The document outlines key issues regarding nursing practice and care of older persons in Wales based on discussions with nurses. It identifies 6 key principles, including that the typical NHS patient is now an older person, and calls for a cultural shift in leadership and a strong community of practice among all nurses caring for older patients. It also stresses the need for adequate and needs-based staffing levels. The document provides a summary of issues raised by nurses, including concerns about staffing levels, skills being deskilled, and a lack of geriatric-focused education and leadership. It calls for greater recognition of the unique role of nursing in caring for older persons outlined in international standards.

1. NURSING PRACTICE AND CARE OF THE
OLDER PERSON IN WALES:
A POSITION STATEMENT
CHAMPIONING FOR REAL CHANGE

2. Welsh Nursing Academy
Academi Nyrsio Cymru
"The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful
death) that they would perform unaided if they had the necessary strength, will or
knowledge. And to do this in such a way as to help the person gain independence as
rapidly as possible." (International Council of Nurses 1960)
KEY POINTS
This statement is based on our discussions with nurses in the NHS and independent sector, as well as
older people, during workshop and other focus group sessions 2010-11. We have attempted to use plain
English and avoid jargon as much as possible. National nursing organisations have already produced
some excellent leadership initiatives. We strongly support these initiatives but we believe that we need to
see more specific action for the older person.
Our six key principles for “Nursing Practice and the Older Person in Wales”, and for all nurses, are listed
below and we offer a summary of the rationale on the following page.
1. The typical NHS patient IS an older person. “Designed for Life” means design for ageing now.
2. We need a strong cultural shift in leadership in nursing practice with the older person now.
3. All Wales, All nurses – we need a strong inclusive and active community of practice.
4. A workforce based on safe staffing levels and a needs-led skill mix is imperative.
5. The Wales Strategy for Older People needs to be alive and embedded in nurse education,
practice and the monitoring and evaluation of practice, as well as management.
6. The public and policy makers in Wales must recognise the ‘unique’ function of the nurse, as set
out above (ICN 1966), must value and use nursing knowledge and skills before these are lost.
This “unique function” is the essence of nursing practice and is especially important for the older
person. This is included in gerontological (ageing) models of nursing. It depends fundamentally upon:
i. Knowledge about the older person as a unique individual, their background and history, their
relationships and their environment; this is what we mean by Relationship-Centred care.
ii. Understanding of the individual’s strengths, needs, wishes and preferences, as derived from a full
assessment guided by a human rights approach; with kindness, compassion, empathy and respect; this
is what we mean by individualised Person-Centred care.
iii. Use of a gerontological model of care which supports the individual’s autonomy and dignity and
includes assessment for personal care as an integral part of health, well being and nursing care;
iv. An individualised care plan (not a task list) developed in partnership with the older person, with
specified care outcomes including the promotion of health and independence, and always monitored.
v. The highest quality personal and clinical care as derived from up-to-date knowledge and skills
supported by strong values, knowledge, evidence and experience.”
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We offer the above description as a Checklist for any older person and any supporter to use as a measure
of contact with, or service from any nurse. We will provide some helpful illustrations of what we mean
by each point in our supporting paper and send to every network of older people to distribute in 2013.
The Older People’s Commissioner said on 20/11/12 about her discussions with older people ‘It is the little
things that really matter’.
We support this further and say that Knowledge on ageing and gerontology practice, Skills,
Partnership and Compassion and Kindness for every older person should be part of every
contact between a nurse and an older person. Kindness and Compassion always.
A Summary of our Rationale
1. The typical NHS patient IS an older person.
Older people now constitute the majority of users of the NHS and social care services (Tadd 2011).
So adult nursing practice – from education, work based training, practice, assessment, to management
and monitoring of how nursing has made a difference, needs to be designed and based on this
premise. (RCN 2005). Make ‘Designed for Life’ a reality for older people and an ageing population.
2. A major shift of thinking, culture and leadership is needed – Now with robust action not just
words. Nursing should take the lead on evidence based gerontology (study of ageing) knowledge and
models of gerontological nursing practice in health and social care environments. The older person
has a right to benefit from this knowledge, and must know about good practice examples around
Wales. It is not just about Dignity, it is about all the other aspects of nursing that make it right.
