Framework for Developing Nursing Roles

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Foreword

photo of Paul MartinRole development is about making an impact for patients. It involves releasing professional capacity to make services more patient-focused, consequently improving health and well-being, developing clinical effectiveness and delivering better outcomes for patients.

Role development builds on what's already been achieved to offer new opportunities for patients, staff and services. It impacts at all levels of the workforce. Not all new roles or role development opportunities are at the highly specialist end of the scale; professionals and support workers throughout the system are being freed-up to take advantage of the opportunities on offer to meet patients' needs in new and better ways.

Services throughout the country are being encouraged to look at their capacity to deliver quality care by reviewing skill mix and creating opportunities for role development. This framework for role development will assist patients, staff and services as they review their needs and systems to map out new ways of working and delivering services.

The themes and principles identified in the framework complement key areas of NHS policy in Scotland and are based on a wide and inclusive national consultation. The framework is therefore not only firmly grounded in the expressed wishes and perceptions of professionals, but is also rooted in the Scottish Executive's aims for NHSScotland. Consequently, it will make a significant contribution to the modernised NHSScotland moving forward.

These are challenging times for all who work in NHSScotland as the changes brought about by service redesign and pay modernisation begin to impact on traditional ways of working.

But they are also exciting times in which healthcare professionals, bolstered by appropriate education and management support, can extend, expand and develop their roles to enhance their skills, knowledge and professional identity, strengthen their influence on the design, delivery and evaluation of services, and increase their impact on improving the health and well-being of the people of Scotland.

signature of Paul Martin

Paul Martin
Chief Nursing Officer

Introduction

The NHS in Scotland is facing unprecedented change and is looking to transform existing models of health care. A national review of the health service has recently been published which aims to ensure that the NHSScotland of the future is sustainable and meets the needs of Scotland's population (Building a Health Service Fit for the Future, 2005). One of its key messages is "In planning the future of the NHS in Scotland we need to: develop new skills to support local services; generalists as well as specialists, nurses and allied health professionals as well as doctors - all with the right skills for patients". Additionally, Fair to All, Personal to Each ( SEHD 2004) states that the NHS of the 21st century needs to have services which are as local as possible and as specialised as necessary. It also reinforces that improvements in healthcare will be achieved by "new and more efficient ways of working, such as using the skills of nurses and allied health professionals to take on more roles and give patients more choice". The development of new roles for Scotland's healthcare workforce is likely to remain a vital approach to underpin these aims over the next few years at least.

Currently, the development of roles may take a variety of forms:

  • Roles change as professionals expand existing roles. This often means that other staff are required to take on some aspects of a previous role; for example, as registered nurses expand their role, healthcare support staff often take on elements of basic care which were previously part of the registered nurse's role.
  • Healthcare professionals may develop new roles which are designed to fit within their scope of practice, for example, new clinical nurse specialist roles and emergency nurse practitioner roles. Such roles are an extension of professional practice for an individual group, although in some circumstances another professional group may feel that the role is equally appropriate for them. A partnership approach to developments will be vital in such circumstances.
  • Completely new roles may be developed which do not fit existing professional boundaries, for example, healthcare support staff who work between nursing, physiotherapy and occupational therapy. These roles can be filled by existing healthcare staff or by staff new to the health service with appropriate training and education.

Whatever type of development is utilised, it requires the adoption of a structured approach.

The purpose of this document is twofold. It presents a generic framework (pull-out at front cover) which can be used to guide the development of new roles. The framework has been developed in partnership with representatives from other staff groups. It may be applied equally to role development in nursing as well as, for example, the Allied Health Professions or Pharmacy. It can be used to assist in the planning process to ensure that roles are needs led, meet governance requirements, are sustainable, as well as ensuring that the development is supported by the whole team thus ensuring its success.

The rest of the document contains a rationale for structured role development in nursing. It describes the context and drivers for change, principles which should underpin nursing roles, and emphasises the importance of a career structure within which new roles may sit comfortably.

The framework presented in this document is designed for use by nurses. However, parallel developments by different health professional groups currently underway may broaden its utility. It provides links to current role developments as well as new nursing roles ( http://www.cci.scot.nhs.uk) and is liberally referenced to include an extensive resource list which guides readers through the vast range of supporting literature, much of which was drawn on throughout the Consensus Conference and subsequent activity.

The framework is aimed at four key groups:

  • Patients and carers, their representatives and voluntary organisations
  • Nurses, midwives, other health professionals and social care professionals
  • Education providers and researchers
  • Managers of services and service providers.

Each of these key audiences has an important part to play in liberating the potential and talents of the nursing workforce to achieve patient and community-focused care and services.

Finally, the Consensus Statement identifies that '... nurses need to value the uniqueness and the range of their own skills and resist the too easy adoption of models from other professions'. This framework should help nurses to move away from task delegation - noticeable as an unintended consequence of so much organisational change - to patient-focused nurse-led care in partnership with other health professionals.

The following digram is a model summarising the driveers for role development, the key groups involved and the intended outcomes which can be achieved through structured development of new and existing roles.

The Model for Career Redesign

The Model for Career Redesign

Guidance
1.
Background

Nursing is in a state of rapid change and perhaps now, as never before, the scope exists for nurses to develop their careers in response to service demands, professional aspirations, policy drivers and, most importantly, patient need.

This document sets out a framework to provide guidance on the development of new nursing roles, building upon lessons from innovative nurse role models, evidence of best practice and an understanding of the necessity to develop services fit for the needs of patients and communities.

The development of new nursing roles presents both challenges and opportunities specifically for the nursing profession. However, this document recognises that "care in the 21st Century is based on partnerships which will depend on flexible teams providing services that patients need, irrespective of organisational boundaries. Staff are the best people to develop these new roles and there is already much good practice to build on." (Scottish Executive, 2003e).

