Education.

Guildford, Society for Research into Higher Education Ltd.Counselling Services (2004) www.uwec.edu/counsel/pubs/

homesick.htm (accessed 23 June 2004).Disability Discrimination Act 1995. London, HMSO.Earwaker J (1992) Helping and Supporting Students:

rethinking the issues. Buckingham, Open University Press.Heath H (1998) Keeping a reflective practice diary: a prac-

tical guide. Nurse Education Today 18:592–8.McInnes B (1999) Stamp out stress. Nursing Standard

13:53–5.Morgan K, Closs SJ (1999) Sleep Management in Nursing

Practice: an evidence-based guide. Edinburgh: ChurchillLivingstone.

Nursing and Midwifery Council (2002) The NMC Code ofProfessional Conduct: standards for conduct, perform-ance and ethics. London: NMC.

Palmer AM, Burns S, Bulman C (1994) Reflective Practice inNursing; the growth of the professional practitioner.Oxford: Blackwell.

Philips R (1994) Providing student support systems in Project2000 nurse education programmes. The personal tutorrole of nurse teachers. Nurse Education Today 14:216–22.

Schon (1983) The Reflective Practitioner: how professionalsthink in action. London: Basic Books.

Special Educational Needs and Disability Act 2001. London,HMSO.

Teasdale K (1989) The concept of reassurance in nursing.Journal of Advanced Nursing 14:444–50.

Townend A (1991) Developing assertiveness. London:Routledge.

USEFUL WEBSITESA lot of advice and information is available fromschools, colleges, friends and family. As we are

living in the so-called information era it seemedpertinent to offer a list of useful websites that display relevant information for students who arecontemplating a university course. There is theusual warning however, that the nature of thesewebsites may change over time.

Professional internet sites

Nursing and Midwifery Admissions Service. www.nmas.ac.ukUniversities and Colleges Admissions Service. www.ucas.comNursing and Midwifery Council. www.nmc-uk.org – this site

is useful as it enables you to search for issues to do withwork, regulations and it helps to explain the responsibil-ities of staff nurses. For example, a staff nurse is respon-sible for the actions of a student nurse who is under hisor her supervision.

Royal College of Nursing. www.rcn.org.uk/ – this site cananswer frequently asked questions and it gives access todiscussion forums for students.

General internet sites about highereducation

www.opsi.gov.uk – this site gives access to the Acts referredto in the text. Explanations can be found that should pro-vide you with the rationale for the changes that have,and those that will, occur in higher education withrespect of the law.

www.aimhigher.ac.uk ‘The key aims of Aimhigher are: A. Tooffer an effective and extensively used entry point thatenables prospective students to seek information abouthigher education institutions and courses. B. To offerinformation and assurance on financial matters to stu-dents entering higher education, specifically informationabout financial support and advice. C. To help widen par-ticipation in UK higher education – and particularlyamong students from non-traditional backgrounds,minority groups and disabled persons.’

www.uni4me.co.uk – ‘will answer many of the questions youhave about what it is like to be a university student. It willhelp you to work out your options and make decisions.’

www.opendays.com – is a service that allows you to search forinteresting university open days and book a place online.

www.dfes.gov.uk/hegateway/ – ‘aims to provide informationon a wide range of topics to enable students and theirparents or advisers to make effective decisions.’

www.nusonline.co.uk – is the National Union of Studentswebsite.

www.slc.co.uk – gives you important information about stu-dent loans from the Student Loans Company UK.

Useful websites 109



www.nmas.ac.uk

www.ucas.com

www.nmc-uk.org

www.rcn.org.uk/

www.opsi.gov.uk

www.aimhigher.ac.uk

www.uni4me.co.uk

www.opendays.com

www.dfes.gov.uk/hegateway/

www.nusonline.co.uk

www.slc.co.uk


Career Management and Developmentfor Registered NursesJane E Schober

9

INTRODUCTIONOne of the most influential actions you take during your working life is making career-relateddecisions. Generally, choosing a job or a course of study and being selected seems achievementenough.However,making effective, relevant choicesis a complex process that is central to your individ-ual well-being and your career development. Thischapter aims to offer you details and guidance relat-ing to career management and takes into accountpersonal, social, professional and educational fac-tors relevant to working as a registered nurse.

The chapter is based on a Ten Point Plan forcareer development. Each point in the plan isexplored in detail and serves as a framework tohelp you make effective career choices. The TenPoint Plan includes:

• Nursing and Midwifery Council (NMC) require-ments to maintain your licence to practise nursing

• NMC requirements for returning to practice• How to maintain your personal professional

profile and your personal development plan• Career options and opportunities available

to you• Sources of employment information• Sources of course and educational information• Factors affecting career choices, i.e. work needs,

personal needs and family/social needs• Factors influencing your job satisfaction• Applying for a new job – the selection process• How to manage the selection interview processes

NMC REQUIREMENTS TO MAINTAINYOUR LICENCE TO PRACTISENURSINGBecoming a registered nurse is the first step in theprocess of career development. It is a period filledwith opportunity, challenges and excitement as professional roles are taken up in practice areas.Support and guidance is available as is the expect-ation from employers, professional colleagues andpatients that you are able to practise safely, compe-tently and in accordance with established standards.Post-registration education and practice (PREP)requirements and the code of professional conduct(see Appendix 2, NMC, 2002b) emphasize theneed to maintain professional standards. Continuingprofessional development (CPD) is both a standardfor achieving PREP and a process contributing tolife-long learning (NMC, 2001):

The NMC’s Code of professional conductrequires you, regardless of where you are working and regardless of whether or not you are currently practising, to maintain and improve your professional knowledge and competence.

(NMC, 2001, p. 8)

Life-long learning and continuingprofessional development

Nurses face many challenges during their careersand need to take responsibility for their professional

development to respond effectively to changes inpractice.Maintaining an enquiring approach to prac-tice is essential to life-long learning (NMC, 2001).Keeping up to date, maintaining and developingnew skills, taking advantage of learning opportuni-ties, whether these are formal teaching sessions orinformal initiatives are all part of this process. Muchof this responsibility lies with the registered nursebecause he or she may determine how the standardsare achieved. However, the NMC PREP standardsand support from employers, mentors and col-leagues all contribute to the guidance and learningopportunities necessary for registered nurses (seealso the section on factors influencing your job satisfaction and Chapter 8).

Renewal of registration

Nurses working in the UK are required to renewtheir registration every 3 years (NMC, 2002a) topractise as a nurse. This process ensures that nursesmeet the standards required for registration, sign anotification of practice form and that PREP require-ments are met (NMC, 2002a). Two professionalstandards must be met to fulfil the legal require-ments for the NMC.These are:

The PREP (practice) standard – you must haveworked in some capacity by virtue of your nursing or midwifery qualification during theprevious five years for a minimum of 100 days(750 hours), or have successfully undertaken an approved return to practice course.

The PREP (continuing professional development) standard – you must have undertaken and recorded your continuing professional development (CPD) over the threeyears prior to the renewal of your registration.All registered nurses and midwives have beenrequired to comply with this standard sinceApril 1995. Since April 2000, registrants need tohave declared on their NOP form that they have met this requirement when they renewtheir registration.

(NMC, 2002a, p. 4)

The PREP (practice) standard

This standard may be fulfilled in a number of ways.The evidence of working as a nurse (or midwife) for

the minimum 100 days may be fulfilled by workingfull time, part time, voluntarily or, for example, bycaring for a relative at home. If you wish to renewyour nursing and midwifery registrations, 200 dayswould need to be completed, 100 hours for eachregistration.

The PREP (CPD) standard

This standard requires you to provide evidence oflearning activities relevant to your practice.This is aminimum standard and should in no way discour-age you from exceeding the recommended criteriawhich are to:

undertake at least five days or 35 hours oflearning activity relevant to your practice during the three years prior to your renewal of registrationmaintain a personal professional profile of yourlearning activitycomply with any request from the NMC toaudit how you have met these requirements.

(NMC, 2002a, p. 7)

NMC REQUIREMENTS FORRETURNING TO PRACTICEMany nurses have a break in service during theircareers. If this break is over five years long, it is anNMC requirement (Box 9.1) to attend an approvedReturn to Practice course to fulfil the PREP prac-tice standard. Many centres in the UK offer thesecourses which are at least 5 days in length (detailsare available on the NHS Careers and NMC web-sites, see Useful websites and addresses at the end ofthe chapter). These courses focus on professionalupdating, current issues in nursing, key skills, legal

112 Career Management and Development for Registered Nurses

Box 9.1 NMC requirements for therenewal of registration

• Signed declaration that the PREP practiceand CPD standards have been met

• Completed notification of practice form• Compliance with the NMC audit• Maintenance of a personal professional

profile

issues and management of care. Successful comple-tion of a course entitles participants to re-registerwith the NMC along with the notification of prac-tice documentation and renewal fee.

HOW TO MANAGE YOUR PERSONALPROFESSIONAL PROFILE AND YOURPERSONAL DEVELOPMENT PLANYour personal professional profile is not just arequirement for PREP and CPD, it is an integralpart of the educational process for pre- and post-registration learning. Many nurses have a substantialprofile from their pre-registration learning coursesand there may be evidence of learning from thisperiod that is relevant to the post-registrationperiod, particularly for those who are newly registered.

Your profile is a personal record of professionaldevelopment. It is an essential record of CPD and assuch should be regarded as a live document.To ful-fil the PREP (CPD) requirement, the profile shouldcontain evidence of learning activities, which mayalso be completed in the Welsh language. However,the profile may also include (Schober, 2003 p. 419):

• ‘biographical information• the record of qualifications, academic and

professional• a summary of current and previous posts• details of relevant responsibilities and activities,

e.g. management roles, interest groups, researchactivities and publications

• the record of education and formal learningexperiences, e.g. courses, study days and updates,conference attendance and teaching activities

• a record of working hours during the previous3 years

• reflection and evaluation of performance; thismay also include critical incident analysis as wellas examples of feedback from mentors and peers

• personal and professional objectives; this may bein the form of an action plan.’

As your profile is a PREP requirement, is has thepotential to grow as a record of your nursing career(Box 9.2) and professional development. It may beused to support a job application and as a source ofevidence that you may wish to refer to if working

alongside a mentor or preceptor. It may also be usedto record details of experiences of nursing and car-ing if undertaking non-paid and voluntary work.

