Will the NMC force occupational health to split from other nurses?

The clock is ticking for occupational health (OH) practitioners to make their voice heard on the Nursing and Midwifery Council’s (NMC) plans for three-yearly checks, or “revalidation”, of practitioners’ fitness to continue to practise and its proposals to revise the NMC Code of Conduct. Nic Paton reports.

The NMC’s consultation

The NMC’s consultation is taking place in two parts, from January to July 2014, with the NMC anticipating launching a new model from December 2015.

The first part of the consultation ran until 31 March and was focused on “how the proposed model of revalidation can be implemented in a variety of employment settings and scopes of practice”. The intention is also to have in place a system that is “flexible and fit for purpose”.

The NMC intends to issue draft guidance in May and test the model operationally through a network of “early implementers” from spring 2015.

From December 2015, all nurses and midwives who are scheduled to re-register will then start using revalidation, meaning that by December 2018 everyone on the register would have undergone revalidation, the NMC has said.

The first part of the NMC’s consultation on its plans (see panel, right) closed at the end of March, with the NMC intending to issue draft guidance in May and test the model operationally through a network of “early implementers” from spring 2015. One problem, as Occupational Health has discovered, is there appears to be deep-seated scepticism, not to mention cynicism, within many parts of the OH community about the rush towards revalidation in the wake of the Mid Staffordshire scandal, the proposed model’s lack of flexibility and, more widely, what this all says about the NMC’s long-term attitude to and understanding of – or lack of – OH as a profession.

Christina Butterworth, president of the Association of Occupational Health Nurse Practitioners (UK), emphasises that the long-standing suspicions many OH practitioners have about the attitude of the NMC to their profession makes it, if anything, even more important that they put aside their misgivings and engage with the process.

“I can understand the cynicism that is out there, but we are just one very small specialty in the great big field of nursing. If we do not get involved, then our voice will never be heard. So we need to make every effort to get our concerns understood – it is very important for OH practitioners to be completing this consultation,” she says.

Nevertheless, it speaks volumes that even for someone as experienced in the politics and complexities of nursing as Butterworth, the NMC’s approach appears to be far from ideal.

“[The consultation] is still very much talking about the NHS. For a professional body, I cannot believe the NMC is forgetting a large proportion of its workforce does not work within the NHS. So that is frustrating,” she concedes.

Red flags

For those making the time and effort to plough through the consultation, many of the NMC’s proposals are causing concern, not least the requirement for “third party” appraisal and “practice-related” feedback from patients, peers and clients.

“Revalidation feels like a slightly knee-jerk reaction because of the understandable outcry there has been,” says Dawn Veal, OH nurse specialist at Devon-based pharmaceuticals company Perrigo.

“The NMC is trying to restore confidence in the professional standing of nursing in general, which is an honourable aspiration. But having a patient or a manager in control of our registration would be, to me, quite concerning as an idea.”

Lindsey Hall, an adviser at OH consultancy Split Dimension, points out another issue: “The problem is the NMC requires you to be assessed by someone above you. But I am a sole practitioner, and there are a lot of people in a similar position to me – so how is that supposed to work for me?

“My clients could not sign me off on a professional basis; all they could say is whether they think I’m doing a good job. Something like OH can be very difficult to measure.”

Jeremy Smith, OH consultant at Occupational Health Services (South East), agrees: “The NMC has no idea what OH does, so it is a concern. My concern is around the fact of being a self-employed, independent practitioner. So who does my appraisal? My customers, generally, are very grateful for the advice I give them – but, of course, sometimes they are also going to be disgruntled because I give independent, objective advice.”

Just for show?

Sharon Naylor, senior OH adviser at Health Management, questions the rationale for annual appraisals: “Our employers should be doing annual appraisals anyway, so I do not understand what the NMC will gain from tagging on to this. I just think it is naïve and pointless, a possibly academic exercise. Is it the NMC justifying increasing its fees; justifying its very existence; doing ‘something’ to reassure the public?