The creation of opportunities for career progression for the healthcare workforce, within supportive governance frameworks, is a priority for the Scottish health service. In nursing specifically, this demands sufficient numbers of appropriately educated and fairly rewarded nurses, practising within a context in which their talents can be liberated to deliver the highest possible quality of care. In response to the challenge of supporting the needs of a modern Scottish nursing workforce, the Facing the Future ( SEHD, 2001) working group, supported by the Minister for Health and Community Care, is focusing on the recruitment and retention agenda. This group, established in November 2001, has developed work under a number of themes (Appendix B). The theme which led to the production of this document was based on a concept identified by nurses at the Consensus Conference - that the development of new roles influence and drive modernisation and redesign of health and social care services.

Major Policy Drivers Influencing New Nursing Roles

The work of the Facing the Future Group has not occurred in a policy vacuum. A wide range of key documents has been published in the last five years that describe the ways in which public services generally, and nursing specifically, are to be modernised. In health and social care policies, the critical aspiration is to develop 'pathways of care from the patient's point of view', to make the process 'smoother, more accessible, less complicated and less subject to delays' ( SEHD, 2003e). This aim complements service redesign initiatives, recognises and is a response to workforce constraints ( RCN, 2003b).

The key policy documents of reference to this work are listed in Box 1.

Box 1: Key Policy Influences on New Nursing Role Development

Community Care: A Joint Future: Report of the Joint Future Group (2000)
Caring for Scotland: The strategy for nursing and midwifery in Scotland (2001)
Nursing for Health - A review of the contribution of nurses, midwives and health visitors to improving the public's health (2001)
Facing the Future (2001)
Implementing a Framework for Maternity Services in Scotland: Overview report of the Expert Group on Acute Maternity Services (2002)
Promoting Health, Supporting Inclusion; The national review of the contribution of all nurses and midwives to the care and support of people with learning disabilities (2003)
Choices and Challenges: A strategy for research and development in nursing and midwifery in Scotland (2003)
A Scottish Framework for Nursing in Schools (2003)
Developing the Nursing and Midwifery Workforce 2002: The SNIP Report and NHS Board Area Projection Report (2003)
Framework for Nursing in General Practice (2004)
Scottish Health Workforce Plan 2004 Baseline (2004)
Modernising Medical Careers - The next steps (2004)
Fair to All, Personal to Each (2004)
Building a Health Service Fit for the Future (2005)

The integration of health and social care, as required by policy and legislation, has been widely acknowledged as a fundamental opportunity to change the way in which services are delivered to priority care groups. Nationally and locally the Joint Future Agenda has been driving agencies and professionals to examine what they currently do and find solutions to integrating care.

Pay Modernisation

The NHS is now facing another significant reason to think about new ways of delivering care - pay modernisation. Across the three elements - the Consultants' Contract, the General Medical Services ( GMS) contract and Agenda for Change - additional investment is delivering modernised services,
new ways of working and improved outcomes for the people who use services. In return, the NHS and primary care workforce will have additional funds devolved to them for local decision making.

The primary element for the nursing workforce is Agenda for Change, implemented on 1 December 2004, and some of its key aspirations are to:

  • Ensure that the new pay system leads to more patients being treated, more quickly and being given higher quality care
  • Assist new ways of working which best deliver the range and quality of services required, in as efficient and effective a way as possible to meet the needs of patients
  • Assist the goal of achieving a quality workforce with the right numbers of staff, who possess the right skills and diversity, and are organised in the right way
  • Meet equal pay for work of equal value criteria (taken from DoH, 2002 Agenda for Change Proposed Agreement).

The General Medical Services Contract which was implemented on 1 April 2004 is a practice based contract, changing the management of workload in Primary Care including Out of Hours Services, incentivising high quality care, and modernising premises, management processes and Information Management & Technology. One of the themes which is emerging that has implications for the nursing workforce amongst others is expansion of the role of other health care professionals.

The Consultants' Contract allows for systematic planning of consultants' time, extended patient access, pay progression linked to a job plan, extra activity for the NHS and importantly for the nursing workforce, integrated change with other staff groups.

Establishing a Way Forward

In order to understand better the contribution that new nursing roles make to nurses, nursing and ultimately, to improving health and healthcare delivery, a Consensus Conference was held in Edinburgh on 17 and 18 November 2003. The primary aims of this conference were to examine the issues, identify best evidence in the arena of new nursing role development, engage nurses in a dialogue around these issues, and debate how this agenda should be taken forward.

A panel, representing a wide range of practitioners, service providers, academics, policy makers and patient groups, compiled a Consensus Statement generated from a range of sources. The sources included oral presentations based on national and international evidence, posters from experts in the field (academic and practice), policy documents and debate between the conference delegates. The statement underwent a number of iterations following feedback and comment from the audience before its final wording was agreed.

Consensus Conference on New Nursing Roles Deciding the Future for Scotland Final Statement

Healthcare in Scotland is in the early stages of the most significant changes in the way services are provided since the inception of the NHS. The status quo is not an option: the nursing profession in Scotland can lead some of this change and has a key role to play in working with others to ensure that new sustainable models of healthcare are designed around the needs of patients.

What are the drivers for change?

  • demographic changes - a declining working population supporting an increasingly elderly population
  • increased burden of chronic diseases within an ageing community
  • the need to promote public health and tackle health inequalities
  • the need to work in partnership with people and communities
  • increased pressure to centralise acute services because of workforce constraints ( e.g.EWTD)
  • Joint Future working
  • patient safety considerations and improving clinical standards
  • the need for sustainable, affordable services
  • educational requirements and competency based frameworks for professional staff
  • pay modernisation (consultant contract, GMS contract, Agenda for Change)
  • recruitment and retention challenges within a competitive global labour market
  • advances in diagnostics and new technologies including telemedicine and eHealth
  • the demands of regulation

This consensus statement needs to be considered in the context of critical strategic documents that are already in the process of being implemented. These include:

  • Partnership for Care
  • Caring for Scotland: a strategy for nursing in Scotland
  • Choices and Challenges: a strategy for research and development in nursing and midwifery in Scotland
  • Nursing for Health
  • Joint Future Report
  • Promoting Health, Supporting Inclusion

The way in which nursing practice is developed must have the interests and needs of patients, carers and wider communities at its core, and the need to work collaboratively with other professionals. This will:

  • Redefine the relationship between patients and those providing their care;
  • Create the opportunity for new partnerships; and
  • Inform the planning and design of services.