Your personal development plan

As an employee and a qualified nurse, you will beentitled to support, learning opportunities andtraining to fulfil the requirements of your role. Inthe National Health Service (NHS) and in mostareas of health care employment, systems of indi-vidual performance review or appraisal exist as theopportunity for your line manager to give youfeedback, advice and guidance about your perform-ance at work. These reviews usually occur at threemonths, six months and then annually. From thisprocess, a personal development plan (PDP) may bereferred to as an aspect of the process that confirmsany learning and training needs, learning opportun-ities and development needs.

Your personal development plan – gettingstartedYour PDP may become an integral part of your per-sonal professional profile as much information iscommon to them both. Planning involves reflec-tion and self-assessment to consider your strengths,learning needs,how you will respond to the needs ofthe work role and the multi-professional team.

Managing your personal professional profile and development plan 113

Box 9.2 Organizing your profile

When organizing your profile, aim to:

• keep your profile up to date• date all entries• structure the document logically• use an index• avoid names and ensure confidentiality• keep your profile secure

Reflective activityConsider your current role: Do you feel confidentin your abilities to fulfil the role? What are yourpriorities, learning needs and goals?

See Box 9.3 and compare your list with the listof skills here. Prioritize your needs and documentthem, these will serve as a basis for your plan andyour discussion with your line manager. Considerthe priorities and skills listed in Box 9.3.

From the outset of your career, your PDP willhelp you to organize your development but with-out resources and support, the implementationmay not be effective.

CAREER OPTIONS ANDOPPORTUNITIES AVAILABLE TO YOUMany factors affect career options and opportun-ities. These include your experience, qualifications,personal and social commitments which may,for example, affect your working hours and youreligibility for a post. Employment opportunitiesfor nurses are wide ranging and there are many examples of roles which subsequently become avail-able depending on the stage of a career (see thesection on Sources of employment information).

Having chosen a branch of nursing for your pre-registration course, you have made a significantchoice which gives you opportunities to discoverand experience a range of options associated withthat branch. This exposure to practise during acourse often influences that choice of first post afterregistration as you may wish to return to a familiarplacement, you may be invited to apply for an avail-able post and in a few cases, you may have to returnto it if you were seconded to undertake the course.

Your first post

It is not unusual for nurses who achieve their regis-tration to apply for a first post in an NHS trust.Nurses are often encouraged to consider posts localto the higher education institution (HEI) wherethey undertook their course as they know the local-ity and associated practices.Also, this goes some waytowards easing the transition from student to staffnurse which, in itself, is a complex process and itmay help consolidate key skills and aspects of thecourse. Many students report that the uncertainty ofthis period is influenced by:

• concerns about impending course results• excitement tinged with apprehension about job

applications• changes in group dynamics as course members

go their own way and support networks change.

Although most nurses opt for a post in the NHS,the independent sector, e.g. private hospitals, clinicsand recruitment agencies also offer posts in the UKand abroad. Key roles for newly qualified nurses(pay band 5) in the NHS are listed in Box 9.4. You


Box 9.3 Examples of personal development priorities and skills

• Clinical skills• Management skills• Professional knowledge• Leadership skills• Specialist communication skills• Academic progression• Research skills and opportunities• Multi-professional working methods

Box 9.4 Roles for newly qualifiednurses in the NHS (pay band 5)

• Qualified nurse: adult, children’s, learningdisability or mental health nurse

• Community nurse• Practice nurse• Nurse (who works in a school)

Qualified nurses who remain in NHS employ-ment,have a wide range of employment optionsas jobs are available in:

• primary, secondary and tertiary health careand practice settings

• teaching as a practice educator• management• research

With experience, relevant education and pro-motion nurses may progress from the roles of newly qualified nurses (pay band 5) tomore senior NHS posts.

will find that there is a wide range of specialitieswithin each branch that are shaped by the needs ofthe patient/client group, their dependency and thetype of care required. With the development ofservices in the community and primary health caretrusts, a wider range of roles are available for nursesfrom all the branches. Box 9.5 identifies key roles in the remaining pay bands for nurses in clinicalpractice.

Details of NHS posts and qualifications requiredfor these posts are available on the NHS and NMCwebsites (see Useful websites). Details specific toeach country in the UK are also available (see Usefuladdresses and websites).

SOURCES OF EMPLOYMENTINFORMATIONIn addition to employment within the NHS, there isa wide range of prospective employers of nurses(Box 9.6) and because of this, you need to be mindful of the range of issues pertinent to a role.Discovering as much information as possible abouta job, your employer, the parent organization andthe conditions of service are vital to this process.

Initially finding a job is a central goal, particularlyat the end of a course or following a period of leaveor travel. Prospective employees tend to refer tospecialist journals, local and national press for detailsof available posts. Box 9.7 lists additional sources of employment information that highlight how toaccess information about available jobs and whereto gain information about an employer.

Sources of employment information 115

Box 9.5 Nurses posts and pay bands6–8

Pay band 6• Community psychiatric nurse• District nurse• Health visitor• Deputy ward manager/ward team leader• Nurse advisor (NHS Direct/NHS 24)• Qualified school nurse• Specialist nurse• Specialist practice nurse• Specialist theatre nurse

Pay band 7• Ward manager• Community psychiatric nurse manager• Health visitor (community practice teacher)• Highly specialist nurse• Team manager district nursing• Team manager health visiting• Team manager school nursing• Sexual health advisory service manager

(community)

Pay band 8• Consultant nurse – range A and B• Professional manager – range C and D

Box 9.6 Employers of nurses in the UK

• Charitable organizations, e.g. Macmillannurses

• HM forces, e.g. army, navy and air force• HEIs/universities• Nursing agencies• Overseas development services, e.g. the

British Red Cross• Independent health care organizations• Pharmaceutical companies• Professional organizations, e.g. the Royal

College of Nursing• Statutory organizations• Trade unions

Box 9.7 Other sources of employmentinformation

• Human resources departments withinorganizations

• Internal communications, e.g. newsletters• Parent organization websites, e.g. local NHS

trust

In addition, you need to be confident about whata prospective employer is able to offer you.The elem-ents of employment which may affect your deci-sion to apply include:

• employment policies, i.e. how policies are oper-ationalized, e.g. family-friendly policies, staffdevelopment

• terms and conditions of service, e.g. contract,salary and leave details

• staff support networks, e.g.preceptorship scheme,mentor support, personal development plan-ning and individual performance review (IPR)

• quality assurance mechanisms• induction programme and staff training.

Job advertisements usually provide summaryinformation about a job and the employer. Whenapplying for a post exploring this employer-specificinformation is vital. In the section on How to man-age the selection interview processes, the issuesrelating to applying for a job and the selectionprocess are explored further.

Working abroad

Many nurses use their professional qualifications totravel and work abroad.There is a range of employ-ment agencies, charities and overseas developmentorganizations that co-ordinate this. Most countrieshave requirements for employment and profes-sional registration. The European Union (EU) haslegislation that facilitates the employment of nursesregistered in the UK.To nurse abroad you should beconversant with:

• registration requirements• employment conditions, contract details and

accommodation• visa and work permit requirements• indemnity and medical insurance options• tax, pensions and leave entitlements• personal health issues• language issues.

Some countries, e.g. USA, require nurses to passexams before they will consider their employment.Usually these are completed in the UK. Details of such requirements may be accessed throughinternational nursing and health care recruitmentagencies (see Useful addresses).

Applying to nurse abroad is a complex and oftentime-consuming process. It is always advisable toseek advice from reputable sources, e.g. the RoyalCollege of Nursing (RCN) International office andthe NMC (see Useful addresses).

Sources of course and educationalinformation

The diversity of nursing and health care, the rates ofchange in practice, policy and roles and professionalrecommendations for ongoing education make itessential for nurses to adopt strategies for life-longlearning. Identifying what is available, what is acces-sible and what is relevant and necessary is a complexbusiness. Here, therefore, is an outline of resourceswhich will support this process of ongoing learning.

General career and course informationBy visiting the NHS career and NMC websites youwill access general information about key roles andtheir educational requirements. In addition each UKcountry has its own website for nurses that offer thelatest details about professional development andcourses (see Useful addresses).

Career advice and guidance – the case for a mentorFinding out about educational opportunities is partof the wider life-long learning and CPD process.As such, it is necessary to discover the opportun-ities available as well as having advice to assistdecisions. Career advice is rarely a formal part of anemployee’s support network, rather, it is usuallyintegral to relationships which emerge at work.Thisis particularly true of relationships between nursesand their line managers, as senior colleagues mayhave knowledge of local and national opportunities,hence the relationship with CPD.

It is not unusual for employees to initiate systemsfor mentoring staff. Indeed, student nurses are familiar with mentorship from their pre-registrationcourses. Whether this is a formal requirement or aninformal system of support, a mentor relationshipmay develop as a catalyst for CPD and career devel-opment.This places enormous responsibility on thementor to provide appropriate support, guidanceand advice. Though mentors may have a good


working knowledge of local and speciality-basedcareer details, it is usually necessary to access othersources of information to ensure relevant informa-tion is available.

Continuing professional developmentKey aspects of CPD and personal developmentplanning depend on the availability of resources forlearning. Within the NHS, there is emphasis onwork-based and team learning (Department ofHealth (DoH), 2001) as a means of co-ordinatingeducation and skill development.Multi-professionallearning facilitates the sharing of learning opportun-ities and resources between professional groups andis particularly effective in relation to, for example,communication skills development, medicolegalissues and practice updates. Many local courses,whether they be short study days or longer courses,are accredited with academic credits and validatedby an HEI.This is usually a feature of learning mod-ules which are part of a longer course. This systemallows credit for learning to be awarded follow-ing successful completion. It is also more flexible asmost of these courses are part time and may runmore than once per annum.

Higher education institutions, universitiesHigher education institutions work in close part-nership with a range of employers including NHStrusts and the independent health care sector. Thisrelationship has resulted in the development ofcourses and learning opportunities which are centralto the CPD of nurses and the support for specialistcourses, e.g. specialist nurses, district nurses, healthvisitors and nurse teachers, as well as role devel-opments, e.g. nurse prescribing. The HEIs’ websitesand prospectus will summarize the courses on offer.This information is vital for choosing a relevantcourse, negotiating study leave and applying for anyavailable resources to cover course fees and requiredmentor support.

Open and distant learningOpen and distant learning opportunities are aflexible option for many nurses who choose to fita course of study around their lifestyle needs. Inrecent years this flexibility has developed furtherthrough e-learning and this is a popular facility in

HEIs. You may find that certain modules within ataught course may be studied in this way, the HEIprospectus and course information will clarifythese options.

