VOL: 98, ISSUE: 41, PAGE NO: 38
Julie Burgess, MSc, RN, DipN, is director of nursing, Frenchay Hospital, BristolThe NHS is focused on achieving the government's modernisation agenda, as laid out in The NHS Plan. The success of the strategy depends partly on the development of an appropriately trained and educated clinical workforce, particularly on the development of nurses and midwives.
The NHS is focused on achieving the government's modernisation agenda, as laid out in The NHS Plan. The success of the strategy depends partly on the development of an appropriately trained and educated clinical workforce, particularly on the development of nurses and midwives.
The nursing and midwifery professional development pathway at North Bristol NHS Trust was designed as a way of meeting the career needs of nurses and midwives, meeting service delivery needs, and closing the gap between education and practice. It provides a pathway for all grades, from newly qualified nurses through to chairs in nursing or midwifery and caters for careers in clinical, education, research and management sectors.
The pathway reflects current government policy on recruitment and retention and the review of workforce planning (Department of Health, 2000). It will also be easy to transfer to the new pay scheme arrangements currently being developed (Department of Health, 1999) because it will clarify the competencies and level of performance required for each grade.
It is suggested that the pathway could contribute to the development of clinical academies and the NHS University. This may be facilitated through the creation of an academic structure within nursing, not dissimilar to a medical deanery. In this way, nurses and midwives could be more proactive in their pursuit of continuous professional development and academic involvement.
At present there do not appear to be any established models that support nursing deaneries and link them into the NHS University, although North Bristol NHS Trust is in discussions with other interested parties to consider how this could be achieved.
The inspiration for the pathway came from the publication of the Department of Health document A Health Service of all the Talents (Department of Health, 2000). The pathway is not dissimilar to the junior doctors' training scheme in which specific clinical experiences/rotations are linked to academic training.
This principle has been lifted and applied to the nursing and midwifery pathway, where nurses and midwives identify their preferred career path and then work towards achieving it through planned clinical rotations supported by academic training. The approach for nurses and midwives differs from the junior doctors' scheme in that posts are not restricted in number. This pathway is a more structured approach to the professional development of nurses and midwives and is being attempted on a scale that it does not appear to have been tried previously. Although it has been designed primarily to meet the needs of nurses and midwives, it is suggested that it could be extended to other clinical professions in the NHS and beyond.
The pathway has five distinct sections:
- Stage one is an 18-month programme for newly qualified nurses and midwives (D grades);
- Stage two is an 18-month programme for experienced nurses and midwives (E grades);
- Stage three is a two-year programme for senior staff nurses and junior sisters (F grades);
- Stage four is a five-year programme for ward managers and above (G grades);
- Stage five is a three to five-year programme for nurse consultants and other senior posts.
Progress to date
Pilot funding for three years was provided by the South West Regional Office of the NHS. This funding paid for a clinical tutor to be appointed to run the pathway, plus a personal assistant to provide administrative support. The University of the West of England in Bristol provided the services of the clinical dean free of charge to support the pilot.
It was agreed that the scheme would be piloted within the medical directorate of the North Bristol NHS Trust. This directorate consists of 600 beds spread across three sites and employs around 700 nurses. It has experienced some recruitment difficulties, particularly with D and E-grade posts.
The pilot commenced in September 2001 and 50 nurses have started on the pathway to date, 30 of whom were external recruits. All 50 of these nurses are working in the medical directorate.
Since the pilot began a number of other clinical directorates, plus outside organisations, have expressed interest in the pathway and a number have asked for details of how to set up their own schemes. The trust is now rolling out the programme to other directorates.
Meeting the needs of nurses and midwives
Each stage of the pathway has specific clinical rotations built into it. For example, a full-time D or E grade undertakes three six-month placements with associated clinical and educational learning outcomes. For the more senior posts, such as nurse/midwife consultants, the emphasis is on academic achievement linked to practice in the workplace.
These posts do not rotate as a matter of routine. The different stages of the scheme are therefore shaped around the individual nurse or midwife's specific clinical and learning needs at different stages of his or her career. The duration of the pathway is lengthened for part-time workers as appropriate.
The rotations are based on moving nurses and midwives into existing vacancies that they have applied for as part of their career development. Therefore, the rotations are planned in advance so that service managers know what staff they have starting and finishing at specific points in time and can appoint staff on a substantive basis. The nurses and midwives are accountable to the ward manager or senior nurse for the area they are working in, in the same way as all other staff on the ward.
For the D, E and G grades there has been general acceptance that rotation is the way forward. However, it is interesting to note that some of the F-grade applicants are uncomfortable about moving from their work base. As a result other options are being considered, for example, time-limited role swaps.
Clinical practice is assessed on a competency basis. There are seven core units of competency: communication; drug administration; clinical governance and risk; clinical equipment; discharge planning; health education and teaching practice; and management. An eighth supporting unit of core competencies is being developed to support the research and IT elements of the pathway.
As part of the programme each nurse is expected to undertake a minimum number of hours of clinical supervision. This is seen as essential to developing practice. Existing mentors for clinical practice are used throughout the programme and need no further training.