“Over the years, I have had difficult situations upon which to advise and, like all of us, sometimes I have given an unwelcome opinion, whether that be for the individual, their representatives or employers. I don’t think that’s something that really happens within the NHS, as it is about direct care and more tangible than individual or collective perceptions about work, ‘fitness’, whether or not absence is compatible with the business need and so on.”

Naylor adds: “The NMC stance appears to assume that people with whom we interact will be only too happy to give feedback and put their name to it. This may not be the case. And, in that context, how would the NMC be able to ensure the feedback I submitted was legitimate? Would they check, or would they just accept a signed piece of paper? What, too, if you are self-employed? It is just so full of holes and potentially a logistical nightmare.”

Anne Harriss, course director of occupational health nursing at London South Bank University, echoes these concerns: “There is not much confidence [in the NMC]. What would be ideal would be for the NMC to bring out a specific register for OH nurses, so you would have to be on that register before you could call yourself an OH nurse.

“I do worry revalidation could be used by some managers as a way to bully OH nurses, simply because it is often our job to tell managers things they don’t really want to hear. Those who are informed and engaged about these issues can already see the problems. But the vast majority of OH nurses, I suspect, will have other things to do and will not be bothered with the consultation exercise.”

Diverse model required

The question is whether the NMC will be able, prepared or even interested to put in place a model that reflects the modern diversity of nursing employment, especially where – like OH – those models represent only a small minority within the larger nursing community, says Karen Coomer, director of OH consultancy KC Business Health.

“I have done the consultation, and the impression I got was there was a lot about appraisal. For me, the concern would be that OH often works outside an appraisal system. Unless we are working within the NHS, in-house or contracted to a big employer, we may not be working with the organisation that does the appraisals,” she says.

“So we need to be sure that whatever system the NMC puts in place is able to cope with the variety of employment models OH faces, and that is going to be quite challenging. Having a statement of principles and ensuring nurses are safe to practise – yes, absolutely that is important, of course. But I am just not convinced the NMC always understands OH and our different employment situations.”

Another concern is the lack of detail around accountability, points out Mairi Gaffney, head of NSS Healthy Working Lives (within NHS Scotland) and a member of the Royal College of Nursing’s (RCN’s) Public Health Forum.

“What is not clear yet is what happens if it goes wrong? What is the accountability of my signature? It feels like it is a bit of a juggernaut because we need to get ‘something’ in place,” she says.

Resourcing requirements

There is also a question over the level of resourcing the NMC will be prepared to put behind revalidation to make it work properly. For example, Gaffney says that it may be necessary to establish a network of peer practitioners to validate and appraise OH practitioners, much like the “responsible officers” that now exist within the General Medical Council’s (GMC’s) medical revalidation process for doctors.

“If having third-person clarification is felt to be the way forward, then that needs to happen in a positive way, and it needs to be backed by proper resources,” she says. “We need to be able to access someone who is able to make this a meaningful event. If you had some people around the country, a network of people, who OH practitioners could call on for objective, worthwhile feedback – that would be valuable.”

It may be important for the NMC, and the nursing community more widely, to look at and try to learn from the experiences of doctors and, indeed, recognise that it is almost inevitable there will be teething issues and a bedding down process, says Dr Alastair Leckie, president of the Society of Occupational Medicine (SOM).

“Medical revalidation has been happening now for around 10 years, and there have been concerns the GMC does not understand what occupational physicians do – the nuances of our role – and I think it is probably the same with OH nurses and the NMC,” he says.

“One of the problems for OH nursing is that it is such a small part of the overall nursing contingent out there that it is difficult to get its voice heard. But it has to be all about engagement in the first instance; understanding what it is about and buying into the process. GP appraisal took eight or nine years to get full buy-in, medical appraisal is still dragging on. So people do need to be confident with it; it has to be about engaging with the profession and getting its buy-in too.”

Views on revalidation welcome

What, then, of the NMC? Is it concerned at the level of scepticism being voiced within the profession about revalidation and will it be prepared to take these concerns on board?