3. All Wales, All nurses. There should be a strong relationship and regular communication between
nurses working in all environments of care, including housing, with a common focus on
gerontological practice. A Community of Practice based on this interest must develop. We need
leadership activity on the Senses Framework and Relationship Centred Care (Nolan 2006), just as is
used in NHS Scotland (NHS Scotland 2010) and in the My Home Life Cymru programme.
4. A workforce based on safe staffing levels and a needs-led skill mix is imperative but real
leadership and challenge is needed at all levels by clinicians, managers and policy makers to achieve
this. There is strong evidence that more nurses and a higher ratio of nurses to support workers produce
better NHS patient outcomes; therefore adequate staffing numbers and needs-led skill mix are
essential (RCN 2012). The NMC requirement to ‘provide a high standard of practice and care at all
times’ applies to all nurses, from the most junior nurse to the most senior manager.
5. The Wales Strategy for Older People needs to be alive and embedded in nurse education,
practice and management. Wales is unique among the countries of the UK in having a high level
government Strategy for Older People. It is vital that all nursing knowledge, education, research,
practice, management and conversations should be guided by this Strategy, and by the UN Principles
which underpin the work of the Wales Older People Commissioner (also unique to Wales), and the
National Service Framework for Older People. Older people need to see evidence of these principles
in practice in the nursing care and services that we provide and they experience. (NPF 2010).
6. The public and policy makers in Wales must recognise the unique function of the nurse, as set
out in internationally accepted definitions of nursing (ICN 1966), and must value and use
nursing knowledge and skills before these are lost. This “unique function” is the essence of
nursing practice and is especially important in the care of the older person.

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Nurses are very worried about the deprofessionalisation of their knowledge and skills, in particular the re-
definition of personal care, which is the core of nursing practice, as social care, and its separation from
nursing care in the categorisation of care homes. As more older people are supported to stay at home for
much longer, those who do require residential care will be older, frailer, and are likely to have more
specific nursing needs. We are concerned that this separation denies to the frail older person the nursing
knowledge and skills which may be critical to their health and wellbeing.
We offer a clear Checklist on page 1. It builds on the regulator’s guidelines (NMC 2010), RCN
Principles (RCN 2011) but adds the core gerontology principles from sound research already cited in
SSIA Cymru website - (Nolan 2006), and other best practice (BPOP 2010).
A Summary of Our Discussions with Nurses 2010-2012
In our workshops we presented a history of key reports of concern, research on practice and we reminded
our attendees of the key principles and codes already developed. We reflected on 3 key questions using
activities to collate and move information around for discussion. Most of the summary statements below
can be supported by research and practice evidence over the past 7 years, so we include some references.
1. What was good about nurses working with the older person: -
a) Nurses stated generally that they wanted to know about and share good practice. Care home nurses
used Care Forum Wales and the My Home Life Cymru networks. www.agecymru.org.uk/mhlc
b) There were local NHS initiatives by some nurse leaders that refocused everyone on the core values
and implementing into practice, using, for example, the RCN online Dignity Tool, NHS Wales
Dignity information.
c) Nurses who worked in Care Homes felt that nursing care was much more individualised and
relationship centred. They felt that there was much more job satisfaction in what they could achieve in
practice. (MHLC 2011 Nurses Network conference presentation).
2. What nurses said could be done better.
a) Nurses were very concerned about staffing levels (Safe Staffing for Older People’s Wards: An RCN
Toolkit) and skill mix which they strongly felt were not appropriate to NHS hospitals that now
contain a significant majority of patients over the age of 65, and with multiple and complex acute and
chronic conditions. (Tadd W et al 2011)
b) They felt that nurses have been deskilled. One nurse said that ‘we now only provide Task and Finish
nursing’ They said that local nursing assessment documentation (part of the unified assessment
process) overrides the use of specific gerontology nursing approaches to care planning, and focuses
too much on ‘activities of daily living.’ Care plans had been reduced to lists of tasks.
c) They felt that all nurse leaders and Universities need to provide core education and post qualifying
learning relating to ageing and/or working with and nursing the older person. Mentioned were issues
around supporting people with dementia, and specific gerontological nursing practice. (RCN 2005)
d) They felt that there needs to be a stronger recognition that care for the older person is not just patient
centred, or indeed person-centred, but relationship centred. This meant enabling an older person to
feel that they matter, that they are a part of an organised plan; care is consistent and purposeful with
goals to achieve.

