Anne Harriss looks back at the history of the nursing profession, and examines some of the implications associated with professional registration and a new system of revalidation.
Nursing has had a long and interesting history. Florence Nightingale established the first School of Nursing at St Thomas’ Hospital, London, in 1860. It was not until 1916 that a professional body for nurses, the College of Nursing was established. This college gained a Royal Charter in 1928 which evolved into the Royal College of Nursing (RCN), a professional body that continues to influence health and nursing policy and practice to this day.
The College of Nursing was integral to nursing becoming a profession. It lobbied for a Private Members Bill to be placed before Parliament, resulting in the establishment of a statutory body in 1921, the General Nursing Council (GNC) and the subsequent development of a Nursing Register. Nursing as a profession was born at this point.
Two further institutions replaced the GNC: the United Kingdom Central Council for Nursing Midwifery and Health Visiting (UKCC) and, more recently, under the Nursing and Midwifery Order of 2001, the current regulatory body, the Nursing and Midwifery Council (NMC), with a remit that is currently UK wide.
Characteristics of a profession
These regulatory bodies have been tasked with standard setting for education, practice and ongoing CPD as these elements are integral to public protection. Registered nurses are not merely highly skilled technicians performing a series of tasks; to be both safe and effective they require expertise in developing holistic strategies planned to meet the specific health needs of their client group.
This article summarises the implications associated with professional registration. It provides an overview of, and the reasons for, the planned NMC changes to their management of continuing registration. It will also highlight the process by which registered nurses will be required to demonstrate their professional suitability and competence to practice through a process known as revalidation.
To appreciate the need for revalidation, an awareness of the implications of being a member of a profession is helpful. Comments made by nurses in response to what they perceive to be recent unreasonable increases in registration fees include: “What do I receive from the NMC in return for the fees I pay to them?” Such statements suggest their lack of understanding of the role and function of the NMC as a regulatory body. It was not established to be an occupation-specific club with benefits to members. Their function is not “nurse gain” but practitioner regulation and public protection. This requires robust approaches to initial education and continuing professional practice. Codes of practice based on ethical principles to which registrants must adhere are integral to their regulatory function.
The NMC maintains the world’s largest professional register regulating approximately 600,000 nurses, midwives and public health nurses. The NMC has a broad remit incorporating multiple practice related functions including:
- investigating complaints and removing registrants from the professional register as a consequence of investigations following such concerns;
- developing guidelines and standards to underpin safe and effective practice;
- setting standards for educational programmes;
- requiring registrants to undertake CPD in order to maintain their practice currency and competence.
To put these functions into perspective it is helpful to consider elements core to a profession as described by Cruess and Cruess (2004). These include, but are not limited to:
- self-regulation and compliance with professional body requirements in order to maintain registration;
- entry restricted to those holding a unique body of knowledge, skills and practice competence;
- compliance with a professional code;
- accountability to clients and society; and
- personal integrity.
Practitioners are required to renew their NMC registration triennially. At this point, a fee is paid and a notification of practice form completed. The registrant confirms they have no adverse health issues with the potential to affect their ability to provide safe, effective client care. They must also confirm that the CPD requirements of the NMC have been fulfilled. Following this process, further retention of registration fees become payable at the end of the first and second years of that registration period. The NMC currently has no power to seek information from other parties to verify registrant claims. Shortfalls in practice, or health issues affecting client/patient safety, may only be identified should the NMC be made aware of concerns relating to the practice or behaviour of the registrant. Consequently, poor practice may go unheeded for a significant period of time.
This was the case at the Mid Staffordshire Hospital Foundation Trust, whereby poor care resulted in many deaths. A subsequent inquiry, led by Robert Francis QC, identified serious shortcomings and regulatory failings. A key recommendation of the Francis review was the requirement of a more robust approach to the process of practitioner re-registration (Department of Health, 2013). This review had significant implications for healthcare regulatory bodies, including the NMC,
An earlier white paper, “Trust safety and the regulation of health professionals in the 21st century” (Department of Health, 2007) had already set out a programme of reform to the UK’s regulatory system for health professionals including the General Medical Council (GMC) and NMC, revalidation being an integral feature.
The proposed NMC approach to revalidation
An effective model of revalidation aims to ensure public protection and confidence. It is designed to embed a culture of quality care, professionalism and accountability into reflective nursing practice. The NMC governing council agreed a draft revalidation strategy in September 2013. A three-month consultation exercise on the proposed revalidation model was instigated in January 2014 followed by a further public consultation on revisions to the NMC professional code completed in June 2014. The revalidation process will be implemented from December 2015.
A robust appraisal system and processes for multi-source, third party feedback will be incorporated within the proposed NMC model. More effective auditing of professional portfolios is also planned. Nurses will revalidate every three years on applying to renew their NMC registration. This registration confers their licence to practice. Practitioners will take ownership of the process and will be required to constantly collect evidence based on criteria incorporated within a revised code that is due for publication in December 2014. The revalidation process will incorporate significant changes designed to enhance public protection. Registrants will be required to confirm key factors demonstrating their fitness for practice including that they:
- remain fit to practice and meet the requirements of the revised code of conduct;
- have worked for at least 450 hours in their chosen field of practice. Those having taken a career break must have undertaken an approved return to practice course during the previous three years;
- have undertaken appropriate continued CPD activities;
- have sought, reflected on and responded to third party feedback from individuals appropriately placed to comment on their practice.
