This section introduces the staff focus theme. Resources to support this theme are:
- RCN products and services and RCN publications relevant to this theme
- agencies that provide further information and resources
- policy and reports which shape the current strategic and policy framework for this theme
- guidance and tools which help with understanding of and implementation of policy.
“NHS success depends from first to last on those who work for it” – this statement was made by the former Minister for Health, Lesley Griffiths, in her vision for NHS Wales (Welsh Government 2012, p4). An educated, trained and developed workforce is an integral part of clinical governance. Valuing the contribution that staff make to quality health care and continuing improvement, and the provision in workplaces of a learning and supportive culture are important to achieving better patient care (Scottish Government 2010).
Workforce development and role development
Strategies for workforce development in the NHS across the UK underline the importance of supporting a skilled workforce able to adapt and respond to changes and the challenges required in sustaining the delivery of safe and effective care (Department of Health, Social Services and Public Safety 2009; Department of Health 2012; Welsh Government 2012). In England this also includes recognition of the need to improve integration of health, public health and social care (Department of Health 2012).
Resources have been created to support specific roles within the nursing team and the development of specific skills and competences. The RCN website has a section dedicated to the support of health care assistants (HCAs) and assistant practitioners (APs). This includes a learning area 'First steps' which provides an induction programme and foundation learning for HCAs working in any context (RCN 2013a). NHS Education Scotland has developed a toolkit focussing on developing health care support worker roles (NHS Education for Scotland 2013a). In England an independent review has been set up to look at how the training and support of healthcare assistants and care assistants can be strengthened (Department of Health 2013). Training and regulation of HCAs is also one of the themes being explored as part of the RCN This is nursing initiative. See: This is Nursing: HCAs – training and regulation.
As more care is delivered closer to home, with an aim to reduce pressure on acute care, the focus on workforce development in the community has increased. Northern Ireland considered the contribution that health visitors and school nurses can make (Department of Health Social Services and Public Safety 2010). The RCN has issued a number of position statements to support developments in community nursing roles for example on health visiting, school nursing and district nursing (RCN 2011; RCN 2012a; RCN 2013b). Resources and tools are also provided in Scotland for a range of community nursing roles to strengthen workforce capacity and capability (NHS Education for Scotland 2013b). The role that all nurses have in protecting and promoting and improving public health, and ‘making every contact count’ is a priority – see Public health topics: Nursing roles.
Specialist competences for many areas of nursing practice have been developed by the RCN based on the core career and competence framework for nurses working at bands 5 to 8 (RCN 2009). The competences include indicators of the required level of knowledge and skills and suggestions of how nurses would apply the identified level in their day to day practice. The competence framework also maps to the KSF core dimensions. A range of competence frameworks can be accessed from the RCN publications list.
Advanced nursing practice is supported by a toolkit which is intended to be a “UK wide repository for consistent, credible and helpful resources relating to advanced practice” (NHS Scotland 2012, para 1).
Quality of care and compassionate care
In recent years in particular, a number of events and reports have highlighted serious failings in the quality of patient care and called into question what is required to deliver compassionate patient-centred care, and to achieve this in an economic climate which is creating serious financial pressures.
In 2010 the Royal College of Nursing (RCN) developed the Principles of Nursing Practice in partnership with members, patient groups and other professional bodies. The Principles clearly articulate what all people can and should expect from nursing practice, whether they are colleagues, patients or the families or carers of patients (RCN 2010). Two years on from this the Chief Nursing Officer in England published a vision of nursing based around six values and behaviours, known as the six C’s with the aim of building the culture of compassionate care in all areas of practice (Department of Health and NHS Commissioning Board 2012). The RCN in its response to the consultation on this vision suggests that the six C’s can be mapped against the Principles of Nursing Practice. The document also suggests the influence that a range of issues has on developing the quality of care and on achieving outcomes (RCN 2012b).
Because of concerns about incidences of poor nursing care the RCN also asked Lord Willis of Knaresborough to lead an independent inquiry which considered the question: What essential features of preregistration nursing education in the UK, and what types of support for newly registered practitioners, are needed to create and maintain a workforce of competent, compassionate nurses fit to deliver future health and social care services? A report of the findings and recommendations of the Commission has been published (Willis Commission on Nursing Education 2012).
The report of the public inquiry into the serious failing in patient care in Mid Staffordshire NHS Foundation Trust has also made a series of recommendations related to the education, training and professional development of the nursing team (Francis 2013).
As a practical step towards highlighting the reality of modern-day nursing and exploring the considerable challenges that nursing staff face in delivering quality care, the RCN established the ‘This is nursing’ initiative (RCN 2012c). This initiative encompasses seven key work streams, aspects of which will be signposted further below.
Current themes and issues
This next section highlights some of the fundamental themes and issues that can impact and interact on how nursing staff deliver safe and effective care, and which are core to many of the current discussions and initiatives focussing on nursing staff.