Dr Katerina Kolyva, the NMC’s director of continued practice, emphasises that it is vital revalidation works for all nurses, “despite their varied practice and employment settings”.

She explains: “In the conversations we have had, we have heard from a range of dedicated nurses and midwives. We have seen willingness to participate in discussions and debate the model of revalidation with openness. Our assumptions have been challenged and we have heard innovative suggestions that have helped us to shape the model so far, but we want to hear from many more people.

“Our consultation, both on revalidation and a revision to the code, is your chance to not only let us know your thoughts on our proposed model, but also to shape the revised code. We look forward to hearing the views and suggestions of OH nurses.”

New home for occupational health?

More widely, revalidation appears to be focusing minds on whether or not OH even needs to stay within the NMC.

Moves towards bringing together SOM, the Faculty of Occupational Medicine and other OH practitioners into a single body for OH are gathering pace. The prospect of an alternative governing body, one that genuinely appears to understand OH, would be attractive to many.

As Veal puts it: “Do we really fit under the NMC anymore? What, too, do I get for my RCN membership? There seems to be very little for the occupational health practitioner. Why do we have to be registered as nurses to be OH advisers? There is an argument that, yes, it gives employees and employers confidence – but do we really need to continue under the banner of the NMC and RCN?

“The roles and models of the 1970s and 1980s – the industrial nurse – have massively changed. We do not wear uniforms, nor do we present ourselves as ‘nurses’ within the workplace any more. So do we see ourselves as OH nurses or more as OH advisers nowadays? What is OH? Is it still a nursing specialty? In the context of revalidation, this leads to all sorts of further questions, about how this ties in with our professional standing and how we move forward. This, in a way, stirs up a real hornets’ nest. Should we be focusing the money we put into the NMC and the RCN into another body or organisation?”

Similarly, Hall adds: “Whether the NMC takes any notice [of OH’s feedback] I don’t know – I would hope so – but it will depend on how many people fill it in. It just adds to the tide of opinion against the NMC and the debate about whether or not a new body is needed for OH, to take on the role of the NMC.”

Butterworth says: “A faculty of OH could be a better place to set up education and professional conduct standards, with the NMC simply enforcing any issues highlighted. I think the NMC needs to be less precious and let the profession manage itself; it needs to let go while retaining the ultimate sanction.”

Revalidation already looks set to be a groundbreaking change for nurses. But in how it resonates across the profession, particularly if it creates a groundswell of support for a break with existing governance and standards-setting structures, it could yet have even more profound consequences for occupational health.

The NMC and revalidation

The NMC intends to establish a framework under which the UK’s 670,000 nurses and midwives will have their licences to practise “revalidated” every three years. As part of this process, it is also revising its Code of Conduct. The move is part of the council’s wider response to the Francis public inquiry and report on the Mid Staffordshire NHS Foundation Trust scandal.

Revalidation will require every nurse and midwife to confirm that they:

  • continue to remain fit to practise by meeting the principles of the revised code;
  • have completed the required hours of practice and learning activity through continuing professional development;
  • have used feedback to review and improve the way they work; and
  • have received confirmation from someone well placed to comment on their continuing fitness to practise.

What it will mean in practice is that every three years at the point of renewal of registration, nurses and midwives will need to demonstrate they continue to remain fit to practise in order to remain on the register.

To do this, they will be required to declare that they have practised for 450 hours during the last three years and have completed the required amount of continuing professional development. They must obtain confirmation “from a third party” on their continuing fitness to practise. This, the NMC has said, “will come from someone well placed to comment on a nurse or midwife’s practice based on the requirements in the code”.

They will also need to show “how they are using practice-related feedback from patients, colleagues and others to improve their standards of care”. The NMC has stressed it is especially keen to hear from nurses who work in “atypical settings”, including those working for agencies, for multiple employers, in single-practice settings or under volunteer arrangements.

Further information on the plans can be found on the NMC’s website.

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