Imperial College Healthcare Trust has narrowed down the titles of its nurses, midwives and support staff to clarify roles and responsibilities. This article comes with a handout for a journal club discussion
When reading the job title on a nurse’s name badge, colleagues are often unclear about that nurse’s role, experience, seniority, education level and competence. This article describes a project conducted at Imperial College Healthcare Trust, London, to narrow down and simplify the titles used for its nurses, midwives and support staff.
Citation: Grundy-Bowers M et al (2018) Harmonising nursing and midwifery titles in an acute hospital. Nursing Times [online]; 114: 1, 36-39.
Authors: Matthew Grundy-Bowers is consultant nurse (HIV and sexual health); Scott O’Brien is head of children’s services; Victoria Harmer is Macmillan consultant nurse (breast); all at Imperial College Healthcare Trust, London.
Hospital badges have several purposes but their key role is to state the bearer’s name and professional status. In nursing and midwifery there is a plethora of job titles appearing on people’s badges (Leary et al, 2017; Lowe et al, 2012; Donald et al, 2010; Grundy-Bowers, 2006). These titles are used to communicate – and imply – many things including education, seniority, role, specialty and skill set. However, their sheer number results in ambiguous role expectations and an unclear scope of practice; it contributes to “turf protection” (Donald et al, 2010) and, in conjunction with a lack of consistency in the use of titles, confuses both patients and colleagues (Leary et al, 2017; Ormond-Walshe and Newham, 2001).
The job titles of nurses, midwives and support staff at Imperial College Healthcare Trust (ICHT) have been narrowed down, simplified and clarified after a year-long, trust-wide project consulting staff and patients. This article describes the project.
Lack of clarity
When looking at a nurse’s job title, it is not uncommon that colleagues – including those within the profession – do not know what to expect regarding the nurse’s seniority, experience and competence. Two nurses who are employed by the same organisation and perform similar roles – or even the same role – may have different titles. Conversely, there could be two nurses who have the same job title but completely different skill sets, who perform different roles or are employed on different pay bands.
This is not an uncommon issue in contemporary healthcare and has been noted recently by Leary et al (2017). They reviewed 17,960 specialist nurse posts and identified 595 different titles, which leads to “confusion among the public, employers and those commissioning services”.
While research from the Royal College of Nursing found almost 50 different job titles in use for specialist nurses working in the field of urological cancers alone, it also found that the inconsistency in titles was linked to an ambiguity regarding requirements and duties (Royal College of Nursing, 2015). Another group of staff in which there are large variations in titles is support staff, such as healthcare assistants, support workers and clinical technicians (Cavendish, 2013).
This lack of clarity undoubtedly has a negative impact on our professional identity (Reveley, 1999) yet, despite calls for a reduction and standardisation of titles in nursing (Leary et al, 2017; Commission on the Future of Nursing and Midwifery in England, 2010), this thorny issue persists. Indeed, Professor Leary’s article led to a circular (07201) on 7 September 2017 from the Chief Nursing Officer for England suggesting nurse directors should:
- Ensure all staff titles recognised as delivering nursing or midwifery care clearly reflect their registered or regulated status;
- Consider whether the word “nurse” is appropriate if used;
- Ensure the correct processes are in place regarding how such roles are advertised in relation to identifying their registered/regulated status, aligned qualifications and the boundaries of their roles (Nursing Times News Desk, 2017).
Tackling the issue locally
In December 2015, Janice Sigsworth, nurse director at ICHT, commissioned a project to assess and address the issue locally around nursing and midwifery titles. The project was undertaken as part of a trust leadership programme and drew wide support across senior teams, from nursing and midwifery to wider management. Its aim was to harmonise the titles used for nurses, midwives and support staff by:
- Reducing their number;
- Simplifying them and making them clear and gender neutral;
- Standardising their use.