Royal College of Nursing study hoursThe RCN offers a scheme for accrediting learn-ing through the CPD article published regularlyin the Nursing Standard. Not only does this strat-egy encourage professional learning, it can beused as evidence for PREP and become part ofyour portfolio.

Other coursesThere is a wide range of topics and subjects on offerthrough CPD programmes and other courses. Alsothe academic level of courses may vary in com-plexity usually from diploma level, through to firstdegree, master’s level and ultimately PhD. In gen-eral, those working at the level of pay band 5 willhave achieved a diploma or first degree as part of their pre-registration course. Subsequently, roles for pay bands 6–8 would necessitate further study at first degree level. Nurse consultants and nurseteachers in HEIs would need to have undertakenstudy at master’s level for eligibility for most posts atthis level.

FACTORS AFFECTING CAREERCHOICESAwareness has grown among employees andemployers of factors that encourage commitmentand well-being at work.These needs are summarizedin Box 9.8 (from Schober, 1990, who identifiesfactors that you may find relevant to career devel-opment decisions). Consider these alongside pre-viously detailed employment, professional andeducational perspectives.

Factors affecting career choices 117

Box 9.8 Factors affecting careerchoices

• Work needs• Need to work• Promotion

Be aware of any compromise that may impacton your job satisfaction as this is a vital motivator.

FACTORS INFLUENCING YOUR JOB SATISFACTIONJob satisfaction remains the central tenet toemployees remaining committed and loyal to awork role and those associated with it. Lack of jobsatisfaction, by implication, results in higher staffturnover and low morale. Although pay is animportant factor for us all, and despite the ongoingdebates about pay levels, the influence on job satis-faction is nebulous. Pay becomes more significant

when employees face the demands of high-costaccommodation, travel and living expenses, partic-ularly in south-east England and in cities.

Job satisfaction is mainly influenced in clinicalposts by effective support networks e.g. preceptor-ship, mentoring and teamwork. Leadership stylesthat promote staff well-being, professional devel-opment and overall commitment to the client orpatient group requiring care, are also essential.

APPLYING FOR A NEW JOB: THESELECTION PROCESSHaving explored the factors affecting career devel-opment, they may now be used to positively influ-ence job applications and the selection process.Yourawareness of the jobs appropriate to your needs, andhow relevant your skills and expertise are for anavailable job, are necessary prerequisites.

Finding a job

Earlier in the chapter employment opportunitiesfor nurses were considered. Adverts for jobs are thebest means of finding a job but the detail given maybe very variable. Subscribing to a relevant profes-sional journal and using the internet are vital sourcesfor advertisements. Details of a job may then be sentfor which should provide you with key information.Aim to have information that clarifies details of:

• location of the post• contract details, grade and pay band


• Motivation and opportunities to learn anddevelop professionally

• Interest/commitment to the work and role• Range of responsibility• Dynamics of the team and management

structure• Personal needs• Job satisfaction• Job security• Status of the role• Salary• Reluctance to change roles• Terms of the contract• Family/social needs• Family need for income• Childcare availability• Availability of accommodation• Travelling distance from home• House prices• Support of partner/family members

Source: Schober (1990)

Reflective activityConsider this list (Box 9.8) when assessing a newjob. Prioritize the factors important to your per-sonal, professional and social life to ascertain towhat extent your new job will fulfil your needs. Ifyou are prepared to compromise, can you antici-pate short- or long-term outcomes?

Summary

Managing your career development depends on:

• assessment of employment opportunities• assessment of work, personal and social

needs• information retrieval about options, the

job and educational opportunities• personal and professional support and

mentorship• fulfilment of PREP and CPD requirements• maximizing personal and professional

development opportunities.

• role description• term and conditions of employment• prerequisites, e.g. qualifications and required

experience• opportunities for support and staff development• IPR/appraisal scheme• closing date for applications.

Elements of preparing an application

The informal visitIf you are applying for a job in a new location,an informal visit is invaluable. This gives you theopportunity to visit the place of work, meet staff,assess the environment and observe, though briefly,aspects of practice. Some employees may not facili-tate such a visit, but others will and realize that youare taking your application seriously. A visit maymark whether to pursue an application or not.

Completing the application formAny application must be accurate and beautifullypresented. Remember, it is usually photocopied forall the members of an interview panel so black ink isessential. Ensure that where necessary, any requestsfor details relating to your motives for the applica-tion are written objectively to highlight your skills,relevance of your experience, your interest in thejob and what qualities you are offering. You mayfind it helpful to use the sub-headings on the roledescription to help you organize this section.

The health assessment formUsually a health assessment form is requested aspart of the application process. This is sent directlyto the occupational health department who willadvise you if further details are required.

Previous convictionsPrevious convictions must be declared on requestand your police record will be checked if youwork with vulnerable people.

Your refereesIt is usual for the names of two referees to berequested. If this is a job following qualification,your HEI will be approached for a reference. Other-wise referees will be approached for a comprehen-sive analysis of your suitability for the post.

Choose your referees carefully, they are advo-cates and supporters of your professional develop-ment.You need to choose them on the basis of theirunderstanding of your skills, qualities, career aspir-ations and commitment. They should know youwell, perhaps they have been your manager or lec-turer. Liaise with them over all your career moves sothat they remain fully conversant with your plans.Give feedback following a selection process, what-ever the outcome.

Your curriculum vitaeIt is usual for a curriculum vitae (CV) to accom-pany an application form, particularly if this is apost beyond pay band 5. A CV is a support docu-ment and should provide complementary and add-itional information to that on the application form.Adapt key aspects of your CV to the post you areapplying for. This will strengthen your applicationfurther. The CV should not replace an applicationform unless the application is by CV only. There isno standard format for a CV, and Box 9.9 providesa suggested outline.

Applying for a new job 119

Box 9.9 Developing your CV

A CV should include your:

• Name• Address• Contact phone/e-mail• PIN number• Qualifications• Previous experience• Professional activities

Reflective activityIf you have not already done so, prepare your CV.It may be kept with your professional profile andbe updated according to any job application youmake. In addition to the outline given (Box 9.9),you may wish to include details of other employ-ment, information relating to gaps in employmentand any voluntary work you undertake.

HOW TO MANAGE THE SELECTIONINTERVIEW PROCESSESA range of selection procedures may be used forselecting a candidate for a job. The method andcomplexity of the process will depend on the seni-ority of the post. For most clinical nursing jobs, thepanel interview is the most popular. It follows thereceipt of application papers and any short-listingprocedures that ensure the criteria for the job havebeen met by each candidate.

Being called for interview

Notification will give you time for final preparation.Most candidates feel apprehensive prior to the eventso thorough preparation is vital. This may include:

• thorough revision of your application form andCV as they relate to the criteria for the post

• revision of key professional and clinical issuesas they relate to the post

• consideration of your key strengths and motivesfor applying

• details of how you keep up to date and fulfilPREP requirements

• preparing questions to ask at interview to clar-ify any key points

• planning for the day of interview includingappropriate dress and travel arrangements.

The presentation

Some selection procedures require candidates togive a presentation on a given topic. This requirespreparation of slides or a computer presentationsuch as in PowerPoint (Microsoft) for a high stand-ard to be achieved. Hard copies of the content maybe prepared for those receiving the presentation.

The interview

Panel interviews usually consist of two or moremembers. They may include the line manager, a senior manager, an educationalist and a member of the human resources team. Questions will relate to the application, the criteria for the post, professionalawareness, key skills and team working. In addition,you may be asked to respond to a problem-basedquestion relating to practice, issues associated with

your teaching and management skills and your careeraspirations. The interview is your opportunity tocommunicate your skills, potential and suitabil-ity for the job. It is also a time to demonstrate yourcommitment, enthusiasm and professionalism.

CONCLUSIONThis chapter has explored key issues necessary forcareer and professional development. Nurses arecharged with the responsibility for maintainingtheir licence to practice nursing as well as beingcompetent accountable practitioners. This chap-ter will support you in this process.

REFERENCESDepartment of Health (2001) Working Together, Learning

Together: a framework for lifelong learning for the NHS.London: DoH.

Nursing and Midwifery Council (2001) Supporting Nursesand Midwives through Lifelong Learning. London: NMC.

Nursing and Midwifery Council (2002a) The PREP Handbook.London: NMC.


Schober JE (1990) Your career – making the choices. In:Tschudin V, Schober JE (eds) Managing Yourself. London:Macmillan.

Schober JE (2003) Maintaining a licence to practice: yourcareer as a professional nurse. In: Hinchliff S, Norman SE,Schober JE (eds) Nursing Practice and Health Care, 4thedn. London: Arnold.


Summary

Professional and career developmentdepends on:

• fulfilling CPD and PREP requirements• maintaining your PDP• using support networks for ongoing

development• thorough assessment of career and

educational opportunities• thorough planning for all application and

selection interviews• commitment to life-long learning.

ANNOTATED FURTHER READINGHinchliff S, Norman SE, Schober JE (eds) (2003) Nursing

Practice and Health Care, 4th edn. London: Arnold. A com-prehensive textbook for all nurses studying nursing and forthose returning to nursing. This multi-authored text pro-vides the reader with a wide range of professional and practice-based issues including ethical and professionalissues, working in a health care team, delivering care to arange of patient/client groups and developments in nurses’roles.

Nursing and Midwifery Council (2002) The PREP Handbook.London: NMC. This vital publication is essential for all nurses. It confirms the statutory requirements for re-registration and returning to nursing.

Ryder T (2000) Health Professionals Abroad. A Directory ofWorldwide Opportunities. Oxford: Vacation Work. A usefulguide to working overseas in a range of health care settings.It refers to opportunities in state and private sectors andoffers practical advice about work permits, conditions ofservice, etc. Some of these details would need checking forany recent changes.

USEFUL WEBSITESwww.myworkplace.nhs.uk – a website to assist NHS nurses

to gain as much as possible from the internet.www.nursingintheuk.co.uk – a site for advice for nurses who

trained outside the UK and who wish to work in the UK.www.jobs.nhs.uk/ – a website listing job vacancies in the NHS

including return to nursing information.www.nhsplus.nhs.uk – a website relating to occupational health.