Nursing practice needs to fit within the legal, ethical and regulatory framework for the profession, and ensure patient safety through a system which clearly defines the professional and legal accountability of nurses to patients.

The distinction between role development and role expansion should no longer be a key issue for the profession. The critical issue is ensuring the delivery of high quality care and safe practice for patients and communities which reflects health needs.

The expansion and development of professional practice and skills should be focused on the needs of the patient and the community based on sound evidence, to enhance clinical credibility and the exercise of professional autonomy.

There is a fundamental philosophy associated with nursing which is discrete to nursing as a discipline but which complements and facilitates the skills of other health care professionals.

The nurse of the future has to continue to reflect this philosophy while retaining the capacity for flexibility which is needed to face the challenges of health care in the 21st century.

Nurses need to value the uniqueness and range of their own skills and resist the too easy adoption of models from other professions.

The nursing profession must recognise that there are different levels and types of nursing care and skill, which need to be differentiated, valued and supported by education, professional organisations, employers and clinical practice.

Nurses must be able to practise flexibly within mutually supportive multi-professional teams, recognising patients' aspirations.

Professional development, which includes education and standards, should be underpinned by evidence, within the context of a national framework.

Professional development is more important than role development and must include and accommodate all nurses, and take place within a policy and planning framework.

There is substantive international evidence in relation to how nursing contributes to the improvements in: health outcomes of patients and consumers, patient satisfaction, enhanced patient involvement, cost effectiveness, improved inter disciplinary relationships and improved nursing practice. This research has developed over many decades and has emerged from primary care, peri-operative, acute, mental health, child health and other new specialist areas. The challenge for researchers over this period of time has been to develop new methods to adequately capture the depth and distinctiveness of how nursing enhances patient care and safety.

Whilst we can learn from the evidence that exists from international research there is a need to develop the case for the establishment of new roles based on health care need, impact on existing services and potential benefits and risks to the health care organisation.

There is a need to create a culture to support confident practitioners, by integrating education, practice, research and continuing professional self-evaluation in order to develop further this body of evidence.

The debate about the relative value of generalist and specialist nurses is a distraction from the need to support the professional development of all nurses. Each is of equal value. Organisationally this needs to be taken into account in the context of implementing Agenda for Change. Under Agenda for Change there is a knowledge and skills framework which needs to be clearly articulated with properly supported educational provision.

Rigid categorisation may encourage independent working rather than team working. It is important that knowledge and skills are shared and that a means is found to accommodate and value a variety of practice. Nurses must be proactive in negotiating the boundaries of the service they provide recognising the potential contribution of others.

Recommendations

  • A national framework needs to be developed which integrates professional requirements, career structure, educational requirements and practice competencies, underpinned by clinical leadership at all levels. The framework must take account of existing practice in all health sectors, including the independent and voluntary sectors, and provide a strategy for moving towards national consistency. This framework must be cognisant of developments in other health professional groups.
  • There must be opportunities for adequately resourced and supported continuing professional development, to facilitate the effectiveness of the nurse in a changing health service, taking particular account of the needs of future patients.
  • Career structures need to be established which provide a real opportunity for professional recognition, fulfillment and progression and are underpinned by research and explicit, appropriate levels of education.
  • The potential of IT in the development of managed clinical networks, electronic patient records, information sharing and e-learning must be fully harnessed to support cross-team working, effective patient care pathways.
  • Models for the development of nursing practice must ensure clinical safety and be sustainable in the long term. Health care organisations must focus on developing integrated workforce planning at regional and local levels.
  • There is a need to close the perceived tensions and misalignment between academic, managerial and clinical communities, building on initiatives that have already been taken.
  • The profession needs to grasp the challenges of the existing national strategies, by developing strategic and participatory leadership within its professional and employing organisations. The profession needs to demonstrate how this will be achieved by developing an action plan which will deliver on the strategic national nursing directions incorporated in Caring for Scotland and inform the national framework.

The key action recommended by the Consensus Panel was that, "…a national framework needs to be developed which integrates professional requirements, career structure, educational requirements and practice competencies, underpinned by clinical leadership at all levels." ( SEHD, New Nursing Roles, 2003).

Subsequently, the Facing the Future Group agreed that a small steering group should begin the development of a draft framework. The group was representative of service providers, professional organisations, education institutions and the Scottish Executive (See Appendix C for membership). Further development and refinement was undertaken in partnership with other professional groups to support the framework in a wider context.

In addition to this activity and to ensure wider professional scrutiny of and input to the framework, a national reference group was established, chaired by Lesley Summerhill, Director of Nursing, NHS Tayside & Steering Group member (See Appendix D for membership). The group met on two occasions to prepare the framework for consultation with the wider profession and after that process was complete to refine the framework for inclusion in this document.

A draft of this document was also the focus for consultation at three regional events held during May and June 2004. These events gave approximately 400 nurses, patients, managers, and other stakeholders the opportunity to express their views about and shape the future for nursing role development. This resulted in a document which was launched by the Facing the Future Group in June 2004 for wider consultation. Thus, this document has been widely consulted upon both by the nursing profession and the wider NHSScotland family.

2.
Principles arising from the Consensus Statement

The Consensus Statement from the 'New Nursing Roles - Deciding the Future for Scotland' Conference was used to identify a set of principles which appear to be fundamental to establishing a framework that will guide nursing role development. Equally, many of these principles may be helpful to other professional groups in producing their own principles to underpin role development. They may also be used by practitioners and service developers as indications of their intent.