Accountability: The Code published by the Nursing and Midwifery Council (2008) underlines the personal accountability of each registered nurse and midwife. Principle B within the RCN Principles of Nursing Practice focuses on ethical and legal integrity, accountability and responsibility for the actions taken by individuals in delivering safe and effective care to patients. In addition to the Code, the law around duty of care provides a regulatory framework that imposes a duty of care on all health care practitioners. This has implications for the ever shifting boundaries of care between practitioners as roles develop and change (Scrivener et al 2011). This article about Principle B also underlines the "positive dimension of accountability" which puts "an emphasis on the development and demonstration of competence in practice" (Scrivener et al 2011, p.36) which all members of the nursing team may take pride in achieving.
Professional attitudes and behaviours: Understanding what influences attitudes and behaviours has been given much greater attention in looking at what makes for higher quality and compassionate care. The vision for nursing developed by the Chief Nursing Officer in England is centred on the six C’s which are seen to represent key values and behaviours in delivering compassionate care (Department of Health and NHS Commissioning Board 2012). Professional attitudes and behaviours is one of the key areas being explored in the RCN’s This is nursing initiative. Activities undertaken so far have highlighted different issues that can impact and full findings are to be reported.
Continuing professional development: Structures for continuing professional development include appraisal, mentoring, preceptorship and clinical supervision as well as additional training and courses. Principle F of the Principles of Nursing Practice focuses on evidence-based practice, technical skills education, training and clinical reasoning which is the ability to apply evidence both according to the needs of individual patients and the context in which care is delivered (Gordon and Watts 2011). CPD involves individual responsibility to maintain and progress skills and keep up to date but also responsibilities lie with employers and other organisations to ensure support and funding for CPD (Willis Commission on Nursing Education 2012).
Examples of initiatives to support CPD in nursing are the RCN Learning Zone which provides learning resources relating to nursing care, career development and workplace issues which are relevant to all in the nursing team. In Northern Ireland the NIPEC Development Framework ebsite includes competence tools, learning activities, a portfolio and sections on career planning and new roles.
The Willis Commission report focuses particularly on the CPD needs of newly qualified nurses (NQN’s). It discusses some of the issues around provision of preceptorship programmes for NQN’s and the variability of these programmes (Willis 2013). The report points to the Flying Start initiative originally developed in Scotland with the specific aim of supporting NQN’s and other professionals in the NHS commencing their practice, and now also available for staff in England (NHS Education for Scotland 2011; NHS 2013).
Team working: In every role the ability to work well as part of a team is essential, and effective teamwork is integral to clinical governance (McSherry and Pearce 2011). Effective teamwork has been described as "team working and interdependency through integrated working with and between health and social care both public and independent" (McSherry and Pearce 2011, p.29). Principle G of the RCN Principles of Nursing Practice is about nurses and nursing staff working closely within their own teams and as part of multidisciplinary teams in coordinating care and treatment. The Willis Commission report calls for increasing interprofessional learning both in pre-registration programmes and CPD, and in England for closer collaboration between health and social care (Willis 2013).
Integrated teams bringing together health and social care are required to meet increasingly complex health needs (King’s Fund 2012). An article about Principle of Nursing Practice G outlines some of the complexity and what is important for good integrated care (Platt et al 2011).
Organisational structure: Although individual accountability and responsibility is paramount in maintaining and raising professional standards, other factors impact. The work done so far as part of the RCN’s This is nursing theme on professional attitudes and behaviours has contributed to understanding of the impact that the culture of an organisation can have on professional standards in nursing. Focus group discussions highlighted the need for organisational cultures to be "open, enable effective leadership and encourage peers to feedback on each others’ performance and challenge poor practice" (RCN 2013c, para8). The vision for nursing in England underlines the importance of creating supportive organisational cultures and the key role that leadership plays in this. Tools are to be developed that enable organisations to measure their organisational culture (Department of Health and NHS Commissioning Board 2012).
Staffing levels: Inadequate levels of staffing in hospital wards and the community have been raised as an ongoing concern by the RCN, particularly as the current economic climate has led to cuts in staffing. A survey has indicated the extent of unsafe staffing levels in England, Wales and Scotland and has led to a further call for mandatory staffing levels (RCN 2013d). An RCN policy briefing presents the policy context and case for mandatory staffing levels (RCN 2012b), and guidance and tools have been developed for safer staffing in older people’s wards. Details of these tools are available in the RCN resource on older people.
As from 2013 nurse and midwife staffing levels in hospitals in Scotland are to be informed by mandatory workload planning tools (Scottish Government 2012).
Issues around staffing levels can impact in many directions. For example in its response to the Chief Nursing Officer’s vision for nursing the RCN refers to a survey of student nurses and midwives which indicated that mentors being too busy was a key reason for those students who spent less than the required time with their mentors (RCN 2012b).
Staff health and wellbeing: The Boorman Review (2009) made clearer the links between the health and wellbeing of staff and productivity, efficiency and better patient experience and outcomes. This is reinforced in a summary of research undertaken by the National Nursing Research Unit (NNRU) at King’s College London which "strongly suggests that there is a relationship between staff wellbeing and staff reported care performance and patient-reported patient experience" (NNRU 2013, p.2). The summary suggests that there are seven staff variables 'wellbeing bundles' which are linked to good patient reported experience.
