14.30 pre registration standards - geraldine walters

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Nursing Standards and Nursing Associate
Standards
CNO Summit 8 March 2018
Professor Geraldine Walters CBE
Director of Education, Standards and Policy Nursing and
Midwifery Council

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Education programme
Communications and engagement
Future Nurse
Proficiencies
Future Midwife
Proficiencies
Standards for
Education
Providers
Quality assurance
of education
Standards for Medicines
management
Prescribing
Standards for learning and
assessment in practice
Nursing Associates

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All part of the same story….
• The Future Nurse proficiency standards
• New Standards for Supervision and Assessment in Practice
• Nursing Associate standards
• Priorities?

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Future Nurse Proficiencies
For publication Spring 2018
Implementation 2019/20

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What was the aim?
(Not just education technicalities. About creating the Nurse of the Future)
• Patient centered care and compassion remains a cornerstone
• Leaders, Accountable, Knowledgeable, Skilled, Compassionate, Flexible, Contemporary,
Politically Aware
• Some post registration knowledge and skills move into the pre-registration phase
• Ambitious - “Top of license” aspiration for all Nurses
• Aim to be future proofed – relevant 2020 - 2030
• Led by Dame Jill Mcleod Clark
• Assisted by an expert reference group

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• Emphasis on production of nurses and midwives who are intelligent critical thinkers, leaders, able
to work safely in a variety of settings (hospital, community, acute physical illness and mental
health) in the future
• Confident and competent in terms of “technical ability”, now
• Council of Deans: Competency based education versus disruptive innovation (ie too much
emphasis on technical competence, not enough on the ability to apply knowledge)
Complex – plus dealing with differing views on what Pre-
registration education should deliver

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Standards for Newly Graduating Registered Nurses
• Seven main ‘outcome statement’ headings
Being an Accountable Professional
Promoting Health
Assessing Needs and Planning Care
Providing and Evaluating Care
Leading Nursing Care and Working in Teams
Improving Safety and Quality of Care
Co-ordinating Care
• Practice Skills and Procedures Annexes
• Communication and relationship management
• Practical skills and procedures

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The Final Standards –Consultation results
• Broadly supportive of direction – nervousness about delivery
• Four fields issues: are the standards too generic?
• Annexes: how applied to the four fields, some skills thought unnecessary
(catheterisation, cannulation, chest auscultation)
• Leadership/Management: wording
• Public Health: Strengthen global health emphasis
• More emphasis on person centered care.

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Standards for Learning and
Assessment in Practice
Mentors, mentorship, time spent with mentors, mentorship programme, registers,
assessment……

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Learning and Assessment in Practice:
What’s the problem?
• Research prior to beginning the work on education identified learning and assessment in
practice as the most vulnerable element of student education
• Frequently an issue in QA
• Issues around variability of mentors and failing to fail
• Difficult to accurately assess the prescribed amount of time spent with the mentor
• Mentor registers – labour intensive to manage
• New models of supervision and assessment in practice are emerging which appear more
successful
• Overly cautious approach to student experiences: not always helpful in developing skills
and confidence at registration

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Aims
• Making the clinical environment a good learning environment is everyone’s business
(Good learning environments and good clinical environments often go together)
• Making the best use of the supervisory and teaching potential of all registrants
• Place more importance on assessment – huge reliance, currently very dispersed
• Removing burdensome process requirements – allow more innovation and creativity
• Better definition of supernumerary status – ie not “in the numbers”, but they should be “in the team”.
• Assure consistency and quality through quality assurance processes – more emphasis and rigour on practice
learning environments

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New model for supporting and assessing
students
Objectives:
• All registrants should be responsible for supervision of students
• Separate the supervision and the assessment roles
• Outcome and not process standards on who, what or how supervisors and
assessors are trained.
• Freedom for organisations to develop their own models to suit local
circumstances, and utilise pre-existing mentorship skills

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Requirements for learning and assessment
• Roles:
• Nominated person to support students in practice
• Practice supervisors: registered healthcare professionals based in
practice, a supervisory, not assessment role (but will feed into the
assessment process)
• Nominated practice assessor
• Nominated academic assessor
• Standards for each role, preparation and support

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Reactions mixed….No rules!
No must do’s?
Risks!
Freedom
Other models
better
Increased placement capacity
Rules didn’t work
anyway
Funding for
Mentorship?