The national Reference Group and participants at the regional events produced statements, which may be linked with the principles and underpin the process of role development, whatever method is utilised. This chapter contains the principles derived from the Consensus Statement matched with the statements produced by the national Reference Group and participants at the regional events.

Principles and Statements underpinning Nursing Role Development

Principle 1 Nursing as a unique profession: nursing is a unique profession in which nurses shape and deliver care in partnership with other health and social care professionals

Nurses have debated the question "What is nursing?" over many years. Definitions are plentiful in the literature, including in the RCN's Defining Nursing document ( RCN, 2003a). It sets out how nursing has been defined in the past, that is, by:

  • Specific tasks and procedures
  • Which agency funds and provides the service and its location
  • The person who does it ( i.e. a nurse).

The document emphatically concludes, "None of these approaches is adequate".

The framework presented in this document supports a patient/public centred approach to care delivery as well as providing a professionally liberating opportunity for nurses in Scotland. Nurses can begin to describe the key attributes of nursing which allow them to develop their role as nurses.

Reference Group statements

Nursing as a unique profession

1. As roles develop, nursing is in a unique position to ensure that patient and community need is the starting point for change.

2. Effective teamwork is based on mutuality and partnership.

3. In order to develop roles, nurses must be clear about the value of current roles, core competencies of all nurses and the value of the generalist.

Principle 2 Caring as core: caring is at the core of nursing and must be central to role development

There is a widespread fear in the nursing profession that the expansion and extension of nursing roles will erode the capacity of nurses to provide basic nursing care which many see as core to the art if not the science of nursing. The Essence of Care programme launched by the Department of Health in England (2001) was widely praised as being a useful resource for nurses, to ensure that nursing roles at all levels maintained that element of the role, even though nurses are caring for increasing numbers of acutely ill patients, careers are being redesigned, and advances in technology are leading the profession into new territory.

Reference Group statements

Caring as a Core

1. Caring is moral action that underpins the activities and responsibilities of all nursing roles

2. Each nursing role must demonstrate nurture and contribute to people centred care

3. Strategic and operational roles must jointly embrace an essence of nursing that reflects and impacts on wider health challenges and solutions

Principle 3 Focused on needs of patient and community: needs of patients, carers and communities should inform the development of professional practice and skills

In Scotland in recent years, a wide range of initiatives to promote and enhance patient and community involvement in health care have been implemented. Patient focus and Public Involvement ( SEHD 2001d and SEHD 2003g) is a central theme in the day-to-day work of health professionals across Scotland. Working in partnership with people, informing and engaging patients in decisions, creating therapeutic relationships to support health and well-being, are all essential elements of nursing. The consultations at regional level across Scotland demonstrated overwhelmingly the ambition of nurses to grow and demonstrate these attributes when developing their role.

Reference Group statements

Focused on Needs of Patient and Community

1. Nursing roles should be developed in response to patient need

2. Nursing roles should incorporate flexibility to respond to evolving physical and social and environmental circumstances facing the population

3. To gauge responsiveness each nurse as part of their role should engage in meaningful dialogue with patient/public

4. Nursing roles must meet patient, carer and public need in collaboration with other health and social professionals

Principle 4 Ensuring patient safety: nursing practice needs to fit within legal, ethical and regulatory frameworks to ensure patient safety is maintained

The promotion of patient safety must be the highest priority. National initiatives continue to develop awareness and the supporting structures to enhance safe and effective care. Any role development must not put patients, or communities, at risk, but must proceed within an ethical, legal and regulatory framework. Throughout the consultation nurses described local and practical approaches to Clinical Governance.

Reference Group statements

Ensuring Patient Safety

1. Patient safety is paramount

2. New roles must operate within boundaries of NMC code of professional conduct and relevant documentation in line with clinical governance requirements

3. Nursing should promote an atmosphere of accountability and a willingness to report and learn from patient safety incidents

Principle 5 Demonstrating leadership: role development should enhance professional leadership, autonomy and clinical credibility

The potential of the nursing workforce must be harnessed to modernise healthcare. The key to realising that potential lies in investment in patient/public focused clinical leadership programmes. Such programmes are becoming more important as nurses become clinical co-ordinators of care and specialist professionals.

Developed roles are likely to have certain key attributes (Adapted from RCN Future Nurse, 2004). They will:

  • Manage risk and critically evaluate research
  • Transform organisational and practice cultures
  • Motivate, and influence a range of key stakeholders and teams
  • Demonstrate transformational leadership
  • Work across organisational and professional boundaries

At all levels leaders must be nurtured and developed - supported to be clinical change agents who lead care for the benefit of patients and communities.

Reference Group statements

Demonstrating Leadership

1. The development of leadership skills must be integral to nurse education

2. A culture which values leadership should be established

3. Leadership should communicate a vision focusing on patient need

4. Leaders should be credible and effective

Principle 6 Recognising policy/frameworks: professional development for all nurses should be recognised as a dynamic process, be resourced, and take place within local and national planning frameworks

Whether it is national documents describing the strategic direction for the NHS workforce in Scotland, or local frameworks to submit service redesign bids, the health service has in place a wealth of policy and planning guidance. The context of much of this development is driven by strategic need or is in response to democratic political direction. Nevertheless, such change has a dynamic impact on the daily work of nurses. They wish to ensure that change is properly resourced. Moreover, they expressed a strong desire to see professional development - not just role development - appropriately identified and resourced.

Reference Group statements

Recognising Policy/Frameworks

1. Role development should be shaped by local policies underpinned by national strategic principles

2. Role development should be driven by the nursing profession, responsive to the changing health and health care needs of individuals/services and local communities

3. Role development policy will emerge from strategic priorities, endorsed by executive teams

4. Robust resource and finance planning should be incorporated into role development

Principle 7 Integration: there is a need to create a culture to support confident practitioners, by integrating education, practice, research, information technology ( IT) and continuing professional development

The essence of this principle is less about the integration of organisations or cultures, and much more about the coming together of elements to support professional development. It is absolutely essential that the key stakeholders in each of these areas come together to share their expertise and resources. No single element will be able to deliver all the aspects needed for robust and sustainable proper development.