USEFUL ADDRESSESCareers advice for applicants to pre-registration nursing courses

EnglandNHS CareersPO Box 376Bristol BS99 3EYTel: 0845 60 60 655 – Careers Helplinewww.nhscareers.nhs.com

ScotlandNHS Education for Scotland, Careers InformationService22 Queen StreetEdinburgh EH2 1NTwww.nes.scot.nhs.uk

WalesHealth Provisions Waleswww.hpw.org.uk

Learn DirectTel: 0900 100900

Northern IrelandNorthern Ireland Practice and EducationCouncil for Nursingwww.nipec.n-i.nhs.uk

Organizations offering advice forapplicants to pre-registration nursingcourses

Degree coursesUniversities and Colleges Admissions Service(UCAS)RosehillNew Barn LaneCheltenhamGloucestershire GL52 3LZTel: 0870 112 2200 (Applications)Tel: 0870 112 2211 (General enquiries)www.ucas.ac.uk

Diploma coursesEnglandNursing and Midwifery Admissions Service(NMAS)RosehillNew Barn LaneCheltenhamGloucestershire GL52 3LZTel: 0870 112 2200 (Applications package)Tel: 0870 112 2206 (General enquiries)www.nmas.ac.uk

ScotlandNBS CatchPO Box 21Edinburgh EH2 1NTTel: 0131 247 6622 (Applications)www.nes.scot.nhs.uk

Useful addresses 121

www.myworkplace.nhs.uk

www.nursingintheuk.co.uk

www.jobs.nhs.uk/

www.nhsplus.nhs.uk

www.nhscareers.nhs.com

www.nes.scot.nhs.uk

www.hpw.org.uk

www.nipec.n-i.nhs.uk

www.ucas.ac.uk

www.nmas.ac.uk

www.nes.scot.nhs.uk

Northern IrelandCareers adviceSchool of Nursing and MidwiferyRegistry OfficeQueen’s University of Belfast1–3 College Park EastBelfast BT7 1LQTel: 028 9027 2233

WalesLearn DirectTel: 0800 100 900

Professional and regulatory bodiesrelated to nursing, midwifery and health visiting

Nursing and Midwifery Council (NMC)23 Portland PlaceLondonTel: 020 7637 7181www.nmc-uk.org

NMC Registration Department

United Kingdom registration: Tel: 020 7333 9333Overseas registration Tel: 020 7333 9333Outside EU enquiries: Tel: 020 7333 6600Professional advice:Tel: 020 7333 6541/6550/6553Professional Conduct: Tel: 020 7333 6564Finance: Tel: 020 7333 6652

British Association of Counselling (BAC)1 Regent PlaceRugbyWarwickshire CV21 2PJTel: 01788 550 899www.counselling.co.uk

Community Practitioners’ and Health Visitors’Association40 Bermondsey StreetLondon SE1 3UDTel: 0207 939 7000www.msfcphva.org

Department of Health (Publications)PO Box 777London SE1 6XHE-mail: [email protected]/Home/fs/en

Institute of Psychiatry16 De Crespigny ParkLondon SE5 8AFTel: 020 7703 5411

The King’s Fund11–13 Cavendish SquareLondon W1G OANTel: 020 7307 2400www. kingsfund.org.uk

Royal College of Midwives15 Mansfield StreetLondon W1G 9NHTel: 020 7312 3535www. rcm.org.uk

Royal College of Nursing20 Cavendish SquareLondon W1M 0ABTel: 020 7409 3333www.rcn.org.ukwww.rcn.org.uk/resources/becomenurse.php

RCN DirectTel: 08457 726100 (24-hour advice line for

members)RCN NurselineTel: 020 7647 3463 (10 am to 4 pm Monday to

Friday)RCN Counselling ServiceTel: 0845 769 7064

UNISON1 Mabledon PlaceLondon WC1H 9AJTel: 020 7388 2366

Working Injured Nurses Group (WING)Tel: 020 7647 3465

Financial support and student grantsNHS Student GrantsDepartment of HealthPO Box 777London SE1 6XHTel: 08701 555 455www.dh.gov.uk/Home/fs/en


www.nmc-uk.org

www.counselling.co.uk

www.msfcphva.org

www.dh.gov.uk/Home/fs/en

www.kingsfund.org.uk

www.rcm.org.uk

www.rcn.org.uk

www.rcn.org.uk/resources/becomenurse.php

www.dh.gov.uk/Home/fs/en

Immigration and Nationality DirectorateThe Home OfficeLunar House40 Wellesley RoadCroydonCR9 2BYTel: 020 8686 0688

NHS Pensions Agency200–220 BroadwayFleetwoodLancashire FY7 8LG

Working abroadNursing AbroadPO Box 8BakewellDerbyshire DE45 1YGTel: 01629 640980www.nursingabroad.netwww.raleighinternational.org

Useful addresses 123

www.nursingabroad.net

www.raleighinternational.org


Appendices

Appendix 1: Standard 7 – First level nurses – nursing standards of education to achieve the NMC standards of proficiency 127Nursing and Midwifery Council

Appendix 2: The NMC Code of Professional Conduct: standards for conduct, performance and ethics 135Nursing and Midwifery Council

Appendix 3: An NMC Guide for Students of Nursing and Midwifery 143Nursing and Midwifery Council

Appendix 4: A Framework for Capable Practice 147The Sainsbury Centre for Mental Health


Standard 7 – First level nurses –nursing standards of education toachieve the NMC standards ofproficiency

Appendix 1

Standard of proficiency for entry to the register: professional and ethical practice

Manage oneself, one’s practice, and that of others, in accordance with The NMC code of professional con-duct: standards for conduct, performance and ethics, recognising one’s own abilities and limitations

Domain Outcomes to be achieved for entry to the Standards of proficiency for entry branch programme to the register: professional and

ethical practice

Professional and Discuss in an informed manner the implications • practise in accordance with The NMC ethical practice of professional regulation for nursing practice code of professional conduct: standards

• demonstrate a basic knowledge of for conduct, performance and ethicsprofessional regulation and self-regulation • use professional standards of practice

• recognise and acknowledge the limitations to self-assess performanceof one’s own abilities • consult with a registered nurse when

• recognise situations that require referral to nursing care requires expertise beyond a registered practitioner. one’s own current scope of competence

Demonstrate an awareness of The NMC code • consult other health care professionals

of professional conduct: standards for when individual or group needs fall

conduct, performance and ethics outside the scope of nursing practice

• commit to the principle that the primary • identify unsafe practice and respond

purpose of the registered nurse is to protect appropriately to ensure a safe outcome

and serve society • manage the delivery of care services

• accept responsibility for one’s own actions within the sphere of one’s own

and decisions. accountability.


Practise in accordance with an ethical and legal framework which ensures the primacy of patient andclient interest and well-being and respects confidentiality


Practise in a fair and anti-discriminatory way, acknowledging the differences in beliefs and culturalpractices of individuals or groups

128 Appendix 1: Standard 7 – First level nurses

Domain Outcomes to be achieved for entry to the Standards of proficiency for entry branch programme to the register: professional and

ethical practice

Professional and Demonstrate an awareness of, and apply • demonstrate knowledge of legislation ethical practice ethical principles to, nursing practice and health and social policy relevant to

• demonstrate respect for patient and client nursing practiceconfidentiality • ensure the confidentiality and security

• identify ethical issues in day to day practice. of written and verbal information

Demonstrate an awareness of legislation acquired in a professional capacity

relevant to nursing practice • demonstrate knowledge of

• identify key issues in relevant legislation contemporary ethical issues and their

relating to mental health, children, data impact on nursing and health care

protection, manual handling, and health and • manage the complexities arising from

safety, etc. ethical and legal dilemmas• act appropriately when seeking access

to caring for patients and clients in their own homes.

Domain Outcomes to be achieved for entry to Standards of proficiency for entry to the branch programme the register: professional and ethical

practice

Professional and Demonstrate the importance of promoting • maintain, support and acknowledge the ethical practice equity in patient and client care by rights of individuals or groups in the

contributing to nursing care in a fair and health care settinganti-discriminatory way • act to ensure that the rights of individuals• demonstrate fairness and sensitivity and groups are not compromised

when responding to patients, clients and • respect the values, customs and beliefs of groups from diverse circumstances individuals and groups

• recognise the needs of patients and • provide care which demonstrates clients whose lives are affected by sensitivity to the diversity of patients disability, however manifest. and clients.

Domain Outcomes to be achieved for entry to the Standards of proficiency for entry branch programme to the register: care delivery

Care delivery Discuss methods of, barriers to, and the boundaries • utilise a range of effective and of, effective communication and interpersonal appropriate communication and relationships engagement skills

Standard of proficiency for entry to the register: care delivery

Engage in, develop and disengage from therapeutic relationships through the use of appropriate com-munication and interpersonal skills

Appendix 1: Standard 7 – First level nurses 129


Create and utilise opportunities to promote the health and well-being of patients, clients and groups


Care delivery Contribute to enhancing the health and • consult with patients, clients and groups social well-being of patients and clients by to identify their need and desire for health understanding how, under the supervision promotion adviceof a registered practitioner, to: • provide relevant and current health • contribute to the assessment of health needs information to patients, clients and • identify opportunities for health promotion groups in a form which facilitates their• identify networks of health and social understanding and acknowledges

care services. choice/individual preference• provide support and education in the

development and/or maintenance of independent living skills

• seek specialist/expert advice as appropriate.


• recognise the effect of one’s own values on • maintain and, where appropriate, interactions with patients and clients and their disengage from professional caring carers, families and friends relationships that focus on meeting

• utilise appropriate communication skills with the patient’s or client’s needs within patients and clients professional therapeutic boundaries.

• acknowledge the boundaries of a professional caring relationship.

Demonstrate sensitivity when interacting with and providing information to patients and clients.


Care delivery Contribute to the development and documentation • select valid and reliable assessment of nursing assessments by participating in tools for the required purposecomprehensive and systematic nursing assessment • systematically collect data regarding of the physical, psychological, social and spiritual the health and functional status of needs of patients and clients individuals, clients and communities • be aware of assessment strategies to guide the through appropriate interaction,

collection of data for assessing patients and observation and measurementclients and use assessment tools under guidance • analyse and interpret data accurately

• discuss the prioritisation of care needs to inform nursing care and take • be aware of the need to reassess patients and appropriate action.

clients as to their needs for nursing care.