ICHT has 4,333 individual posts for registered nurses and midwives, and 1,088 individual posts for unregistered staff, so the scale of the problem was potentially huge. A search of the address book on the trust’s email system identified 91 different nursing titles, but this was thought to be an underestimation. A further examination of the email list, focusing on clinical nurse specialists, identified 226 different titles in use for nurse specialists and practitioners.
During the engagement process (detailed below), it was identified that there were:
- 11 different titles to describe 15 nurse or midwife educators;
- 46 different titles to describe 74 senior nurses;
- 10 different titles to describe 65 support staff;
- Nine different titles to describe 11 members of the senior midwifery team.
From December 2015 to February 2016, a series of engagement events were held across the organisation to reach as many stakeholders as possible. Targeted groups included:
- Nursing and midwifery staff – two staff surveys were sent out: the first one was sent to nurse/midwife specialists and the second was open to all nursing and midwifery staff;
- Senior nurses and midwives – two “back-to-the-floor” Friday sessions were held so that senior nurses/midwives from across the organisation could meet to discuss pertinent issues;
- Patients – these could make use of the ICHT patient communication group;
- Senior human resources team;
- All trust staff – the partnership committee;
- Healthcare support workers at their annual conference;
- The nurse education team;
- Nurse specialists and nurse practitioners – a dedicated meeting was held;
- Department nurse and midwife leads – a professional practice committee workshop was conducted.
At all of these events there was broad support for the harmonisation of titles. Reaching a consensus on the titles to feature in the final list, however, drew much debate.
The patients present at the patient communication group meeting unanimously reported that this was an area well worth tackling.
Outcomes of engagement activities
Endorsement from staff survey
The divisional nurse directors sent the second survey to their teams via email.
A total of 138 staff responded: 85% were registered nurses or midwives, 5% were unregistered support staff and the remainder were from other staff groups. The majority of respondents were in broad agreement that:
- We should attempt to reduce the number of nursing and midwifery titles in use (85%);
- Titles should be gender neutral (80%);
- Specialist titles should be simplified to ‘nurse specialist’ or ‘nurse practitioner’.
Furthermore, 60% of respondents endorsed the suggested list of titles developed from engagement events and various searches, considering them “clear” and “appropriate”. In total, 35% of respondents had comments or suggestions but did not specifically endorse or oppose the list, with some thinking the proposed titles should be more nuanced. Only 5% of respondents disagreed with the list.
From the outset it was felt that it was important to have gender-neutral titles to clearly show that nurse and midwife roles are open to all. Most staff supported the use of gender-neutral titles but continued to feel attached to historical titles such as “sister” and “matron”.
Support staff titles
Most support staff preferred the titles “nursing assistant” and “midwifery assistant”, while the midwifery team preferred “midwifery support worker” (which was already in use). However, it was felt that “nursing assistant” was too similar to the title for the new nursing associate role, so the senior nursing team thought it more appropriate to use “healthcare assistant” to avoid confusion.
Specialist and practitioner titles
There was a desire to have a single unifying title for nurse specialists and nurse practitioners; “specialist nurse in advanced practice” – as outlined by Read (2015) – was suggested but deemed inappropriate because it was too wordy. Furthermore, the nurse specialists and practitioners at the trust thought that, due to their professional identities within their teams, they were not currently in a position to unify titles; however, they were keen to revisit this at a later date.
There were tensions around how best to describe band 6 nurse specialist or practitioner posts. Many felt there should be a distinction between band 6 and higher bands, but there was little consensus on how to achieve this. Some felt that the term “trainee” would be appropriate, as these posts are often developmental ones for those progressing to become specialist or practitioner. However, some posts, are not developmental and some postholders do not desire progression; as such, “junior” was suggested instead – although many felt this was also inappropriate. The consensus of the senior nursing and midwifery team was that band 6 posts could be nurse specialist or nurse practitioner, and that for some “trainee” would be appropriate.