Reference Group statements

Integration: Education and Competencies

1. Education is central to any role development and is a continuous process

2. A national core competency framework should be developed to support and reflect patients, carers' and community needs

3. Collaboration between service and educational partners should ensure that the most appropriate learning experience is accessible

4. Commitment for appropriate resources is necessary to support and enable education/development in terms of finance, human resources and time

5. Nurses need access to a national network for peer support and supervision

Integration: The Potential of IT

1. The national IT strategy should collate clinical data to inform and audit practice in role development

2. IT must be readily available and accessible to all nurses

3. An IT culture is harnessed through investment in work based training and development

Principle 8 Evidence-based development: role development should be evidence-based and build the body of nursing knowledge

The process of developing this national framework has been founded on the need to encompass evidence-based policy. Indeed, nurses across Scotland re-emphasised the need not only for evidence to inform role development, but also that it was incumbent on nurses to expand the body of nursing knowledge. Recent investment to enhance the capacity and capability of the nursing and AHP research community is critical ( SEHD, 2003b). It will, with other work, enhance the clinical credibility and authority of the nursing profession.

Reference Group statements

Evidence Based Development

1. Ensure role development is informed by needs assessment and substantiated by an evaluation of effectiveness

2. Demonstrate the use of, and critically evaluate, local and national guidance for effective patient focus and public involvement

3. All nursing roles both use and generate knowledge

4. The tools and processes used to generate knowledge should be built into electronic clinical record systems

5. Role development must demonstrate effective patient and public involvement

Principle 9 Evaluation and dissemination: role development should be evaluated and the findings widely disseminated

Demonstrating to all key stakeholders that new roles are effective or that professional development has enhanced the quality of patient care, is essential. At the Consensus Conference and throughout the regional events, nurses emphasised their eagerness to evaluate the benefits of change. An essential element of all evaluation is that patient/carer/community evidence is sought in an effective and meaningful way. This must be given equal weight with evaluation from professionals and managers.

The profession also recognised the need to go beyond evaluation and widely disseminate findings. Modern technology obviously aids speedy communication. Future leadership from the Centre for Change and Innovation on workforce design will assist in disseminating findings across NHSScotland ( http://www.cci.scot.nhs.uk).

Reference Group statements

Evaluation and Dissemination

1. Outcome measures should capture patient/carer experiences

2. Outcome measures should be dynamic and influenced by best practice and research

3. Role development must enhance, or maintain the quality of care and effectively meet the needs of patient, carer, community, service and organisation

4. Lifelong learning needs should evolve from critical evaluation of outcomes which will be inherently linked to patient experience

Principle 10 Enhancing the Profession: role development should enhance the professional recognition, fulfilment, career progression and rewards of nurses

The Consensus Statement delivers a vision of professional development which builds on a professional philosophy, yet is flexible to meet the challenges of health care in the 21st century. The statement also describes what the nursing profession must recognise, value and support at different levels and types of nursing care and skill. Professional enhancement is achieved by recognising the family of nursing and the wider healthcare team. These points were emphasised during the consultation period. Moreover, nurses recognised the need to create powerful leaders who would 'tell and sell' this dynamic credible professional vision.

Appropriately rewarding the individual and the professional is a key aim of Agenda for Change. Potentially, it can create a system which facilitates a clear link between responsibilities, career developments and rewards.

Reference Group statements

Enhancing the Profession

1. A career structure which supports role development has to be meaningful to the individual and the public

2. Role development must be adequately resourced (equipment, time, £s, staff, space)

3. Role development should provide a range of career opportunities, both horizontal and vertical

4. Role development should be based on competency frameworks and underpinned by relevant ongoing education

5. Titles have to be readily understood by the public

3.
Developing a Framework for Nursing Careers

Introduction

The development of a career framework for nursing must be founded on the need to develop a workforce that is fit for purpose. However, it is also important to create a framework which acknowledges the aspirations of an ever more highly educated nursing workforce within an organisational and professional context.

Opportunities for Developing New Roles offered by Agenda for Change

Agenda for Change ( DOH, 2002) offers a clear career structure within which roles can be developed. Central to Agenda for Change is the Knowledge and Skills Framework ( DOH, 2003) ( KSF), which is made up of a number of dimensions. Each dimension of the KSF is elaborated by a series of level descriptors. Each level is defined by successively more advanced stages of knowledge and skill and/or increasing complexity in application of knowledge and skills to the demands of work. The KSF provides a development tool which staff can use to:

  • Identify the knowledge and skills that individuals need to apply in their post
  • Help guide the development of individuals
  • Provide a fair and objective framework on which to base review and personal development plans for all staff
  • Provide the basis of pay progression in the service.

Another important aspect of Agenda for Change is the information contained in the job profiles. These provide a job title and a job statement matched with a set of factors, such as communication and relationship skills, knowledge, training and experience, and freedom to act, amongst others. Staff working in different jobs function at different levels within each of the relevant factors. There are job profiles for healthcare assistants, healthcare assistants (higher level), midwives, nurses, district nurses, health visitors, specialist nurses, highly specialist nurses, specialist midwives, consultant nurses and consultant midwives. The factors which make up the specialist nurse and highly specialist nurse are shown in Appendix A.

The KSF and job profiles can be used during the continued cycle of review, planning, development and evaluation for staff in the NHS, linking in to both organisational and individual development needs. Nurses who have developed their role can, therefore, use the KSF for continuing development (this applies to all staff covered by Agenda for Change). However, nurses who want to expand their role can also use both the job profiles and the KSF to plan their development in preparation for a new role. Similarly, service managers can use both Agenda for Change and the KSF to help them to plan role development as part of service redesign.