Undertake and document a comprehensive, systematic and accurate nursing assessment of the physical,psychological, social and spiritual needs of patients, clients and communities



Formulate and document a plan of nursing care, where possible, in partnership with patients, clients,their carers and family and friends, within a framework of informed consent


Care delivery Contribute to the implementation of a programme • ensure that current research of nursing care, designed and supervised by registered findings and other evidence are practitioners incorporated in practice• undertake activities that are consistent with the • identify relevant changes in practice

care plan and within the limits of one’s own abilities. or new information and disseminate Demonstrate evidence of a developing knowledge base it to colleagueswhich underpins safe and effective nursing practice • contribute to the application of a • access and discuss research and other evidence in range of interventions which

nursing and related disciplines support and optimise the health • identify examples of the use of evidence in planned and well-being of patients and

nursing interventions. clientsDemonstrate a range of essential nursing skills, under • demonstrate the safe application of the supervision of a registered nurse, to meet the skills required to meet the needs individuals’ needs, which include: of patients and clients within the maintaining dignity, privacy and confidentiality; current sphere of practiceeffective communication and observational skills, • identify and respond to patients including listening and taking physiological and clients’ continuing learning and measurements; safety and health, including moving, care needsand handling and infection control; essential first • engage with, and evaluate, the aid and emergency procedures; administration of evidence base that underpins safe medicines; emotional, physical and personal care, nursing practice.including meeting the need for comfort, nutrition and personal hygiene.


Care delivery Contribute to the planning of nursing care, involving • establish priorities for care based on patients and clients and, where possible, their carers; individual or group needsdemonstrating an understanding of helping patients • develop and document a care plan to and clients to make informed decisions achieve optimal health, habilitation, • identify care needs based on the assessment of a and rehabilitation based on assessment

patient or client and current nursing knowledge• participate in the negotiation and agreement of • identify expected outcomes, including

the care plan with the patient or client and with a time frame for achievement and/or their carer, family or friends, as appropriate, review in consultation with patients, under the supervision of a registered nurse clients, their carers and family and

• inform patients and clients about intended friends and with members of the nursing actions, respecting their right to health and social care team.participate in decisions about their care.


Based on the best available evidence, apply knowledge and an appropriate repertoire of skills indicativeof safe and effective nursing practice



Provide a rationale for the nursing care delivered which takes account of social, cultural, spiritual, legal,political and economic influences

Domain Outcomes to be achieved for entry Standards of proficiency for entry to the to the branch programme register: care delivery

Care delivery • identify, collect and evaluate information to justify the effective utilisation of resources to achieve planned outcomes of nursing care.


Evaluate and document the outcomes of nursing and other interventions

Domain Outcomes to be achieved for entry to Standards of proficiency for entry to the branch programme the register: care delivery

Care delivery Contribute to the evaluation of the • collaborate with patients and clients and, appropriateness of nursing care delivered when appropriate, additional carers to • demonstrate an awareness of the need to review and monitor the progress of

assess regularly a patient’s or client’s individuals or groups towards planned response to nursing interventions outcomes

• provide for a supervising registered • analyse and revise expected outcomes, practitioner, evaluative commentary and nursing interventions and priorities in information on nursing care based on accordance with changes in the individual’s personal observations and actions condition, needs or circumstances.

• contribute to the documentation of the outcomes of nursing interventions.


Demonstrate sound clinical judgement across a range of differing professional and care delivery contexts

Domain Outcomes to be achieved for entry to Standards of proficiency for entry to the branch programme the register: care delivery

Care delivery Recognise situations in which agreed plans • use evidence based knowledge from nursing of nursing care no longer appear appropriate and related disciplines to select and and refer these to an appropriate accountable individualise nursing interventionspractitioner • demonstrate the ability to transfer skills • demonstrate the ability to discuss and and knowledge to a variety of circumstances

accept care decisions and settings• accurately record observations made and • recognise the need for adaptation and

communicate these to the relevant adapt nursing practice to meet varying and members of the health and social unpredictable circumstancescare team. • ensure that practice does not compromise

the nurse’s duty of care to individuals or the safety of the public.


Standard of proficiency for entry to the register: care management

Contribute to public protection by creating and maintaining a safe environment of care through theuse of quality assurance and risk management strategies


Demonstrate knowledge of effective inter-professional working practices which respect and utilise thecontributions of members of the health and social care team


Delegate duties to others, as appropriate, ensuring that they are supervised and monitored

Domain Outcomes to be achieved for entry to Standards of proficiency for entry to the branch programme the register: care management

Care Contribute to the identification of actual and • apply relevant principles to ensure the safe management potential risks to patients, clients and their administration of therapeutic substances

carers, to oneself and to others, and • use appropriate risk assessment tools to participate in measures to promote and identify actual and potential risksensure health and safety • identify environmental hazards and • understand and implement health and eliminate and/or prevent where possible

safety principles and policies • communicate safety concerns to a relevant • recognise and report situations that are authority

potentially unsafe for patients, clients, • manage risk to provide care which best oneself and others. meets the needs and interests of patients,

clients and the public.

Domain Outcomes to be achieved for entry to Standards of proficiency for entry to the branch programme the register: care management

Care Demonstrate an understanding of the role of • establish and maintain collaborative management others by participating in inter-professional working relationships with members of the

working practice health and social care team and others• identify the roles of the members of the • participate with members of the health and

health and social care team social care team in decision-making • work within the health and social care concerning patients and clients

team to maintain and enhance integrated • review and evaluate care with members of care. the health and social care team and others.

Domain Outcomes to be achieved for Standards of proficiency for entry to the entry to the branch programme register: care management

Care • take into account the role and competence management of staff when delegating work

• maintain one’s own accountability and responsibilitywhen delegating aspects of care to others

• demonstrate the ability to co-ordinate the delivery of nursing and health care.



Demonstrate key skills

Domain Outcomes to be achieved for Standards of proficiency for entry to the entry to the branch programme register: care management

Care Demonstrate literacy, numeracy and • literacy – interpret and present information in a management computer skills needed to record, comprehensible manner

enter, store, retrieve and organise • numeracy – accurately interpret numerical data data essential for care delivery and their significance for the safe delivery of care

• information technology and management – interpret and utilise data and technology, taking account of legal, ethical and safety considerations, in the delivery and enhancement of care

• problem-solving – demonstrate sound clinical decision-making which can be justified even when made on the basis of limited information.

Standard of proficiency for entry to the register: personal and professionaldevelopment

Demonstrate a commitment to the need for continuing professional development and personal super-vision activities in order to enhance knowledge, skills, values and attitudes needed for safe and effect-ive nursing practice

Domain Outcomes to be achieved for Standards of proficiency for entry to the entry to the branch programme register: personal and professional development

Personal and Demonstrate responsibility for one’s • identify one’s own professional development needs by professional own learning through the engaging in activities such as reflection in, and on, development development of a portfolio of practice and lifelong learning

practice and recognise when • develop a personal development plan which takes into further learning is required account personal, professional and organisational • identify specific learning needs needs

and objectives • share experiences with colleagues and patients and • begin to engage with, and clients in order to identify the additional knowledge

interpret, the evidence base which and skills needed to manage unfamiliar or underpins nursing practice. professionally challenging situations

Acknowledge the importance of • take action to meet any identified knowledge and

seeking supervision to develop safe skills deficit likely to affect the delivery of care within

and effective nursing practice the current sphere of practice.

ACCESS TO THE REGISTER BY EUROPEAN SECOND LEVEL NURSESSecond level nurses trained in a European Economic Area [EEA] country are eligible to apply for entryto the NMC register.Those who wish to work in the UK must first apply to the registering body (com-petent authority) in their own country who will confirm their eligibility under European Law to workin the UK. They may then apply to the NMC providing copies of their certificates, confirmation ofgood health and good character, verification in accordance with EU Directives, photocopy of passportor identity card and Register extract where appropriate. Nurses who are registered in another EEAState but who are not nationals of an EEA State will be treated as overseas applicants, taking intoaccount that they have been registered in another EEA State.

Such nurses who register with the NMC will be deemed to have met the standards of proficiency forsecond level nurses. Once registered, they will have the right to access continuing professional develop-ment to advance their knowledge, skills and proficiency beyond that of initial registration. They may alsoenter a pre-registration nursing programme to enable them to become a first level nurse. They may seekappropriate accreditation of prior learning, in accordance with NMC nursing standards 3 and 4, to enablethem to undertake a shortened programme of preparation.


Domain Outcomes to be achieved for Standards of proficiency for entry to the register:entry to the branch programme personal and professional development

Personal and • contribute to creating a climate conducive to learningprofessional • contribute to the learning experiences and development development of others by facilitating the mutual

sharing of knowledge and experience• demonstrate effective leadership in the establishment

and maintenance of safe nursing practise.

Standard of proficiency for entry to the register: personal and professionaldevelopment

Enhance the professional development and safe practice of others through peer support, leadership,supervision and teaching

The NMC Code of ProfessionalConduct: standards for conduct,performance and ethicsProtecting the public through professional standards

Appendix 2

The Code of professional conduct was published by the Nursing and Midwifery Council in April 2002and came into effect on 1 June 2002. In August 2004 an addendum was published and the Code of pro-fessional conduct had its name changed to The NMC code of professional conduct: standards for conduct,performance and ethics. All references to “nurses, midwives and health visitors” were replaced by“nurses, midwives and specialist community public health nurses” and a new section on IndemnityInsurance was included. This updated version of the code was published in November 2004.

1 Introduction

1.1 The purpose of The NMC code of professional conduct: standards for conduct, performance andethics is to:• inform the professions of the standard of professional conduct required of them in the

exercise of their professional accountability and practice

The NMC code of professional conduct: standards for conduct, performance and ethics

As a registered nurse, midwife or specialist community public health nurse, you are personallyaccountable for your practice. In caring for patients and clients, you must:

• respect the patient or client as an individual• obtain consent before you give any treatment or care• protect confidential information• co-operate with others in the team• maintain your professional knowledge and competence• be trustworthy• act to identify and minimise risk to patients and clients.

These are the shared values of all the United Kingdom health care regulatory bodies.

• inform the public, other professions and employers of the standard of professional conductthat they can expect of a registered practitioner.

1.2 As a registered nurse, midwife or specialist community public health nurse, you must:• protect and support the health of individual patients and clients• protect and support the health of the wider community• act in such a way that justifies the trust and confidence the public have in you• uphold and enhance the good reputation of the professions.

1.3 You are personally accountable for your practice. This means that you are answerable for youractions and omissions, regardless of advice or directions from another professional.

1.4 You have a duty of care to your patients and clients, who are entitled to receive safe and competent care.

1.5 You must adhere to the laws of the country in which you are practising.

2 As a registered nurse, midwife or specialist community public health nurse, you must respect the patient or client as an individual

2.1 You must recognise and respect the role of patients and clients as partners in their care and thecontribution they can make to it. This involves identifying their preferences regarding care andrespecting these within the limits of professional practice, existing legislation, resources and thegoals of the therapeutic relationship.

