The Future of Nursing and Midwifery

Michael Fanning RN, Dip PSN, MSc, qualified as a registered nurse in 1983 and has since worked clinically and as a manager, including acting director, across a range of district general and teaching hospitals. Two consecutive Smith & Nephew scholarships enabled him to study for his Masters degree. He has published in the nursing media and written about governance and non-medical prescribing and has a particular interest in the protection of vulnerable adults. Michael was appointed as a NMC panellist in 2008. He is currently on secondment from the Oxford Radcliffe Hospitals NHS Trust as the Communication Manager for the Chief Nursing Officer and Professional Leadership team.

After qualifying as a registered nurse, it was a few years later before I studied for my degree. At the time, I was working in an accident and emergency department and I particularly remember taking the modules in psychology and sociology.

It was then that I fully began to appreciate the value and benefit of an analytical, enquiry and evidence based framework.

I was able to put into practice the learning and knowledge around older people and the use of orientation techniques in hospital environments. I placed clocks in the very bland and sterile examination cubicles to help provide a focus to orientate older patients who had been admitted as an emergency.

This was not the application of a theoretical concept but a practical translation and application of research into a clinical environment to enhance the fundamental aspect of care and compassion.

I believe the process of learning, ability to seek evidence and to challenge and translate knowledge enhanced my ability to provide practical, direct and personal care.

Judith is Chief Executive of NHS Blackburn with Darwen. Judith trained as a Nurse Cadet in the 70s, becoming a Community Nurse, Health Visitor and then a Midwife. She is leading plans to integrate health and social care commissioning to tackle health statistics and work, solving longstanding poor health and health inequalities by establishing a pioneering NHS Care Trust Plus organisation.

To get the best out of our workforce we need to support staff and acknowledge that we all have issues outside of work that will impact on our day to day lives.  This is more important than ever in the difficult financial times we are experiencing.

In Blackburn with Darwen we are just launching a service that will give every member of staff and all members of their families access to 24 hour advice, support and counselling on any issue, from advice on money worries to practical information on parenting.

Too often care can be seen to start and end at the door to the hospital, treatment room or surgery. Even in people’s own homes when we feel under pressure and are rushing to the next visit we may end up thinking just about the treatment rather than the person we are caring for and all their concerns.

The things that we worry about as individual members of staff are often the things that worry patients and members of the public – a good education for our children, having enough information to make sensible choices about our lifestyles or choosing the best services to meet our needs. We want homes that are safe and warm, sufficient income to pay the bills, and to live in communities where we feel safe and are valued as individuals with equal rights.

When people do not have these things, we know inequalities occur. Those who live in deprived communities, in poorer houses or have neither the skills nor the means to get the best out of services will die earlier than those who are better educated, live in nice houses or can make their voice heard. In the NHS people who are disabled, who have mental health problems or who are unable to communicate their needs will often not get the same access or standards of care as others.

I know many nurses and midwifes share my outrage that people die earlier or live lives in greater ill health just because of where they are born or the lack of opportunities available to them.

Each day every one of us will encounter someone who has some form of disadvantage and thus experiences a ‘lesser’ standard of care. By seeing others in the context of the lives they live outside their contact with the NHS and being prepared to advocate and stand up for patients who need a greater level of support or care every one of us, each and every day, can start to address inequalities and ensure everyone receives the care and compassion we all expect and need.

Professor Janice Sigsworth took up her post as director of nursing at Imperial College Healthcare NHS Trust in 2008, coming to the Academic Health Science Centre from the Department of Health. As deputy chief nurse (England), she worked extensively to modernise nursing careers and on the nursing contribution to the Department of Health’s Next Stage Review.

I am not sure if I’m the only one, but the whole focus of improving patient care and the patient experience seems to have fallen at the feet of the ward sister or charge nurse.

In many ways this is true, but is it the answer to the steady stream of bad press stories and the sad and distressing relative’s stories published by the Patients Association?

The NHS Institute, inventor of ‘Productive Ward’, gives ward sisters and charge nurses the tools and techniques to challenge their practices and help staff spend more time at the bedside caring for patients. Here at Imperial College Healthcare Trust the Productive Ward has been well received by clinical staff as a way of improving practice and care.

But is this enough? My own experience and early outcomes from our Productive Ward programme show that it is the bigger systems, processes and environments of care that we need to get right, as well as the work of the individual staff themselves. By this I mean how beds are managed; how doctors work, when stores are delivered, how well bank and agency systems run, how quickly ‘take home’ tablets get to the ward once the doctor has ordered them. I am sure you can think of many more.

So it’s not as simple as sorting out the ward sisters and charges nurses, we have to get the whole organisation lined up behind them and the patient to truly deliver a good patient outcome and experience.

Staff survey results are a helpful balancing act: broadly, if staff are content and happy in their work then you generally find content patients. So let’s focus on the systems as rigorously as the staff themselves, otherwise I fear both will fail.