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3. What nurses said were the barriers to good practice?
a) Nurses felt that there was still a low value placed on working with the older person even though the
older person was the typical acute NHS patient. (Tadd et al 2007, 2011).
b) Care Home nurses continue to feel excluded from All Wales nursing discussions and leadership. They
also felt that NHS and Care Home gerontological nursing practice development lacked leadership and
felt unsupported by government, regulation and inspection actively. ‘Who do we go to in Wales to
support our development of practice and working with the older person?” The independent sector is
now dealing with this gap – but there still needs to be a sharing of good researched practice.
c) There are stereotypical attitudes and default language used towards the older person in general, in
nursing practice and in medical practice and NHS management. These are just not challenged
appropriately. (NPF 2010, OPC 2011)
d) They still felt that Nursing had little teeth to actually change practice. Comments included “We just
have to go with the flow of the latest flavour of the month.” “There seems to be only action for
change when it is mandatory to do so - or there is an Ombudsman Report.”
e) Care Home nurses felt that the objectives of profit driven care, and inaccurate costing of care,
overrode any development of nursing practice in some care homes. New care home categories now
mean that personal care is separated from nursing care. They felt this discriminated against older
people in particular, as their right to the knowledge and skills that must underpin personal care
elements is eroded if nurses are not involved at assessment, practice or care management.
Background
The Welsh Nursing Academy is an independent nursing association in Wales, is committed to the
development and improvement of services and the care of the older person in Wales. It was set up as a
result of the 1999 Strategic Framework for Nursing, Midwifery and Health Visiting from the National
Assembly for Wales. In 2004 Health Professions Wales was given a remit to facilitate and provide
support to establish the Academy and in 2005 it was launched.
We established some unique Master Classes and in 2010, after a successful public Master Class on “The
Status Quo of Nursing Practice and the Older Person” was presented around Wales during 2008/9 it was
decided to focus for the next two years on this subject area. We would like to thank A Dignified
Revolution for supporting us in this activity around Wales.
This Statement is therefore based on our discussions with nurses in the NHS and the independent sector
of health and social care. Workshops were offered to all Health Boards around Wales and some engaged
with us. We also used My Home Life Cymru care home conferences to collate comments, as well as
sending out our information and questions to networks of nurses in the independent sector.
For each statement in our summary of issues that nurses raised, we provided a research evidence base to
underpin what the nurses were saying from their own experience.
We presented the issues raised by NHS nurses in a public seminar in December 2010. Unfortunately
none of eight Directors of Nursing and none of the Deans of the universities around Wales who provided
pre-registration nurse education attended. However there was interest from some university based nurse
academics and some NHS lead nurses attended as well as some independent sector nurses. We hence feel
that we need to repeat these issues again in this statement.
The time line of reports presented below seems to suggest that the status quo of nursing practice and the
older person seems to have changed very little since the UK report in 2000. This is far too simple a
statement and further work needs to be undertaken with older people as partners in terms of finding out
where good gerontological nursing research into practice exists in Wales, who are the leaders and
innovators for change.

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A Timeline of some of the important reports of concern, guidelines and discussions.
1998 – Dignity on the Ward. Help the Aged UK campaign.
2000 – “Care of Older People: A Nursing Priority”. UK Standing Nursing and Midwifery Committee.
2000 – “Dignity and the Older Europeans’ project” Dr Win Tadd. Cardiff.
2004 - “Beyond Person-Centred Care: a new vision for gerontological nursing.” Nolan M et al, Sheffield.
2004 – 08 “Caring in Partnership.” Nursing Older People Forums’ Strategy. Royal College of Nursing.
2005 – “An Ageing Population: Education/Practice. A resource pack for student nurses. RCN.
2006-8 – Action on Elder Abuse reports in England and Wales.
2008-10 – Patients’ Association Report – “The Lottery of Dignified Care in Wales.”
2008 - A Dignified Revolution is founded in Wales.
2008 and 2010 - Nursing Practice Status Quo and the Older Person in Wales”. WNA Master Class
2008 - Welsh Government funding of My Home Life Cymru 5 year care home project.
2010 - National Partnership Forum for Older People Report – care practice and learning about ageing.
2008-2011 – Welsh Government Dignity programme.
2010 – 2012 Older People Commissioner “Dignified Care: One year on.”
2011 - “The Principles of Nursing Practice” Royal College of Nursing
2011 - “Dignity in practice: an exploration of the care of older people in acute NHS trusts” NIHSR.