2.2 You are personally accountable for ensuring that you promote and protect the interests anddignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status,lifestyle, culture and religious or political beliefs.

2.3 You must, at all times, maintain appropriate professional boundaries in the relationships youhave with patients and clients. You must ensure that all aspects of the relationship focusexclusively upon the needs of the patient or client.

2.4 You must promote the interests of patients and clients. This includes helping individuals andgroups gain access to health and social care, information and support relevant to their needs.

2.5 You must report to a relevant person or authority, at the earliest possible time, any conscientiousobjection that may be relevant to your professional practice. You must continue to provide careto the best of your ability until alternative arrangements are implemented.

3 As a registered nurse, midwife or specialist community public health nurse, you must obtain consent before you give any treatment or care

3.1 All patients and clients have a right to receive information about their condition. You must besensitive to their needs and respect the wishes of those who refuse or are unable to receiveinformation about their condition. Information should be accurate, truthful and presented insuch a way as to make it easily understood. You may need to seek legal or professional advice orguidance from your employer, in relation to the giving or withholding of consent.

3.2 You must respect patients’ and clients’ autonomy – their right to decide whether or not toundergo any health care intervention – even where a refusal may result in harm or death tothemselves or a fetus, unless a court of law orders to the contrary. This right is protected in law,although in circumstances where the health of the fetus would be severely compromised by any

136 Appendix 2: The NMC Code of Professional Conduct

refusal to give consent, it would be appropriate to discuss this matter fully within the team andwith a supervisor of midwives, and possibly to seek external advice and guidance (see clause 4).

3.3 When obtaining valid consent, you must be sure that it is:• given by a legally competent person• given voluntarily• informed.

3.4 You should presume that every patient and client is legally competent unless otherwiseassessed by a suitably qualified practitioner. A patient or client who is legally competent canunderstand and retain treatment information and can use it to make an informed choice.

3.5 Those who are legally competent may give consent in writing, orally or by co-operation. Theymay also refuse consent. You must ensure that all your discussions and associated decisionsrelating to obtaining consent are documented in the patient’s or client’s health care records.

3.6 When patients or clients are no longer legally competent and have lost the capacity to consentto or refuse treatment and care, you should try to find out whether they have previouslyindicated preferences in an advance statement. You must respect any refusal of treatment orcare given when they were legally competent, provided that the decision is clearly applicable tothe present circumstances and that there is no reason to believe that they have changed theirminds. When such a statement is not available, the patients’ or clients’ wishes, if known, shouldbe taken into account. If these wishes are not known, the criteria for treatment must be that itis in their best interests.

3.7 The principles of obtaining consent apply equally to those people who have a mental illness.Whilst you should be involved in their assessment, it will also be necessary to involve relevantpeople close to them; this may include a psychiatrist. When patients and clients are detainedunder statutory powers (mental health acts), you must ensure that you know the circumstancesand safeguards needed for providing treatment and care without consent.

3.8 In emergencies where treatment is necessary to preserve life, you may provide care withoutconsent, if a patient or client is unable to give it, provided you can demonstrate that you areacting in their best interests.

3.9 No-one has the right to give consent on behalf of another competent adult. In relation toobtaining consent for a child, the involvement of those with parental responsibility in theconsent procedure is usually necessary, but will depend on the age and understanding of thechild. If the child is under the age of 16 in England and Wales, 12 in Scotland and 17 inNorthern Ireland, you must be aware of legislation and local protocols relating to consent.

3.10 Usually the individual performing a procedure should be the person to obtain the patient’s orclient’s consent. In certain circumstances, you may seek consent on behalf of colleagues if youhave been specially trained for that specific area of practice.

3.11 You must ensure that the use of complementary or alternative therapies is safe and in theinterests of patients and clients. This must be discussed with the team as part of the therapeuticprocess and the patient or client must consent to their use.

4 As a registered nurse, midwife or specialist community public health nurse,you must co-operate with others in the team

4.1 The team includes the patient or client, the patient’s or client’s family, informal carers and healthand social care professionals in the National Health Service, independent and voluntary sectors.

Appendix 2: The NMC Code of Professional Conduct 137

4.2 You are expected to work co-operatively within teams and to respect the skills, expertise and contributions of your colleagues. You must treat them fairly and without discrimination.

4.3 You must communicate effectively and share your knowledge, skill and expertise with othermembers of the team as required for the benefit of patients and clients.

4.4 Health care records are a tool of communication within the team. You must ensure that thehealth care record for the patient or client is an accurate account of treatment, care planningand delivery. It should be consecutive, written with the involvement of the patient or clientwherever practicable and completed as soon as possible after an event has occurred. It shouldprovide clear evidence of the care planned, the decisions made, the care delivered and theinformation shared.

4.5 When working as a member of a team, you remain accountable for your professional conduct,any care you provide and any omission on your part.

4.6 You may be expected to delegate care delivery to others who are not registered nurses ormidwives. Such delegation must not compromise existing care but must be directed to meetingthe needs and serving the interests of patients and clients. You remain accountable for theappropriateness of the delegation, for ensuring that the person who does the work is able to doit and that adequate supervision or support is provided.

4.7 You have a duty to co-operate with internal and external investigations.

5 As a registered nurse, midwife or specialist community public health nurse, you must protect confidential information

5.1 You must treat information about patients and clients as confidential and use it only for thepurposes for which it was given. As it is impractical to obtain consent every time you need toshare information with others, you should ensure that patients and clients understand that someinformation may be made available to other members of the team involved in the delivery ofcare. You must guard against breaches of confidentiality by protecting information fromimproper disclosure at all times.

5.2 You should seek patients’ and clients’ wishes regarding the sharing of information with theirfamily and others. When a patient or client is considered incapable of giving permission, youshould consult relevant colleagues.

5.3 If you are required to disclose information outside the team that will have personalconsequences for patients or clients, you must obtain their consent. If the patient or clientwithholds consent, or if consent cannot be obtained for whatever reason, disclosures may bemade only where:• they can be justified in the public interest (usually where disclosure is essential to protect the

patient or client or someone else from the risk of significant harm)• they are required by law or by order of a court.

5.4 Where there is an issue of child protection, you must act at all times in accordance with nationaland local policies.


6 As a registered nurse, midwife or specialist community public health nurse, you must maintain your professional knowledge and competence

6.1 You must keep your knowledge and skills up-to-date throughout your working life. In particu-lar, you should take part regularly in learning activities that develop your competence and performance.

6.2 To practise competently, you must possess the knowledge, skills and abilities required for lawful,safe and effective practice without direct supervision. You must acknowledge the limits of yourprofessional competence and only undertake practice and accept responsibilities for thoseactivities in which you are competent.

6.3 If an aspect of practice is beyond your level of competence or outside your area of registration,you must obtain help and supervision from a competent practitioner until you and youremployer consider that you have acquired the requisite knowledge and skill.

6.4 You have a duty to facilitate students of nursing, midwifery and specialist community publichealth nursing and others to develop their competence.

6.5 You have a responsibility to deliver care based on current evidence, best practice and, whereapplicable, validated research when it is available.

7 As a registered nurse, midwife or specialist community public health nurse, you must be trustworthy

7.1 You must behave in a way that upholds the reputation of the professions. Behaviour thatcompromises this reputation may call your registration into question even if is not directlyconnected to your professional practice.

7.2 You must ensure that your registration status is not used in the promotion of commercialproducts or services, declare any financial or other interests in relevant organisations providingsuch goods or services and ensure that your professional judgement is not influenced by anycommercial considerations.

7.3 When providing advice regarding any product or service relating to your professional role or area of practice, you must be aware of the risk that, on account of your professional title orqualification, you could be perceived by the patient or client as endorsing the product. Youshould fully explain the advantages and disadvantages of alternative products so that the patientor client can make an informed choice. Where you recommend a specific product, you mustensure that your advice is based on evidence and is not for your own commercial gain.

7.4 You must refuse any gift, favour or hospitality that might be interpreted, now or in the future,as an attempt to obtain preferential consideration.

7.5 You must neither ask for nor accept loans from patients, clients or their relatives and friends.

8 As a registered nurse, midwife or specialist community public health nurse, you must act to identify and minimise the risk to patients and clients

8.1 You must work with other members of the team to promote health care environments that are conducive to safe, therapeutic and ethical practice.


8.2 You must act quickly to protect patients and clients from risk if you have good reason to believe that you or a colleague, from your own or another profession, may not be fit to practisefor reasons of conduct, health or competence. You should be aware of the terms of legislationthat offer protection for people who raise concerns about health and safety issues.

8.3 Where you cannot remedy circumstances in the environment of care that could jeopardisestandards of practice, you must report them to a senior person with sufficient authority tomanage them and also, in the case of midwifery, to the supervisor of midwives. This must besupported by a written record.

8.4 When working as a manager, you have a duty toward patients and clients, colleagues, the widercommunity and the organisation in which you and your colleagues work. When facingprofessional dilemmas, your first consideration in all activities must be the interests and safety ofpatients and clients.

8.5 In an emergency, in or outside the work setting, you have a professional duty to provide care.The care provided would be judged against what could reasonably be expected from someonewith your knowledge, skills and abilities when placed in those particular circumstances.

9 Indemnity insurance

9.1 The NMC recommends that a registered nurse, midwife or specialist community public healthnurse, in advising, treating and caring for patients/clients, has professional indemnity insurance.This is in the interests of clients, patients and registrants in the event of claims of professionalnegligence.

9.2 Some employers accept vicarious liability for the negligent acts and/or omissions of theiremployees. Such cover does not normally extend to activities undertaken outside the registrant’semployment. Independent practice would not normally be covered by vicarious liability, whileagency work may not. It is the individual registrant’s responsibility to establish their insurancestatus and take appropriate action.

9.3 In situations where employers do not accept vicarious liability, the NMC recommends thatregistrants obtain adequate professional indemnity insurance. If unable to secure professionalindemnity insurance, a registrant will need to demonstrate that all their clients/patients are fullyinformed of this fact and the implications this might have in the event of a claim for professionalnegligence.