Educational and academic outcomes
Essentially, the pathway links the nurse or midwife's clinical experiences with measurable educational and academic outcomes to assist them along their proposed career pathway. It focuses on building flexibility and transferability of skills through the integration of theory, practice and management. For example, the nurse/midwife can build on the clinical competencies associated with communication by underpinning these with reflective practice techniques or workplace learning modules, for which there is academic accreditation from the University of the West of England.
Finally, the scheme is flexible in that it can be undertaken on a full-time or part-time basis and nurses/midwives can step on and off the pathway at various points. By its very design, the scheme encourages succession planning, as opportunities for 'acting up' and alternative workplace experiences are offered as part of the pathway.
Meeting service delivery needs
The nursing and midwifery professional development pathway meets the service requirements of the organisation. It also meets the requirements of the nurse/midwife. Although it is still in pilot stage, the pathway is already proving to be a useful recruitment tool for the trust and has been well-received by newly qualified nurses. A number of clinical directorates have now adopted the programme.
Before the scheme was developed the trust was already recruiting around 50% of nursing students graduating from the University of the West of England. The pathway is seen as ann attractive opportunity by the students and the trust has already appointed a number of students at least four months before they formally graduate. The majority of these students want to start the pathway. Interestingly, the number of new students requesting to come to the north Bristol zone is also increasing.
As the programme extends to a wider range of nurses and midwives, specific clinical competencies are being developed. Areas that have specific recruitment difficulties are now included in the rotation with the aim of showing nurses and midwives the opportunities these areas can provide and encouraging clinical environments to provide suitable learning environments to aid recruitment. In this way the pathway provides the opportunity for the organisation to aspire to high standards of practice and education in all of its clinical areas, which will have a positive impact on patient care.
The trust took the opportunity to agree the competencies jointly with the University of the West of England. This has enabled the university to encapsulate these competencies in accredited work-based learning packages based on existing models, for example, Hunt (2000). The university's vision for developing work-based learning follows a multiprofessional, multidisciplinary approach and it is thought that the work-based learning associated with the pathway will complement this vision.
The competencies provide the organisation with a measure of the quality of clinical care provided by staff that can be audited. Consequently the minimum standard required for each clinical skill can be raised, potentially raising the standard of care across the trust.
The competencies have been viewed with interest by nurses, midwives and managers across the organisation and there has now been a request to use them as core competencies for the trust. This work is being developed and it is likely that the core competencies will be published within six months.
Closing the gap between education and practice
The pathway has provided a new focus for work between the trust and a university that transcends the gap between education and practice. The University of the West of England has been closely involved with the development of the pathway since its inception. It is actively developing its programmes and can demonstrate how accredited work-based learning, developed alongside clinical competency, provides the platform for career development that is underpinned by academic achievement.
In stages three, four and five of the pathway the links between the university and the trust become even closer. The aim is to enhance the quality of education in both practice and university settings using the pathway as the vehicle. This will further enhance the opportunity for collaborative working between the university and the trust through joint research projects; further development of evidence-based practice guidelines; and opportunities for joint appointments.
The pathway has been well evaluated to date by those within the medical directorate. Although the formal evaluation has not yet taken place, informal feedback is positive. The staff within the directorate have been very keen to become involved in planning and implementing the pathway. Indeed the development of the competency framework was undertaken by one of the senior nurses in medicine who, basing her work on Fearon's model (Fearon, 1998), developed the core competencies for the pathway.
There have also been positive press reviews and television coverage of nurses involved in the pathway. One article (Duffin, 2001) discusses the pathway as an example of progress on the skills escalator. The Department of Health is also interested in the pathway and The Commission for Health Improvement commended the programme when it undertook its recent inspection of North Bristol NHS Trust (CHI, 2002).
A research proposal has now been drawn up in conjunction with the University of the West of England to undertake a longitudinal evaluation of the professional development pathway. The research study will address the following issues:
- The impact on recruitment and retention within the medical directorate of North Bristol NHS Trust;
- Whether the pathway met staff's needs and how to guide the development of the pathway in the future;
- The impact of the professional development pathway on clinical care.
The original concept of the professional development pathway was to develop flexible career pathways for nurses and midwives, while reducing the gap between education and practice. A number of other benefits have emerged since its establishment.
The pathway has ensured that the relationship between the University of the West of England and the North Bristol NHS Trust has become closer. The formation of links between the pathway and accredited work-based learning packages is exciting and has far greater potential than was originally considered when the pathway was conceived.
There is the potential to develop the pathway across other staff groups and across the NHS. The potential to raise clinical and educational standards is promising and should be exploited fully.
On the less positive side, one potential hurdle is the growing discomfort that senior nurses, particularly F-grade nurses, have with rotating out of their clinical area. This is being reviewed.
The application of the pathway in one trust has indicated that it has the potential to revolutionise service delivery and the career pathways of nurses and midwives, while closing the gap between education and practice. The pathway also helps the trust to meet some of the requirements of The NHS Plan.