Claire Rayner is president of the Patients Association and a nationally known author, journalist, broadcaster and agony aunt. After leaving home at 14 for a nursing job, she later trained as a nurse, won a gold medal for outstanding achievement in 1954, and studied midwifery before starting her writing career in 1960. She was the agony aunt on The Sun and Sunday Mirror and has written over 90 books about home nursing, family health, sex education, and baby and childcare. She believes passionately in standing up for patients.

We live in an ageing country. At the start of the 20th century most women could find a husband, and vice versa. Family sizes were fairly large – four, five or even six children per household was not unusual and even in small houses, grandparents lived with the family. Few people lived much later than about 70, a great many more only reached their sixties; 65 was set as Old Age Pension time because most people died well before.

Massive changes resulted from the two world wars. So many young men were swept away in a morass of mud and blood during WW1; a similar carnage, this time including women and children, occurred in WW2. Today’s pensioners grew up in a female-dominated world run by women whose potential spouses were dead… Our teachers were all single women; our hospital and district nurses were all single women; offices, shops and all sorts of institutions knew they could rely on hard-working female staff.

But enough men survived WW2 to come home and father the next generation and they did so with such enthusiasm, as did their wives, that the birth rate leapt. The Baby Bulge it was called – and it is now becoming a Pensioner’s Bulge.

This is the background to our current dilemma. People’s bodies and attitudes age less quickly. In the mid-Fifties, 40 was well into middle age. I had my first baby at 28, and was described by my midwife as ‘an elderly primipara’. Now, with IVF clinics working flat out, motherhood at 40-plus is not uncommon.

I offer this précis of what has happened to the population because of its huge importance to graduate nurses. You have to accept that most of your patients are likely to be very old. So many people in their seventies, eighties, and nineties, stay safely home now, with caring GPs and Community Nurses and family support. Those who are frail and need hospital care will be very dependent indeed.

If you are one of those who find helping to keep an incontinent old person clean a ‘menial’ task, you may need to change your career.

If you think it a waste of the time of a nurse educated to degree level to feed a helpless old patient, you too are in the wrong job.

Donna E Shalala, Ph.D, is a former Secretary of the US Department of Health and Human Services; president of the University of Miami; chair of the, Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, and is the inaugural post for the Initiative on the Future of Nursing.

Here in the United States, our healthcare system is on the cusp of major change. As in the UK, efforts are underway to ensure that the expertise of nurses and the value that the nursing profession brings to healthcare is used to inform how our future is shaped.

The Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, which I chair along with Linda Burnes Bolton, chief nursing officer at Cedars-Sinai Medical Center, will take on some of the most pressing and systemic problems facing the nursing field. Our end goal is nothing short of transforming the way Americans receive health care services, and determining the most effective ways to apply the skills of nurses is at the center of our process.

The goals of health reform efforts in the US are not only health insurance, which seems to dominate much of our current national discussion, but also how we make quality healthcare affordable. I share wholeheartedly the belief of your Commission chair Ann Keen, which she shared with us at our recent Initiative meeting in Washington, DC, that “you can deliver quality care cheaper if you get it right the first time.” Nurses have the expertise to make that happen.

As a function of their jobs, and by the very nature of nursing, these men and women are on the front lines of patient care; they spend the most time with patients and their families, and the knowledge they bring to the table prevents costly medical errors, unneeded tests, expensive hospital stays, and avoidable hospital readmissions through effective chronic care management. As the largest group of health professionals, the experience of nurses is key to the effective design and implementation of health system change. To reform our system without gleaning from their expertise would be a fool’s errand.

One of the tasks of the Initiative on the Future of Nursing is to determine how to ensure this critical part of the workforce is adequately staffed and prepared to meet the changing needs of our society. A significant hurdle is the continuing shortage of nurses across the US. If left unaddressed, the US faces a shortage of 500,000 nurses by the year 2025, and this number is only expected to rise as our population ages and faces the enormous challenges of managing chronic disease.

The Initiative will address these challenges and examine the optimal utilization of nursing care through a series of technical workshops and forums which have already begun. Each forum will focus on particular challenges facing the nursing profession; one will address nursing in acute care settings, another will deal with nursing issues in community and public health care settings, and the third will examine the changes needed in nursing education. All of the forums will follow a town hall format to provide an avenue for input from healthcare professionals at all levels from all healthcare settings.

Similar efforts underway in the UK are both enlightening and encouraging to us. We have much to learn from one another in our parallel efforts to ensure that patients receive the right care, at the right time, in the right place, and by the most appropriate members of the healthcare team.

Professor Eileen Sills, Chief Nurse and Chief Operating Officer at St Guy’s & St Thomas NHS Foundation Trust, is known for strong, visible, clinical leadership. Her drive to take senior nurses back to the bedside earned her a national reputation for her Clinical Fridays initiative.

A unique experiment was started at Guy’s & St Thomas NHS Foundation Trust in May 2006, taking all senior nurses back into clinical practice one day a week. This sees over 100 nurses, including the Chief Nurse, working together clinically every Friday. Three years on, this is now well embedded, a part of routine practice and has received national recognition.

It is very important that senior nurses are clinically credible and up-to-date just like our senior doctors. It is also important to our patients and the public – who valued the role of the Matron – to see senior nurses on the wards. After losing this aspect over many years, this initiative has regained much of that ground.