Glossary

Accountable Responsible for something or to someone.Care To provide help or comfort.Competent Possessing the skills and abilities required for lawful, safe and effective professional practice with-

out direct supervision.Patient and client Any individual or group using a health service.Reasonable The case of Bolam v Friern Hospital Management Committee (1957) produced the following defi-

nition of what is reasonable. “The test is the standard of the ordinary skilled man exercising andprofessing to have that special skill. A man need not possess the highest expert skill at the risk ofbeing found negligent… it is sufficient if he exercises the skill of an ordinary man exercising thatparticular art.” This definition is supported and clarified by the case of Bolitho v City and HackneyHealth Authority (1993).


FURTHER INFORMATIONThe NMC code of professional conduct: standards for conduct, performance and ethics is available on the Nursing and

Midwifery Council’s website at www.nmc-uk.org. Printed copies can be obtained by writing to the PublicationsDepartment, Nursing and Midwifery Council, 23 Portland Place, London W1B 1PZ, by fax on 020 7436 2924 or by e-mailat [email protected].

A wide range of NMC standards and guidance publications expand upon and develop many of the professional issues andthemes identified in The NMC code of professional conduct: standards for conduct, performance and ethics. All are avail-able on the NMC’s website. A list of current NMC publications is available either on the website or on request from thePublications Department as above.

Enquiries about the issues addressed in The NMC code of professional conduct: standards for conduct, performance andethics should be directed in the first instance to the NMC’s professional advice service at the address above, by e-mail [email protected], by telephone on 020 7333 6541/6550/6553 or by fax on 020 7333 6538.

The Nursing and Midwifery Council will keep The NMC code of professional conduct: standards for conduct, performanceand ethics under review and any comments, suggestions or requests for further clarification are welcome, both frompractitioners and members of the public. These should be addressed to the Director of Registration and Standards, NMC,23 Portland Place, London W1B 1PZ.

November 2004

Summary

As a registered nurse, midwife or specialist community public health nurse, you must:

• respect the patient or client as an individual• obtain consent before you give any treatment or care• co-operate with others in the team• protect confidential information• maintain your professional knowledge and competence• be trustworthy• act to identify and minimise the risk to patients and clients.


www.nmc-uk.org


An NMC Guide for Students of Nursing and MidwiferyProtecting the public through professional standards

Appendix 3

What does the NMC do?

The NMC is the regulatory body for nursing and midwifery. Our purpose is to establish and improvestandards of nursing and midwifery care in order to protect the public. These standards are set out inthe Code of professional conduct, which the NMC will send to you when you first register. We urge youto get hold of a copy now. You should be able to obtain it through your university; if not, please writeto our Publications Department.

You may not be aware that the standards set by the NMC already apply to you. The level of entry tothe programme of education that you are undertaking and the content, type and length of your pro-gramme are all part of these standards. Our other key tasks are to:

• maintain a register of qualified nurses and midwives• set standards for nursing and midwifery education, practice and conduct• provide advice for nurses and midwives on professional standards• consider allegations of misconduct or unfitness to practise due to ill health.

Registration and professional accountability

When you successfully complete your course, your higher education institution will notify the NMCthat you have met the required standards and that you are eligible for entry on the register.Your coursedirector will also complete a declaration of good character form on your behalf. When we have

As a pre-registration student of nursing or midwifery, you will already have started to think aboutyour future career as a registered nurse or midwife. Once you have successfully completed yourprogramme of education, you will need to register with the Nursing and Midwifery Council[NMC] before you can practise as a nurse or midwife.This leaflet sets out some basic informationabout the NMC and some guidance for the clinical experience you will undertake during yourstudies. It is based upon extensive consultation with individual pre-registration students of nurs-ing and midwifery, organisations representing students and lecturers in higher education. Theleaflet should be read in conjunction with advice provided by your higher education institution.

received this information and you have paid your registration fee, your name will be entered on theNMC register and you will be eligible to practise as a registered practitioner.

Registration is not simply an administrative process. The NMC’s register is an instrument of publicprotection and anyone can check the registered status of a nurse or midwife. Registering with theNMC demonstrates that you have met the standards expected of registered nurses and midwives. Italso demonstrates that you are professionally accountable at all times for your acts and omissions.

Professional accountability involves weighing up the interests of patients, using your professionaljudgement and skills to make a decision and enabling you to account for the decision you make. Onrare occasions, nurses and midwives fall short of the professional standards expected of them. TheNMC investigates in the public interest any complaints made about the professional conduct or fitnessto practise of registered nurses and midwives.

Throughout your career, you will need to keep up to date with developments in your area of prac-tice. Your continuing professional development is an integral part of your professional accountability.In order to continue to practise, you will need to meet the NMC’s standards for post-registration education and practice [PREP].

Detailed information about PREP is available in The PREP Handbook, which you can obtain free ofcharge by writing to the Publications Department. You will also need to complete a notification ofpractice form and pay your periodic registration fee when you renew your registration every threeyears. Practising midwives also need to complete a notification of intention to practise form annually.

GUIDANCE ON CLINICAL EXPERIENCE FOR STUDENTS

Your accountability

As a pre-registration student, you are never professionally accountable in the way that you will be afteryou come to register with the NMC. This means that you cannot be called to account for your actionsand omissions by the NMC. So far as the NMC is concerned, it is the registered practitioners withwhom you are working who are professionally responsible for the consequences of your actions andomissions. This is why you must always work under the direct supervision of a registered nurse or mid-wife. This does not mean, however, that you can never be called to account by your university or bythe law for the consequences of your actions or omissions as a pre-registration student.

The wishes of patients

You must respect the wishes of patients at all times.They have the right to refuse to allow you, as a stu-dent, to participate in caring for them and you should make this right clear to them when they are firstgiven information about the care they will receive from you. You should leave if they ask you to do so.Their rights as patients supersede at all times your rights to knowledge and experience.

During your studentship, you will come into close contact with patients. This may be throughobserving care being given, through helping in providing care and, later, through full participationin providing care. At all times, you should work only within your level of understanding and com-petence and always under the direct supervision of a registered nurse or midwife. The sectionbelow provides some guidance on working with patients during your studies. The principlesunderpinning this guidance reflect the standards that will be expected of you when you becomea registered practitioner.

144 Appendix 3: An NMC Guide for Students of Nursing and Midwifery

Identifying yourself

Introduce yourself accurately at all times when speaking to patients either directly or by telephone. Indoing so, you should make it quite clear that you are a pre-registration student and not a registeredpractitioner. In fact, it is a criminal offence to represent yourself falsely and deliberately as a registerednurse or midwife.

Accepting appropriate responsibility

You will find yourself at times in a position where you may not be directly accompanied by your men-tor, supervisor or another registered colleague. You will also experience emergencies. As your skills,experience and confidence develop, you will become increasingly able to deal with these situations.However, as a student, do not participate in any procedure for which you have not been fully preparedor in which you are not adequately supervised. If such a situation arises, discuss the matter as quicklyas possible with your supervisor.

Patient confidentiality

Patients have the right to know that any private and personal information that is given in confidencewill be used only for the purposes for which it was originally provided and that it will not be used forany other reason. If you want to refer in a written assignment to some real-life situation in which youhave been involved, do not provide any information that could identify a particular patient. Obtain accessto patient records only when absolutely necessary for the care being provided. Use of these recordsmust be closely supervised by a registered practitioner and you must follow the local policy on the hand-ling and storage of records. Any written entry you make in a patient’s records must be counter-signedby a registered practitioner. You can find more advice about confidentiality in the NMC’s Code of professional conduct. You should also refer to our Guidelines for records and record keeping.

Handling complaints

Be aware of the local procedures for dealing with complaints by patients, or their families, about thetreatment or care they are receiving. If patients indicate to you that they are unhappy about their treat-ment or care, you should report the matter immediately to the person who is supervising your clinicalexperience or to another appropriate person.

We hope that you will find these notes helpful during your studentship and in understanding theimportant responsibilities you will undertake as a registered nurse or midwife. If you need to discuss any of these issues with us, please contact our professional advice service on 020 73336541/6550/6553, by e-mail at [email protected] or by fax on 020 7333 6538. If you would liketo find out more about the work of the NMC, please write to our Publications Department for alist of current publications. The NMC’s website at www.nmc-uk.org includes copies of all NMCpublications, position statements issued by our professional advice service and further usefulinformation and contacts for students of nursing and midwifery. We wish you success in your programme of preparation for registration and in your future career.

Appendix 3: An NMC Guide for Students of Nursing and Midwifery 145

www.nmc-uk.org


Appendix 4

Acuteinpatient

care

Primarycare

The values and attitudes necessaryfor modern mental health practice

Policy and legislation

Mental health & mental healthservices

Effective partnership in teamsand with other agencies

Care planning, co-ordination &reviewSupervision, professionaldevelopment, and lifelong learning

Clinical & practice leadership

Medical & physical care

Psychological

Social and practical

Mental health promotionEvidence-based bio-psycho-social andhealth promotional approaches to care

Continuing care &Rehab.

Day centres,Residential &

Vocationalprogrammes

Comprehensive assessment

Effective partnership with usersand carers

Effective communication

SOMEMUSTHAVE

Increasingspecialisation

ALLMUSTHAVE

Ethicalpractice

Processof care

Knowledge

Interventions

Application to specific NSF/NHS Plan service settings

Services forpeople with

complex andspecial needs

e.g. dual-diagnosis and

personalitydisorders

Crisisresolution &

earlyintervention

Assertiveoutreach

Community-based care

co-ordination(CMHTs)

Basic assumptions about mentalhealth and mental health service

Working in partnership to delivereffective care

Foundation of effective practice

A Framework for Capable Practice


accomodation 97–8accountability for practice 16–18

student nurses 17–18Accreditation of Prior Learning 74adolescent nursing 53Adoption and Children Act (2002) 48adult nursing 35–45

essential aspects of nursing care 42–3key areas 36scope of practice 36–7shift handovers 41shift times 40skills 36–7training programme 38–40

care delivery 38care management 38personal and professional development 38professional and ethical practice 38placements 39–40

advocacy 67–8, 90, 92advocacy agencies 68, 78A First Class Service – quality in the new NHS 30Agenda for Change 16, 24, 76assessors of practice 12

behavioural intervention techniques 85–6benchmarks 73best practice 43Better Services for the Mentally Handicapped

report (1971) 82–4Bolam Test 17branch programmes 8, 48

learning disability 91mental health 75

Briggs Report (1972) 24, 84buddy system 107

capable practice, framework for 147careers

advice 116–17choices, factors affecting 117–18development 111–23

continuing professional development 111–12life-long learning 111–12returning to practice 112–13

management 111–23personal development plan 113–14personal professional profile 113–14renewal of registration 112

options 114–15employers of nurses in the UK 115first post 114–15working abroad 116