A Career Framework

Agenda for Change provides a clear framework for NHS staff including the professions of nursing, midwifery and Allied Health Professionals. Job profiles will be evaluated using a scoring system to assign them to a particular point on one of the eight pay bands.

Staff may progress within the pay band using the KSF to plan and measure their development. They will also be required to progress through gateways at specified points on the pay band by successfully demonstrating they have achieved the necessary knowledge and skills. Movement to a higher pay band will only be possible if a staff member's job has been evaluated as being on the higher band. One of the aims of Agenda for Change is to allow staff to progress within pay bands at a steady rate, without being affected by moving job.

A Sub-committee of the National Workforce Committee is responsible for taking forward the agreed work stream on Careers, Recruitment and Retention. The purpose of this group is "to provide NHS Scotland with leadership and direction on strategies for modern careers and improved recruitment and retention of the workforce. Under consideration is the development of a career framework for all NHS staff, which will reflect the roles needed now and in the future, be flexible, and reflect a team based approach which will assist in removing rigid professional demarcations.

Agenda for Change should also help to identify more clearly, and so value more appropriately, the practical skills and competencies which comprise nurses' roles. The new system could ease the problem of transferability of staff between clinical areas and between NHS organisations.

Educational Preparation

The discussion about the preparation of staff for new roles stated that in relation to education, the emphasis should move from purely academic study to partnerships between education and service to provide learning that underpins nursing and midwifery practice. This shift means that education programmes to support role development should be flexible, cumulative, largely work-based, and give academic credit for learning gained in practice. This is already well underway and an excellent example is the Out of Hours work which has been co-ordinated by NES. ( www.nes.scot.nhs.uk/multi/out_of_hours/default.asp)

The level of educational credit is still subject to much debate, but at the moment educational programmes to support advanced roles are mainly at undergraduate level. This is entirely consistent with a profession that studies to Diploma level in order to achieve registration. However, as the prospect of a pre-registration workforce studying to degree level comes closer, it may be logical that education for role development to be at Honours or Masters level. However, delegates at the Consensus Conference did not support the development of such programmes at Masters level, per se. Ideally, education programmes should be developed with a choice of outcome levels so that, depending on an individual's previous level of attainment, they can choose to pursue modules at degree, masters or doctoral levels.

It may also be logical that the skills and competencies being developed for new roles should be recognised at degree, masters, or doctoral level, even if academic credit is not sought, rather than attaching academic credit to all underpinning education. This should help to ensure that education programmes developed outside academic institutions have the necessary rigour, and that the safety of both those undertaking preparation for new roles, and the patients/clients on the receiving end of such care is maintained.

Workforce, Recruitment and Retention

NHSScotland needs a skilled workforce who can provide high quality, timely care. This requires the right staff, in the right place, at the right time ( SEHD, 2002b). It also requires different types of nursing roles, all of which are as valuable as each other.

Opportunities for Health Care Support Workers There is a need for a skilled, well-supported nursing assistant workforce. Increasingly, support staff are providing many of the fundamental caring tasks of nursing and some tasks are being delegated to them which previously, nursing staff would have considered their domain.

Support staff, such as nursing auxiliaries and healthcare support workers, are receiving more training and education, and must be encouraged to apply this to best effect. Induction programmes are the norm, as are many other programmes such as SVQ 2 & 3, Higher National Certificates ( HNCs), and other in-house education and awareness programmes.

Increasingly a wide range of staff are taking on roles which were formerly the responsibility of registered health professionals. Support workers are valued members of clinical teams and provide an important service in supporting nurses and AHPs in caring for patients and communities. It is vital in ensuring the delivery of safe and effective care that arrangements are in place that require staff caring for patients to meet standards of practice, conduct and training.

Nurses are well placed to lead the training of support workers and to undertake supervision in practice settings. A consultation was recently undertaken looking at the need to regulate health care support staff and social care support staff in Scotland. A national group is now progressing this work.

Generalists The vast majority of nurses in NHSScotland are skilled generalists who work in increasingly specialist areas and roles, whether this is in community or acute care settings. Indeed, generalist nurses often have areas of special interest and act as link nurses to specialist support. This encourages all staff to continue to develop and remain enthusiastic. However, such activity should be supported by appropriate education and technical competence.

Specialists A small but significant number of nurses (less than 1% of the nursing and midwifery workforce) choose to progress to a specialist role, whether that be clinical nurse specialist, nurse practitioner, or nurse consultant. Nurses who develop a special interest and/or who act as a link nurse may be the nurse specialist of the future, although by no means all will progress in this way. Indeed, a nurse may change his/her area of special interest many times during his/her career. Or as a nurse moves through different clinical areas they could maintain an area of special interest and simply apply it differently.

4.
Ensuring the Safe and Effective Delivery of Patient Care

Introduction

As NHSScotland strives to modernise services through redesign and the development of NHS-wide integrated solutions, it is crucial that patients and the public feel confident that the NHS will continue to provide high quality care and treatment consistently across the country.

Challenging old ways of working and changing practice requires leaders to have a clear vision and a willingness to take risks. Clinicians, managers and leaders of services require clarity and assurance that organisational, professional and legal processes supporting role development can benefit patients, while ensuring the safe and effective delivery of patient care. It is important that these processes are recognised by all as key stages in the support of role innovation and development rather than as obstacles to be overcome in the pursuit of patient-focused services. It is important that nursing role development facilitates good interprofessional and multiprofessional team working.

Clinical Governance: Ensuring accountability in new roles

Clinical governance is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of clinical care and thus ensuring patient safety. This is achieved by creating an environment which encourages continuous quality improvement. Clinical governance focuses on the safe and effective delivery of patient care. To achieve this, clinical governance defines the values, culture, behaviours, processes and procedures that are essential for the provision of safe, sustainable quality services.