2011 - “What the Older Person should expect from Nursing Practice”. NMC/WNA leaflet
2012 – “Safe Staffing for older person :Royal College of Nursing Report, Calculator, recommendations.
2012 – “Call for Mandatory training on Human Rights and Dignity for NHS staff. Ann Clwyd’s NHS
experience –the normalisation of cruelty. http://www.bbc.co.uk/news/uk-wales-20601927
REFERENCE AND RESOURCE LIST
AgeCymru (2012) My Home Life Cymru Programme and Resources. www.agecymru.org.uk/mhlc
Bridges J, Flatley M, Meyer J et al (BPOP) (2011) Best Practice for Older People in Acute Care Settings:
Guidance for Nurses. http://www.staff.city.ac.uk/~rbbc318/bpop/index.htm Free CD, Booklet/Research.
Care Council for Wales (2012) Workforce Development update. Working with People Experiencing
Dementia Report. http://www.ccwales.org.uk/library/?letter=W&page=2
Chief Nursing Officer Wales (2012) Work programmes – current and publications.
http://wales.gov.uk/topics/health/ocmo/professionals/officechiefnursing/groups/?lang=en
Clark J (2012) “The unique function of nursing”. Public lecture UN. Older Persons day. Cardiff. Unpubl.
Dignified Revolution (2008 onwards) – Resources in Wales on Dignity.
http://dignifiedrevolution.org.uk/index.php?option=com_content&view=article&id=932&Itemid=51
Goodrich J and Cornwall J, (2008). ‘Seeing the Person in the Patient: Point of Care Review Paper.
London: King’s Fund. http://www.kingsfund.org.uk/publications
Henderson V (1960) (revised 1969) Basic Principles of Nursing Care. Geneva. Int. Council of Nurses
NHS Scotland (2010) (http://www.jitscotland.org.uk/action-areas/reshaping-care-for-older-people/
Nolan M et al (2006) ‘Beyond Person-Centred Care: a new vision for gerontological nursing.’ Cited in
www.ssiacymru.org.uk/media/.../Beyond_Person_Centred_Care.pdf

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Older People Commissioner (2012) “Dignified Care: One year on.” Also other Reports on Advocacy,
Position Papers. www.olderpeoplewales.com
Patterson M, Nolan M “From Metrics to Meaning: Culture change and quality of acute hospital care for
older people.” http://shef.ac.uk/management/iwp/researchprojects/frommetricstomeaning
RCN (2011) “The Principles of Nursing Practice”
http://www.rcn.org.uk/development/practice/principles/the_principles
RCN (2004-2008) “Caring in Partnership: older people and nursing staff”
www.rcn.org.uk/__data/assets/pdf_file/0004/115474/003195.pdf
Reed J, Clarke C, McFarlane A edited by (2012) “Nursing Older Adults” Open University Press.
RCN (2005) An ageing population: Education and practice preparation for nursing students learning to
work with older people: A resource pack for nursing students. Partnership with Age Concern England.
www.rcn.org.uk/__data/assets/pdf_file/0004/149557/003230.pdf
RCN Publishing (2012) A useful webpage to show the campaigns and attempts to improve practice.
http://nursingstandard.rcnpublishing.co.uk/campaigns
Tadd W et al (2011) “Dignity in practice: an exploration of the care of older people in acute NHS trusts”
found on PANICOA www.panicoa.org.uk
Tadd W et al (2012) Dignity: A Tale of Two Wards.” Found in ‘Dignity in Practice” HSRN/SDO
project. http://www.cardiff.ac.uk/socsi/dignity/dignityinpractice/index.html
Waters A (2005) Nursing the Future: the desired core values of nursing. Nursing Standard 22 april6:vol
19 no30 page 23-28. www.rcnpublishing.co.uk
Welsh Government (2012) Planning for an Ageing Wales. Consultation on Phase 3 of Strategy for Older
People. http://wales.gov.uk/newsroom/olderpeople/2012/6739426/?lang=en
WNA (2011) “What the Older Person should expect from Nursing Practice”. Leaflet given to Older
People Commissioners Office in 2011 which combined 2010/11 RCN and NMC guidance. Please contact
lorraine.morgan@open.ac.uk for an electronic version of the leaflet.
Research undertaken by WNA Council Members - Professor Emeritus Dame June Clark, Dr J Hesketh,
Sue Gregory and Lorraine Morgan.
Paper written and presented to Welsh Government in December 2012 by Lorraine Morgan - President.