Care Programme Approach 65Chief Nursing Officer’s Review of Mental Health

Nursing 67Children Act (1989) 48–50Children’s National Service Framework 48–9children’s nursing 47–61

areas of practice 49child health policy 48–9emotionally challenging situations 56–7family-centred care 50–1, 52historical insights into 47–8pre-registration courses 53–8

common foundation programme 53–4community placements 54–6placement 58–9

opportunities in 49–50philosophy of 50shift patterns 57skills of 50–3, 55–7sources of information 57–8specialties in 49

children’s rights 50Children’s Taskforce 48clinical audit 29, 70, 78clinical effectiveness 70clinical excellence, support for 29–31clinical governance 25, 30, 70clinical practice 75

developments in 23–7clinical supervision 29, 30code of professional conduct 6, 12–13, 15, 111code of professional practice 20cognitive behavioural therapy 69cognitive development 53, 59Commission for Health Improvement 31Commission for Nursing and Midwifery

Education 12–14

IndexNumbers in bold refer to figures and tables.

common foundation programme 7–8, 37, 48,53–4, 67, 74–5

children’s nursing 53–4communication 42, 56, 87, 90community nursing 37competency 56, 73–4complaints procedures 19consultant nurses, see nurse consultantscontinuing professional development 15–16,

76–7, 111–13, 117Continuing the Commitment Report (1995) 86coping mechanisms 57courses 2–3

applying for 2–7branch programmes 8, 48


Common Foundation Programme 7–8, 53–4degree 3diploma 3entry requirements 3–4

access programmes 3, 74Accreditation of Prior (Experiential)

Learning 74Accreditation of Prior Learning 74foundation degrees 3GCSEs 3National Vocational Qualifications 74nursing cadet schemes 4secondments 4

flexible entry opportunities 3–4foundation degrees 3lecturers 4, 106mentors 5, 12, 39–40, 54–6, 106, 116–17secondments 4sources of information 3, 116–17support networks 5, 95–109

accomodation 97–8buddy system 107lecturers 106peer support 106–7personal tutor 104–6placement mentors 106sickness 100–1students with special needs 107–8

tutors 5, 104–6curriculum 13–14curriculum vitae 119

drug administration 42duty of care 17–18dyslexic students, help for 107–8

employers of nurses in the UK 115–16employment

information 115–17job applications 118–19job interviews 120while a student 99–100

emotionally challenging situations 56–7Essence of Care 43essential aspects of nursing care 42–3European second level nurses, entry to the NMC

register 134evidence-based practice 20, 28, 43, 59, 68–70,

91learning disability nursing 91mental health nursing 68–70

expressed emotion 69

family-centred care 50–1, 52family interventions 69family support for students 102, 104finance management as a student 98fitness

for practice 14for purpose 14to practise 14

Fitness for Practice 23, 29, 73–4foreign students, support for 104framework for capable practice 147

Great Ormond Street Hospital for Sick Children47

Health and Social Care Bill (2000) 68health studies 35–6Healthwork UK 77homesickness 102Human Rights Act (1998) 48–9

International Council of Nurses’ Code 67

Jay Report (1979) 82–4job

application 118–19interviews 120satisfaction, factors influencing 118

150 Index

learning, managing as a student 98–9learning disability nursing 81–93

assessing care 89behavioural intervention techniques 85evidence-based practice 91knowledge 87–8managing challenging behaviour 88mental health care 87–8philosophies of care 90–1physical health care 88–9planning care 89–90positive reinforcement 85–6skills 87–8

lecturers 4, 106life-long learning 76–7, 111–12

Making a Difference 25, 30–1, 37, 73, 76matrons 25mature students, support for 97–8, 100, 102–4Mental Deficiency Act (1913) 81–2Mental Health Act (1959) 82–3Mental Health Act (1983) 83–4mental health nursing 63–80

attitudes 72–3benchmarks 73capabilities 66cognitive behavioural therapy 69competency 73early intervention 69–70education and training 73–6evidence-based practice 68–70family interventions 69knowledge 72–3patient’s advocate 67preceptorship 75pre-registration training

clinical experience 75–6common foundation programme 74–5placements 76training programmes 69

skills 70–3specialist practice 76–7therapeutic relationship 67, 70training programmes 69value of 68workforce 66

Mental Health Nursing Care ProgrammeApproach 65

Mental Health Nursing Review 67

mentors 12, 39–40, 54–6, 106, 116–17multi-disciplinary teams 16, 43

in adult nursing 37–8in children’s nursing 56in learning disability nursing 86in mental health nursing 66

National Development Group Report (1978)83–4

National Health Service, see NHSNational Institute for Clinical Excellence

(NICE) 1–2, 28–9National Service Frameworks 2National Service Framework Standards for

Mental Health 64–7NHS

current developments in 16modernization programme 64pay bands 114–15primary-care led 24priorities 1

NHS and Community Care Act (1990) 24NHS Direct 25, 37, 52, 59NHS Improvement Plan 1NHS Modernisation Agency 16NMC 3, 5–6, 11–12, 24

establishment of 14requirements for licence maintenance 111–12

NMC Code of Professional Conduct 6, 12, 15NMC Guide for Students of Nursing and

Midwifery 11, 143–5NMC Standards of Proficiency 11, 14–15,

127–34care delivery 38, 128–31care management 38, 132–3personal and professional development 38,

133–4professional and ethical practice 38, 127–8

normalization theory 82–3, 85–6nurse consultants 25, 37, 50Nurse Registration Act (1919) 12–13, 47nurse-led services 25–6Nurses, Midwives and Health Visitors Act

(1979) 12–13Nurses, Midwives and Health Visitors

Ammendment Act (1992) 13nursing

as a profession 11–14definition 2

Index 151

Nursing and Midwifery Admissions Service 3Nursing and Midwifery Council, see NMCNursing and Midwifery Order (2001) 14, 17nursing auxiliaries 42nursing courses 2–3

applying for 2–7branch programmes 8, 48


cadet schemes 4common foundation programme 7–8, 37, 48,

53–4, 67, 74–5children’s nursing 53–4

curriculum 13–14degree 3diploma 3entry requirements 3–4, 74

access programmes 3, 74Accreditation of Prior (Experiential)

Learning 74Accreditation of Prior Learning 74foundation degrees 3GCSEs 3National Vocational Qualifications 74nursing cadet schemes 4secondments 4

flexible entry opportunities 3–4foundation degrees 3lecturers 4, 106mentors 5, 12, 39–40, 54–6, 106, 116–17secondments 4sources of information 3, 116–17support networks 5tutors 5, 104–6

nursing development units 26, 30nursing models 41, 82nursing practice, recent developments in 23, 24,

25–33Nursing Process 41

outcomes-based education 74

parental responsibility 48partnerships with patients 12patient-centred care 25patient’s

forum 68records 20rights 18

Peach Report (1999) 24, 73–4peer pressure 103peer-reviewed articles 59peer support 106–7personal development plan 76, 113–14personal professional profile 113personal tutor 104–6placements 54–5

adult nursing 39–40children’s nursing 54–6, 58–9mental health nursing 76

portfoliosprofessional 5student 5, 74–5

post-registration education and practice (PREP)requirements 111, 113standards 112

practice-centred learning 20pre-registration courses 3

adult nursing 38–40children’s nursing 53–8mental health nursing

clinical experience 75–6common foundation programme 74–5placements 76training programmes 69

see also branch programmes; commonfoundation programme

primary-care led NHS 24profession

definition 11–12nursing as a 11–14

professional organizations 18–19professional portfolio 5professional register 14professional self-regulation 13, 16–18, 29–30professional standards of proficiency 14–15proficiency, standards of 14–15, 21Project 2000 13–14, 67, 74, 85Protection of Children Act (1999) 48Pulling Together: the future roles of training of

mental health staff 66, 72–3, 77

quality framework 29Quality Protects 48, 59

reflective practice 28registration, renewal of 112research 27–29, 36

152 Index

returning to practice, NMC requirements for112–13

rights of patients 18role models 12Royal College of Nursing 2, 18–19, 50, 67–8Royal College of Nursing Association of Nursing

Students 18, 20

Sainsbury Centre for Mental Health 66, 72–3,77

Capability Framework 66Sainsbury Report (1997) 66, 72–3, 77social role valorization, learning disability and

86, 92sources of information

children’s nursing 57–8courses 3, 116–17

Special Education Needs and Disability Act(2001) 107

special needs, supporting students with 107–8standards of proficiency 11, 14–15, 21, 127–34

care delivery 38, 128–31care management 38, 132–3personal and professional development 38,

133–4professional and ethical practice 38, 127–8

Standing Nursing and Midwifery AdvisoryCommittee 69–70

stress, coping with 100–1student portfolio 5, 74–5students

academic support for 104–6see also lecturers; mentors; tutors

family support for 102, 104foreign, support for 104mature, support for 97–8, 100, 102–4peer support for 106–7with special needs, support for 107–8well-being 100, 101working 99–100

study, management of 98–9student support systems 5, 95–109

accomodation 97–8buddy system 107lecturers 106peer support 106–7

personal tutor 104–6placement mentors 106sickness 100–1students with special needs 107–8

supervision issues 20Sure Start 48, 59

telemedicine, see NHS DirectThe Nature and Scope of Professional Practice 68The New NHS – modern and dependable

25, 30The NHS Plan – an action guide for nurses,

midwives and health visitors 1, 16, 37, 68The NMC Code of Professional Conduct:

standards for conduct, performance andethics 6, 11, 17, 135–41

theory–practice gap 28–9The Patient’s Charter 26The Scope of Professional Practice 24Thorn Programme 69time management 98–9trade unions 18–19tutors 5, 104–6

UCAS 3UKCC 13, 73UKCC code of professional conduct (1984) 12UKCC Commission for Nursing, and Midwifery

Education (1999) 12–14UKCC Fitness for Practice 23, 39, 73–4UNISON 19United Kingdom Central Council for Nursing,

Midwifery and Health Visiting, see UKCCUnited Nations Convention on the Rights of the

Child (1989) 48–50Universities and Colleges Admissions Service, see

UCAS

Valuing People 91–2Victoria Climbié Inquiry 48

well-being 100, 101Workforce Action Team 66working abroad 116Working in Partnership 67, 70, 77working while a student 99–100

Index 153

Documents

0340759704 Nurses Professional