"Clinical governance is a framework which helps all clinicians - including nurses - to continuously improve quality and safeguard standards of care" ( RCN, 2002).

The central purpose of clinical governance is to improve the patient's experience of healthcare. Developing robust clinical governance systems such as risk management, clinical audit and benchmarking, accountability, research and effectiveness and clinical guideline development, will create an environment in which role development and innovation that is focused on the patient experience can flourish.

Nurses are obliged to be aware of current best evidence that underpins care (Nursing & Midwifery Council, 2002); evidence-based clinical guidelines and protocols are a key feature of clinical effectiveness. Developing protocols and guidelines collaboratively will enable new practitioners to understand how these can help to ensure consistent, high quality clinical standards, while allowing nurses to exercise clinical judgement in response to the patient pathway and need.

Effective clinical governance will strengthen accountability for individuals, teams and organisations and provide the necessary assurance on safety and quality for patients and public. Enabling transparency about accountability for all aspects of service and clinical delivery is critical to allow individuals the freedom to ensure the delivery of safe and effective care. Complexity and misconceptions around accountability have the potential to be significant barriers to the pursuit of changes in practice and patient care.

Organisational and clinical leaders have a key role in applying clinical governance frameworks as a strategy for supporting innovation and change. Adopting this approach will ensure that the patient is placed at the centre of all decisions about care and that clinical governance is seen as a process and not an event. Clinical governance should be integral to the planning, development and implementation of innovation and change between all members of the healthcare team, managers of service and directors.

A Framework for Nursing in General Practice has been produced because practice nursing is a rapidly developing field of nursing practice. Practice nurses are expanding their scope of practice to accommodate the new demands of patients and the public for modern primare care services. The framework sets out a series of standards and supporting good practice guidance for practices to equip them to effectively and safely develop and support their nursing staff in the challenging environment of modern primary care. (Scottish Executive, 2004a)

Professional Regulation

The main purpose of professional regulation is ensuring patient safety. In the case of nursing and midwifery, the Nursing & Midwifery Council ( NMC) meets this requirement by setting and maintaining standards of entry to the profession and of professional conduct following registration, and holding the 'register' of qualified nurses and midwives. Other professional groups have equivalent regulators such as the Health Profession's Council ( HPC) for the Allied Health Professions and the General Medical Council for doctors.

The Code of Professional Conduct

All registered nurses are required to work within the Nursing & Midwifery Council ( NMC) Code of Professional Conduct (2002). This states that:

as a registered nurse or midwife, you are personally accountable 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 shared values of all the United Kingdom health care regulatory bodies.

The Code of Professional Conduct ( NMC, 2002) sets out guidance on clarifying the scope of a nurse's practice. This places a specific requirement on the nurse '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 your professional competence and only undertake practice and accept responsibilities for those activities in which you are competent.'

An employer cannot require a nurse to take on a new role or task if the nurse does not consider him or herself to be competent. To do so would place the nurse in breach of the Code of Professional Conduct and open to a charge of professional misconduct.

The Legal Position on Role Development

Historical perceptions and lack of knowledge around the interface between healthcare and the legal framework that governs practice can be an immense barrier to change. Differing views about what a nurse can or cannot do leads to confusion. Achieving clarity on legal issues pertaining to role development enables individual clinicians and others to recognise the limits of practice within the current legal framework. (DoH, 2003b)

The Expansion of Nursing Roles Nurses who develop their role to include roles/tasks currently undertaken by other healthcare professionals must be aware of the legal boundaries. Within the legal framework they will be judged by two legal standards:

  • The "rule of law" which requires a nurse to act within the law.
  • The "rule of negligence" which requires a nurse who takes on roles/tasks currently undertaken by another healthcare professional to perform that role or task to the same standard of ordinary skill (Bolam). Nurses are expected to have undertaken sufficient training and preparation to ensure that they are competent to perform the role to the required standard.

Prescribing as an Expansion of Role

The potential for role development in nursing has for many years been limited by the lack of nursing authority to prescribe. The recent developments in nurse prescribing therefore offer opportunities which nurses should grasp. This is particularly the case in acute services, where nurse prescribing has not been welcomed with as much enthusiasm as in primary care services.

Prescribing is controlled by various orders and regulations: The Prescription Only Medicines (Human Use) Order 1997, as amended by the Prescription Only Medicines (Human Use) Order Amendment 2002; NHS (Charges for Drugs and Appliances) Amendment Regulations 2002; and the NHS (Pharmaceutical Services) and (General Medical Services) (No 2) Amendment Regulations 2002.

Two forms of independent nurse prescribing are legally identified at present:

  • District Nurse and Health Visitor independent prescribers, following training incorporated into their specialist practitioner programmes, can prescribe from the Nurse Prescribers' Formulary for District Nurses and Health Visitors. This comprises a limited list of medicines and a large number of dressings and appliances relevant to community nursing and health visiting practice.
  • "Extended Formulary" independent nurse prescribers undertake a specific programme of preparation and can prescribe from the Nurse Prescribers' Extended Formulary. This includes all Pharmacy and General Sales List medicines prescribable by GPs on the NHS, together with a list of specified Prescription Only Medicines to treat conditions in four broad therapeutic areas - minor illness, minor injury, health promotion and palliative care. Extended Formulary Nurse Prescribers are now able to prescribe a range of Controlled Drugs, some of which are specifically for palliative care.

Patient Group Directions are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment. It is important that all professionals realise that the majority of clinical care should be provided on an individual, patient-specific basis. Consequently, the supply and administration of medicines under Patient Group Directions should be reserved for those situations where this offers an advantage for patient care, without compromising patient safety, and where it is consistent with appropriate professional relationships and accountability.