The professional attitudes and behaviours theme in the RCN’s This is nursing initiative in particular highlights the stress and fatigue that can result from shift patterns and long working hours (RCN 2013c).
NHS Employers created a website to support employers in putting the recommendations of the Boorman Review report into practice (NHS Employers 2013a). The Scottish Government (2011) has published a new strategic framework for occupational health and safety of NHSScotland staff. In April 2013 a press release from NHS Employers announced five pledges that NHS leaders in the new NHS system in England have pledged to in supporting staff health and wellbeing (NHS Employers 2013b).
Further resources relevant to these themes and issues can be found in the other pages within the staff focus section. See also the section on Leadership.
Most of the items in this reference list are available online. They were last accessed on 22 May 2013. Some of them are in PDF format – see how to access PDF files.
Boorman S (2009) NHS health and well-being review, London: Department of Health.
Department of Health (2012) Liberating the NHS: developing the healthcare workforce: from design to delivery, Gov.UK website.
Department of Health (2013) Patients to get better care from healthcare assistants, Gov.UK website.
Department of Health and NHS Commissioning Board (2012) Compassion in practice. Nursing, midwifery and care staff: our vision and strategy (PDF 850.5KB), Redditch: NHS Commissioning Board.
Department of Health, Social Services and Public Safety (2009) A workforce learning strategy for the Northern Ireland health and social care service (PDF 559.5KB), Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (2010) Healthy futures 2010-2015: the contribution of health visitors and school nurses in Northern Ireland (PDF 1.71MB), Belfast: DHSSPS.
Francis R (Chair) (2013) Mid Staffordshire NHS Foundation Trust Public Inquiry: Final report, London: The Stationery Office.
Gordon J and Watts C (2011) Applying skills and knowledge: Principles of Nursing Practice F (PDF 559KB), Nursing Standard 25(33), pp.35-37.
King’s Fund (2012) Integrated care for patients and populations: improving outcomes by working together, London: King’s Fund.
McSherry R and Pearce P (2011) Clinical governance: a guide to implementation for healthcare professionals, 3rd ed., Chichester: Wiley.
NHS (2013) Flying Start England website.
NHS Education for Scotland (2011) Flying Start website.
NHS Education for Scotland (2013a) Healthcare Support Workers Toolkit. NES website.
NHS Education for Scotland (2013b) Modernising nursing in the community: resources and tools. Modernising nursing in the community website.
NHS Employers (2013a) NHS Well-being at work website.
NHS Employers (2013b) NHS leaders pledge support for staff health and wellbeing, NHS Employers website.
NHS Scotland (2012) Advanced Nursing Practice Toolkit website.
NNRU, King’s College London (2013) Does NHS staff wellbeing affect patient experience of care (Policy+ issue 39 May) (PDF 554KB), London: NNRU.
Nursing and Midwifery Council (2008) The Code: standards of conduct, performance and ethics for nurses and midwives, London: NMC.
Platt M et al (2011) Continuous care across teams. Principles of Nursing Practice G (PDF 84KB), Nursing Standard 25(34) 27 April, pp.31-33.
RCN (2009) Integrated core career and competence framework for registered nurses (PDF 1.5MB), London: RCN.
RCN (2010) Principles of Nursing Practice, RCN website.
RCN (2011) RCN’s UK position on health visiting in the early years (PDF 324KB), London: RCN.
RCN (2012a) The RCN’s position on school nursing (PDF 240.5KB), London: RCN.
RCN (2012b) Royal College of Nursing response to the Chief Nursing Officer (England) vision for nursing, midwifery and care-giver (PDF 250KB), London: RCN.
RCN (2012c) This is nursing website.
RCN (2012b) Mandatory nurse staffing levels (Policy briefing 3/12) (PDF 394.3KB), London: RCN.
RCN (2013a) RCN health care assistants and assistant practitioners, RCN website.
RCN (2013b) District nursing –harnessing the potential. The RCN’s position on district nursing (PDF 237KB), London: RCN.
RCN (2013c) Professional attitudes work moves forward. This is nursing website.
RCN (2013d) Mandatory staffing levels urgently needed, says RCN, RCN website.
Scottish Government (2010) The healthcare quality strategy for NHSScotland, Edinburgh: Scottish Government.
Scottish Government (2011) Safe and well at work: occupational health and safety strategic framework for NHSScotland, Edinburgh: Scottish Government.
Scottish Government (2012) Nurse staffing levels, Scottish Government website.
Scrivener R et al (2011) Accountability and responsibility: Principle of Nursing Practice B (PDF 554KB), Nursing Standard 25(29) 23 March, pp.35-36.
Welsh Government (2012) Working differently, working together: a workforce and organisational development framework, Cardiff: Welsh Government.
Willis Commission on Nursing Education (2012) Quality with compassion: the future of nursing education, London: RCN on behalf of the Willis Commission.