Every Friday, all our senior nurses leave their offices: no emails are answered and no meetings attended. They work together across the Trust to support staff, monitor standards of care and attempt to resolve problems staff are experiencing by enabling and facilitating them to take action and to think creatively to resolve problems.

A meeting is held each Friday afternoon at which senior nurses and other staff discuss the previous week’s clinical indicators and share best practice.

This way of working has made an enormous difference. The patient is returned to the heart of the organisation, staff feel supported and we are able to respond to any problems around standards of care very proactively.

Effective relationships have been built with other staff groups, such as our facilities staff, who participate in the initiative. We also now run major change programmes and undertake audits of practice.

This has been the most rewarding thing I have ever done. The difference we have made is enormous and I am very proud of our nursing and midwifery workforce. This is not about compression five working days into four; it’s about working differently and smartly on a Friday. After all this is why we are here.

The Prime Minister’s Commission on the Future of Nursing and Midwifery recently held a Students’ Day to learn how people starting out as nurses and midwives viewed their future and how they hope to see it grow. The event was organised in conjunction with the Royal College of Nursing.

Dr Kuldip Bharj is a senior lecturer in midwifery and lead midwife for education at the University of Leeds and has 10 years of board level experience in the NHS. She writes:

Complex and multiple factors disadvantage mothers. Many policy initiatives acknowledge ‘disadvantage’ as an area of priority and focus on providing adequate and appropriate services, often harnessing a ‘woman-centred’ approach to care.

Like other mothers, disadvantaged mothers, consistently call for kind and approachable healthcare professionals with whom they can develop trusting relationships. They want to be treated with respect and dignity. They desire accurate and timely information to enable them to negotiate their way through their childbirth journeys and choose the kind of care they want. Some mothers do receive this but many do not.

Many healthcare professionals assert that they draw upon fundamental caring skills when delivering individualised care, confirming their competency to deliver culturally-sensitive and anti-discriminatory care.

Disappointingly, despite policy initiatives and competent healthcare professionals, there remains a variation in disadvantaged mothers’ experiences and outcomes. Evidence confirms that there are inequalities in health outcomes for disadvantaged mothers and their babies – they have a poorer experience and poorer access to services.

This raises many questions:
• What are the issues hindering translation of policy to practice?
• Do diverse policies lead to fragmentation?
• Would a summary of key directives leading to a care pathway be a way forward?
• What support do practitioners need to deliver woman-centred care to disadvantaged mothers?
• Are service models provided on ‘ad hoc’ bases or should they be mainstreamed?

Ann Keen MP, Commission Chair, writes:

On Thursday 4 August I had the pleasure of speaking to nurses working out of Northgate Hospital in Great Yarmouth. They showed me the great work they are doing in a range of areas, including sexual health, breastfeeding clinics and admission prevention.

I was deeply impressed by the innovation and commitment to improving services that they showed. What particularly struck me was how these nurses had been able to take control of services that they deliver and take them to the next level. This not only benefitted patients, but also the nurses themselves in the improved job satisfaction that they gained.

These initiatives are directly linked to the culture created locally by managers who were brave enough to give the nurses the support they needed to allow the free-thinking and managed risk-taking required to nurture innovation.

The feedback and suggestions I received on the future of nursing and midwifery were greatly appreciated. These were fed into the information-gathering stage of the Commission’s work. So, a big thank you to Amanda Cousins and her team for their work and hospitality!

Commissioner Heather Lawrence trained as a nurse before moving into nurse education, HR Management and running healthcare services. Since May 2000, she has been CEO at Chelsea and Westminster Healthcare NHS Trust, a London Teaching Hospital. The lessons learned during nurse training have influenced every aspect of her career:

Do your staff feel valued? As importantly, do you feel valued? We all want to feel valued and it is easy to achieve this if we remember some simple rules of personal behaviour and, of course, create an environment where this is possible.

For me, valuing staff starts with the recruitment process. Selection should be a two-way process – while we want to select the best candidates, the best candidates must also feel that they selected us. The next priority is induction and local orientation, followed by annual appraisal and PDPs. A question that I ask managers at interview is “how many of your staff know you?”

I am always asked how I know so many members of staff. It is quite simple. I believe it is important to be approachable, to say hello to people and to ask how they are. They nearly always tell you something interesting or useful. Effective two-way communication will also help staff feel valued.

A monthly team brief followed by a face-to-face cascade system, a daily news bulletin and a monthly newsletter all help. Individual staff members and teams can also be recognised through employee and team of the month awards.

When patients write to express their gratitude to a staff member, ward or department, I write to each member of staff to thank them – it is important to recognise the positive as well as the negative feedback.

In clinical areas where there is clear leadership, teamwork, good communication and face-to-face meetings – rather than relying on e-mail – staff feel more valued. Each of us can play our part by just asking people how they are and using those two simple words: ‘thank you’.

As we move into a period of less growth and higher cost improvement targets, it is essential that we have transparency with staff concerning the issues we face and that we work together to ensure all staff feel valued, even when we are asking for more productivity and more efficiency. If we do not, then patient care will suffer and staff will feel less valued.