Supplementary prescribers prescribe in partnership with a doctor or dentist (the independent prescriber). They are able to prescribe all medicines (with the current exceptions of Controlled Drugs, unlicensed drugs, unless they are part of a clinical trial which has a clinical trial certificate or exemption, and any restrictions set by Schedules 10 and 11 of the NHS (General Medical Services) Regulations). They may prescribe for the full range of medical conditions, provided that they do so under the terms of a patient-specific Clinical Management Plan ( CMP). The Plan should be drawn up, with the patient's agreement, following diagnosis of the patient by the independent prescriber, and following consultation and agreement between the independent and supplementary prescribers.

The Position on Professional Indemnity Insurance and Employers' Liability

The majority of nurses have professional indemnity insurance through membership of a professional organisation or trade union. Cost of legal representation, support and third party damages are covered up to a pre-set limit.

NHS organisations have vicarious liability for all nurses they employ alongside the nurse's own professional accountability to the NMC. Employers need to be aware of changes to a nurse's current role. Role development should be reflected in the post holder's job description requiring agreement between post holder and employer. It is essential that employers ensure that there is a robust understanding of the role in the organisation.

5.
Taking the Next Steps…

Introduction

Scottish policy and wider UK employment reforms are creating a context in which nurses working closely with employers and based on patient or community need, have significant opportunities to develop their current roles and to begin taking steps to build new roles. Ultimately, however, change will continue to be undertaken by individual nurses. In order to move developments forward, it is essential to identify the key steps upon which change will be founded. This section outlines some of these steps.

Preparing Job Descriptions and Participation in Appraisal

Job descriptions All staff should have up to date and accurate job descriptions. All job descriptions and person specifications are being developed with reference to Agenda for Change. This will help to ensure a degree of national consistency between roles, which in turn will assist staff to transfer between roles and between organisations. There was evidence that, at the time of the Consensus event, a number of clinical nurse specialists did not even have a job description. While the implementation of Agenda for Change will deal with this, there is an important principle at stake that this is not a situation which can be tolerated because staff cannot be clear about their roles, responsibilities, and boundaries without a clear job description. It is important that staff should be developing within their role at all times and should be encouraged to plan their development on an ongoing basis. All staff should, therefore, participate in annual appraisal and professional development planning, which again should be dealt with under the auspices of Agenda for Change and the Knowledge and Skills Framework.

Data Collection The Information Services Division ( ISD) has begun collecting workforce information on Clinical Nurse Specialists, which will be produced annually as part of the workforce statistics. This data shows the number of clinical nurse specialists in Scotland in each of the NHS Boards, and allows a degree of transparency which has never been available before. Trends, gaps and areas for development will be identified, which should help role development at regional and local level. ( http://www.isdscotland.org)

Support in the role Staff who have developed their role to specialist level or beyond require support, supervision and continuing professional development to prevent them becoming isolated. Typically, they have a high level of autonomy and responsibility and may be at risk of 'burn out' unless they are adequately supported. They should also be able to take a break from their role, or to move posts without detriment, to allow them to refresh themselves.

ISD's data collection on the workforce may also help clinical nurse specialists to identify others with whom they may set up useful support networks, even if these are virtual given the geographical spread of such staff.

Investment in and Sustainability of New Roles

There has been a tendency in the past for posts not to have been adequately resourced. When considering developing a new role, resources must be available particularly for support with administration, accommodation, furniture and equipment, computers, education, and so forth. The role should also include access to an appropriate budget. This will ensure that decision making can be devolved to the most appropriate level to fix the focus clearly on the best care for the patient and clients.

The sustainability of many new roles has been an issue of concern in the past. While new roles should be reviewed to ensure that they continue to be required, posts should be established with a sufficiently long timescale to allow the post-holder to achieve a level of success before evaluation is carried out. One-year funding of posts is not generally sufficient either to attract good candidates or to allow the post to be established. Succession planning and the viability of single handed services must also be given due consideration.

Some roles should be developed at a Regional level, rather than Board or Divisional level. Regional planning structures should give consideration to the development of roles which support tertiary services or which would have a wide spread of clients with a particular condition. A process needs to be put in place to allow the review of such posts as the need for them arises.

Building on E-Health Opportunities

Consideration should be given to the availability and appropriateness of developments in technology which will assist staff to maximise their skills, provide them with the best support, and allow patient care to be improved as much as possible. This includes development of the electronic patient record, and e-learning, e-library, e-health and e-networks.

Evaluation of New Role Developments

All new roles must have an evaluation strategy built in to assist the process of continuous quality improvement and to ensure that the service fits the patients' needs. This evaluation should be as holistic as possible, incorporating the views of patients and communities. There should also be a dissemination strategy in place to ensure that evidence as it emerges is available to others including potential employers. The implementation of any new role will have implications for the wider system of working, and such posts cannot be considered in isolation. It is important, therefore, to map service provision ( e.g. the role and contribution of other practitioners in the team) when attempting to evaluate the impact of changes in clinical roles (Humphries & Masterson, 2000).

Undertaking Periodic Role Reviews

Roles which have been developed require to be reviewed periodically to ensure they continue to be fit for purpose and changing need. Annual appraisal of post holders will assist in this process, but a more strategic review of developed roles within an organisation, and NHS-wide, may also be helpful. The data collected annually by ISD should also assist in a strategic review of present and future posts. This should include the vital element of succession planning if the role has to continue.

6.
Conclusion

Role development offers huge opportunity to modernise the quality of health services and the health of the people of Scotland. This framework and associated guidance offers a structure for the development of roles whether this involves the expansion of existing roles or the development of new ones. The framework provides the tools to consider the implications for role development within teams rather than in isolation which is sometimes the case at present.

Evidence suggests that resources and sustainability also needs to be covered in some detail as this has been a weakness in the past. The evaluation of role developments also features strongly in this document, and as the body of evidence builds, perhaps cost benefit analysis will be able to be carried out robustly allowing planners to see the benefits of fully funding such developments.

And finally, but of major importance, it is clear that roles must be developed with the patient or community at the centre. When role development is being considered, it is essential to ensure that the role is one which will improve patient care, rather than simply improve the working lives of staff or teams.