The nursing regulator is not alone in this approach. The GMC established a similar process for doctors in 2012. In contrast to the triennial approach of the nursing profession revalidation is only required for doctors every five years. The GMC approach links to regular appraisals, and is based on the GMC document “Good Medical Practice” (General Medical Council 2013). This publication incorporates the following four key domains integral to safe and effective practice:
- knowledge, skills and performance;
- safety and quality;
- communication, partnership and team working; and
- maintaining trust.
Central to the GMC approach to ensuring public protection was the establishment of responsible officers (RO). ROs are tasked with ensuring fitness of doctors to practice and base their judgments on regular appraisals. Areas of concern must be investigated, remedial action taken and where deemed necessary subsequent referral of the practitioner to the GMC. The NMC approach to revalidation may be similar to, but may not entirely replicate, the approach of the GMC.
The NMC instigated a two-part consultation process with stakeholders and practitioners across the UK, which started in January 2014, focusing first on the revalidation process and then on revisions to the NMC professional code. Having collected this data the NMC formulated a draft version of the proposed code and further consultation on those documents ensued. The final version of the code, although currently unavailable for comment, will be underpinned by the following principles:
- putting patients first;
- ensuring honesty and integrity;
- incorporating compassion, respect and patient dignity within patient/client care;
- transparency, openness and a professional duty of candour;
- raising concerns regarding patient care and effective handling of complaints;
- leadership, delegation and mentoring.
Themes, which undoubtedly will be incorporated within the code, include risk minimisation; accountability; confidentiality; record-keeping; prescribing; and medicine management. It will reflect developments in information technology and the responsible use of social media and will be formulated in response to stakeholder and employer feedback.
A fundamental change – third party validation
There is a fundamental change in approach to ongoing NMC registration– historically, registrants have merely self-confirmed their fitness to practice. There are obvious flaws as it relies on the integrity of the professional. The new approach of the NMC supplemented with third-party validation, is linked to the employer’s appraisal system The diversity of practice areas across the family of nursing will lead to obvious challenges associated with this approach.
Not all nurses are employed in the NHS and approaches to appraisal may vary. Furthermore, some OHNs practice as self-employed consultants and do not report to a line manager. Such OHN consultants may decide to ask “contractual clients” to validate their standard of practice. For OHNs employed within a traditional OH service, asking clients for their opinion of the care they have received may be inappropriate. The views of employees referred to the OHN for an opinion on their health status that could put their ongoing employment at risk may not be inclined to give very positive feedback on that experience.
The majority of the employers consulted with by the NMC are likely to have been those from healthcare settings that provide a traditional approach to health care delivery. OH nursing sits within the family of nursing, sharing common values but there are significant differences to the nursing practices undertaken in more traditional care settings. For OHNs, using third party confirmation is not without difficulties, particularly as their role is not primary one of client advocate but of impartial adviser to both employer and employee.
Seeking service-user feedback could be problematic, particularly for those working within services with a significant involvement in advising management regarding attendance management strategies. Their role in management referrals to assess the health status of those employees with very high levels of non-attendance that is not associated with significant health problems could be problematic. Objective feedback is unlikely from clients who are uncomfortable with the recommendations made by these OHNs. Their feedback could significantly disadvantage those practitioners.
OHNs frequently report poor line manager understanding of their role and function and disregard for their professional responsibilities. It would be interesting to have an insight into any discussions undertaken with employers of OHNs from establishments other than the NHS or similar care settings. Revalidation alone is unlikely to assist all employers gain a deeper understanding of professional regulatory requirements. Some practitioners have expressed concern that some managers may use the requirement for validation as a stick with which they can threaten their staff.
An online NMC fact sheet states that there will be benefits associated with revalidation for registrants, their employers and their clients (NMC, 2014). They suggest nurses will develop a deeper understanding of professional regulation and assert that employers will gain from better access to evidence that the nurses they employ maintain CPD. They also believe that employers will gain a better understanding of the requirements of professional regulation. This is questionable for employers operating outside traditional healthcare institutions.
Without doubt the process of revalidation is designed to make re-registration a more robust process. As there are more than half a million practitioners registered with the NMC the process of revalidation has significant financial and personnel resource implications for practitioners and for the NMC. The process of revalidation follows a period during which the NMC has been placed under the spotlight as a result of poor financial and organisational management (RCN, 2014). An important question is whether revalidation will be funded centrally using public funds or will it result in a further increase in registration fees which will be unpopular among registrants?
Cruess SR, Johnston S, Cruess RL (2004). “’Profession': a working definition for medical educators”. Teach Learn Med; Winter 16 (1), pp.74-76
Department of Health (2007). “Trust safety and the regulation of health professionals in the 21st century”. London: The Stationery Office.
Department of Health (2013). Report of the Mid Staffordshire Foundation Trust Public Enquiry. Executive summary. London: The Stationery Office (accessed 17 July 2014).
General Medical Council (2013). “Good Medical Practice”. London: General Medical Council.
Nursing and Midwifery Council (2014) Revalidation (fact sheet) (accessed 17 July 2014)
Royal College of Nursing (2014) RCN Briefing on the Nursing and Midwifery Council Consultation on a Proposed Model of Revalidation. London: Royal College of Nursing (accessed 17 July 2014).