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All about implementation…..
• The new nursing programmes will begin in 2019-2020
• Programme approvals will begin in Autumn this year
• Including approval of new practice supervision and assessment
requirements – are you ready?
• Working in partnership with University
• Who will your assessors be?
• Do clinical areas know about the new arrangements?
• Lots of freedom – could shoehorn current arrangements into the new model
….but this won’t realize the benefits

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Nursing Associates

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• NMC asked to regulate in January 2017 (NB programmes already underway)
• Only England intends to use this role at the current time.
• The role will be generic – i.e. no fields.
• Nursing associate will be a role in its own right and a progression route to graduate
nursing.
• Intention is that the full suite of regulatory functions applies to nursing associates.
Registration, Code and standards, Education Approvals and QA, Revalidation, Fitness
to practise.
Background

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No agreed vision?
• A “bridge” between the unregulated support worker, and the Registered
Nurse
• Hypothesis: some of our current workload and care requirements, require
more assured knowledge and skills than those of an unregulated care
worker, but less than those of a registered nurse
• Increases in care needs of the elderly and frail
• Increase in care requirements in the community to support living at home
• More activities delegated to support workers
• Ad hoc growth in AP roles

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Pros and Cons?
Positives Concerns
Increased confidence in delegating activities to
regulated professionals than unregulated care
workers
Poor understanding of the role leading to
inappropriate delegation
Offers an alternative route to RN qualification,
for those able
Poor acceptance of the role, leading to lack of, or
inappropriate utilisation
Potential to tap into a cohort of people who
would not be attracted by the current support
worker role
Inappropriate substitution of RN by NA
Provides more support to the RN Inappropriate role/scope creep
Complements the development of local
workforce strategies: “growing your own”
Poor local governance

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Regulation: alone won’t resolve concerns
• What we can’t do (as for the RN) :
• Make a statement of what NAs cannot do
• Place limits on the development of individual’s sphere of competence
• State within the proficiency standards, that NAs only work under the
direction of a registered professional

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Our powers:
• The Proficiencies: State minimum threshold of what NAs need to know and
do to join the NA part of the register
• The Code: the conduct and behaviour required of NAs, which includes the
requirement to work within the limits of your competence and raise
concerns if asked to exceed those limits
• What we have done: Derived the NA standards of proficiency from the
Future RN standards, specifically to show the key areas of difference
between the two roles

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The Clear Blue Water……
NA: 6 platforms
•Accountability
•Promoting Health and Preventing Ill Health
•Provide and Monitor care
•Working in Teams
•Improving Safety and Quality
•Contributing to Integrated Care
RN: 7 platforms
•Accountabilty
•Promoting Health and Preventing Ill Health
•Assessing Needs and Planning Care
•Providing and Evaluating Care
•Leading and Managing Nursing Care and working
in teams
•Improving safety and quality of care
•Coordinating care

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Key differences
• No NA proficiencies on primary assessment of patients
• No NA proficiencies on prescribing plans of care, decision making
and goal setting

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Additional areas
• Research knowledge and application
• Critical thinking skills
• Decision making
• Bringing about behaviour change
• Referral
• Restricted aspects of medicines
administration
• Leadership
• Management
• Supervision
• Risk Management
• Evaluation of nursing care
• Discharge
• Health legislation and policy
• Health economics

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Examples
FN “Demonstrate the knowledge and ability to respond proactively and promptly to signs of
deterioration and distress in mental, physical, cognitive and behavioural health and use this
knowledge to make sound clinical decisions”
NA “Demonstrate the ability to recognize when a person’s condition has deviated from their normal
state by undertaking monitoring of their condition (Annexe B). Interpret, respond, share findings and
escalate as needed”
FN “Demonstrate an understanding of how to identify, report and critically reflect on near misses,
critical incidents, major incidents and serious adverse events in order to learn from and influence
future practice”
NA “Understand what constitutes a near miss, critical incident, a major incident, and a serious
adverse event”

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Can they learn to undertake more skills after
registration? Yes
• Some pilot sites disappointed…..
• Minimum standards of proficiency have to apply across all settings
• Some settings may want additional “bespoke” skills for patient benefit
• I/M injections
• Renal dialysis??
• But: local governance around quality of training and assessment of competence
and safety will need to be assured

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Not a panacea
• Can work independently within the scope of the regulated proficiencies,
and potentially other activities in which they have been trained and
demonstrated to be competent following well governed local programmes.
• If you want skills that are much narrower, deeper and more bespoke…..….
• If you want broader knowledge, more skills and more autonomy….…..

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Safe implementation
Professional
regulation
System
regulation
National
guidance
Sound local
decision
making

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Summary
• Future Nurse Standards have an ambition for all nurses to be
working at the “top of their licence” - for patient benefit
• New standards for practice learning allow more innovation and
creativity to create better learning environments – benefits can be
realised by fully utilising the freedom the new standards allow
• The Nursing Associate role is potentially complimentary to the
aspirations of the “Future Nurse” – regulation is a start

14.30 pre registration standards - geraldine walters

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