One of the largest areas of contention was the use of the words “clinical” or “advanced” for nurse specialists and nurse practitioners. Many felt passionately about these being included in their titles. For some, this was because “advanced” was associated with education at Master’s level; for others, it was about “clinical” featuring in national guidelines.
Concerns were raised by clinical educators that some members of their team were allied health professionals and so could not have “nurse” or “midwife” in their title. It was agreed that “clinical” would be used for these education posts instead.
The new titles
The existing myriad titles was reduced to a core list of 12 titles (Table 1), supplemented with prefixes, along with suffixes in brackets indicating division, department or area of specialty if needed. There was broad agreement to restrict the prefixes used to a defined list (Table 2). The principles that were followed when determining the new titles are listed in Box 1.
Communication and a mapping exercise took place with senior nurses and midwives in each of the trust’s divisions, so they could identify and report issues they expected to encounter when adjusting the titles of nurses and midwives within their care. This exercise did not highlight any major issues.
Box 1. Principles governing the new titles
- Fewer titles
- Clear, unambiguous and easy to understand
- Gender neutral
- Approved list of prefixes
- Titles to include details of division, department or specialty at the end in brackets if needed
- Titles to include the word “nurse”, “midwife”, “nursing” or “midwifery” when possible
- Extra details incorporated in job description when possible
- How an individual presents themselves within the trust may differ from how they present themselves outside of it
- Title configuration to be: prefix (if needed)/core title/(division, department or specialty) (if needed)
The project team worked with human resources and other departments – such as security, which issues name badges – to ensure a smooth implementation and embedding of the initiative. The security department and the external company printing the name badges knew they were to limit people’s options to the agreed list.
The project and communication teams developed initiatives to ensure that patients, staff and colleagues are aware of the changes, including:
- Leaflets and posters for patients and clinical areas to explain what to expect from each staff group;
- An update on the project at the monthly chief executive briefings;
- A screensaver for staff computers to inform them about the project.
The project team had received a grant from Imperial Health Charity to support implementation across the organisation. The money covered the cost of replacing security and identification badges, and producing the information leaflets and awareness campaign targeted at trust staff and patients.
It was decided that the document of work should be turned into a trust policy to embed it into clinical practice and the trust’s wider environment. Work is ongoing to finalise this trust policy – finalisation of it was postponed so the national announcement from Health Education England (2017) regarding advanced practice could be incorporated.
This work has allowed us to narrow down the number of nursing and midwifery titles across ICHT to reduce confusion among patients and health professionals. We hope it sets a precedent for others and will result in more clarity in the roles and responsibilities of the nursing and midwifery workforce.
- A large number of different job titles are used for nurses and midwives
- The number of titles and lack of consistency in their use confuse patients and staff
- Many different titles results in ambiguous role expectations and the scope of practice being unclear
- Confusion around titles has a negative impact on the professional identity of nurses and midwives
Commission on the Future of Nursing and Midwifery in England (2010) Front Line Care: Report by the Prime Minister’s Commission on the Future of Nursing and Midwifery in England – 2010.
Donald F et al (2010) Clinical nurse specialists and nurse practitioners: title confusion and lack of role clarity. Nursing Leadership; 23: 189-201.
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Health Education England (2017) Multi-Professional Framework for Advanced Clinical Practice in England.
Leary A et al (2017) Variation in job titles within the nursing workforce. Journal of Clinical Nursing; 26: 23-24, 4945-4950.
Lowe G et al (2012) Time to clarify – the value of advanced practice nursing roles in health care. Journal of Advanced Nursing; 68: 3, 677-685.
Nursing Times News Desk (2017) Nursing directors encouraged to check unqualified staff are not working under ‘nurse’ titles. Nursing Times; 19 September. Bit.ly/NTNDNursetitles
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Reveley S (1999) The professional and legal framework for the nurse practitioner. In: Walsh M et al (eds) Nurse Practitioners: Clinical Skills and Professional Issues. Oxford: Butterworth-Heinemann.
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