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A total health economy approach to revalidation

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With a range of healthcare providers, the Bailiwick of Guernsey developed a revalidation support system and training for all staff to ensure consistent implementation

Abstract

Revalidation has been a source of anxiety and uncertainty for some nurses and midwives. With a mixed health economy including private and public sector organisations, the Bailiwick of Guernsey wanted to ensure the system was implemented consistently. A programme of training was developed to help staff through the revalidation process and link the Nursing and Midwifery Council’s Code of Conduct to practice. Training and support was also provided for confirmers. 

Citation: Falla J et al (2016) A total health economy approach to revalidation. Nursing Times; 112: 27/28, 15-17.

Authors: Julie Falla is revalidation and practice development lead; Elaine Burgess is assistant director; Tracey McClean, is head of institute, all at the Institute of Health and Social Care studies, Guernsey.

Introduction

Revalidation for nurses and midwives was introduced to protect the public, increase public confidence in nurses and midwives, and enable those on the register to verify that they meet the professional standards required of them (Nursing and Midwifery Council, 2015a). Its implementation has raised questions and anxieties for many registered nurses and midwives who are concerned about the processes and revalidation requirements. However, those in the Bailiwick of Guernsey (which includes the islands of Guernsey, Alderney, Herm and Sark) have risen to the challenge and are leading the way with an intensive programme of activity to prepare them for revalidation.

Guernsey is the second-largest Channel Island. It is located 70 miles south of the UK and 30 miles away from the French coast, and has a population of 63,000. Although self-governing with its own legislative framework, it is a Crown dependency of the UK. The Health and Social Services Department is currently the bailiwick’s largest government department and employs over 1,000 nurses and midwives.

Guernsey’s health and social care system is a complex infrastructure of private and public-sector organisations, which could have made the introduction of revalidation complex and inconsistent. It was decided, therefore, to adopt the same approach to the process across the whole bailiwick to reduce inefficiencies and inconsistencies. This approach also provided an opportunity to bring all nurses and midwives together as “one family”, resulting in a more collegiate approach.

The journey began with the appointment of a revalidation lead in August 2015; this proved to be a major contributing factor to the successful implementation of revalidation in the bailiwick. An external consultant:

  • Provided guidance and support;
  • Became the interface with the NMC;
  • Helped to develop an action plan.

The plan was monitored and the group’s work prioritised using a traffic-light system, with actions classified as red, amber or green to indicate progress or blue to indicate completion.

Development of a working group

A revalidation working group was set up, which included representation from all healthcare providers across the bailiwick.  The group consisted of 30-40 staff drawn from the front line through to chief-nurse level. There was representation from across the organisation including:

  • Practice development leads;
  • Specialist nurses;
  • Lecturers;
  • Mediators;
  • Revalidation champions.

The group’s work was taking place during the pilot phase of revalidation, when few healthcare providers in the UK were engaging in the process. This gave Guernsey’s nurses and midwives the opportunity to influence an initiative that would affect all registrants in the UK.  The validation lead linked in with three pilot sites to gain further insight into how revalidation could be implemented.  

Working group meetings were used to plan implementation of revalidation, and provided a means of communicating progress to as many registrants as possible. The attendance of senior nurse and midwife leaders at group meetings and training sessions highlighted the importance of revalidation to all staff – their input in the development of training sessions and support for staff attendance was invaluable.

Training and education

A key factor in the success of our initiative was developing a programme of educational sessions for all nurses and midwives across the bailiwick. This approach highlighted the importance of complying with the process and equipped staff with the necessary tools to meet their revalidation requirements, making them more likely to embrace the concept.

Three waves of training sessions were held in a number of locations:

  • First wave: basic IT skills – this was an anxiety highlighted by some registrants who were not IT literate;
  • Second wave: the concept and requirements of revalidation and portfolio development. These sessions included the key tenets of the revised NMC Code, as revalidation is centred on registrants demonstrating how they uphold the Code and “act out” these tenets in practice;
  • Third wave: training for confirmers, with an additional session for a small group of confirmers who would also be moderators. This moderator role was identified as an important third party to become involved in situations where there were some questions related to evidence presented to a confirmer, or any other issues related to the revalidation process.

After completing training, all attendees provided feedback on the sessions through a closed-response questionnaire. The results (Fig 1) were particularly interesting on the inclusion of the NMC Code in the sessions; it was apparent that few staff were familiar with the Code and further sessions were needed to support them in applying it to their practice.

Although the training sessions were successful, there were times when staff could not be released to attend due to the ongoing issue of staff shortages and increased service demands. However, we achieved over 50% attendance for the portfolio training and over 75% for the confirmer training, while over 100 registrants attended one-to-one sessions for support in areas of their choice. Separate duty of candour training ran alongside these sessions, as this had been recognised as a need from the organisation and registrants’ feedback.

Revalidation champions

Effective communication was crucial to the successful implementation of revalidation. We were working to the NMC’s proposed model but this was likely to change in response to the outcomes of the national pilot, and local implementation could also change in response to initial experiences; these changes would need to be communicated to all registrants in the bailiwick. We decided that each clinical area should have a revalidation champion, who would be the main point of contact for people who had questions about the process.

Revalidation champions were either self-nominated or put forward for the role by their line manager, and attended monthly meetings with the revalidation lead to discuss current issues related to the process. They were also responsible for collating the revalidation dates and named confirmers of staff in their area. This information was held centrally on a database with an alert function to highlight registrants approaching their revalidation date.

The champions and other frontline staff also developed “revalidation boards” within their respective clinical areas. These information boards aimed to raise the profile of the NMC Code and how it links to revalidation and professional practice. The intention was to adopt a normative re-educative  approach to change by inculcating the professional values of the code within daily practice.

The revalidation boards were also a way to educate the public and service users about the role and function of the NMC and the standards of professional practice they can expect from nurses and midwives. This aimed to reassure the public that local registrants behave in a professional manner and adhere to the Code. The boards provide an opportunity to invite questions from patients and members of the multidisciplinary team, and make it easy for registrants to engage with patients to ask for feedback about their professional practice – another element of the revalidation process.

Reflective practice

Revalidation requires registrants to engage in facilitated reflective practice. While the Health and Social Services Department had a policy supporting the concept of supervision, its implementation was inconsistent. We decided to review this policy and rename it so the terminology was consistent with revalidation. The policy provided guidance as to how and when staff could engage in facilitated reflection, especially with respect to sessions that provided an opportunity for participatory learning. Revalidation requires registrants to undertake 20 hours’ participatory learning in each three-year registration period, and this component of the system had caused some anxiety and confusion.

Embedding the Code

The Code is a set of principles that should underpin the practice of all nurses and midwives, and remind them of their professional responsibilities. We provided training sessions on the revised Code when it became effective in March 2015 but attendance was poor, which may account for the lack of awareness of the Code during the revalidation training sessions later in the year. It was evident that staff needed more guidance on how the Code links with their practice. This inspired a number of creative initiatives across the service.

One area developed a quiz around the key components of the Code, while another used patient handover as an opportunity to consider how registrants’ experiences during the previous shift linked to the Code. For example, they reflected on how staff were able to identify a patient whose condition was deteriorating, then linked this to the “practise effectively” and “preserve safety” components of the Code. In addition, senior nursing and midwifery team meetings are used to discuss issues across the healthcare context and how these relate to the Code – for example, attendees were provided with teaching sessions on the new duty of candour policy, then discussed how this would be used in practice and how the group reflection could be used as evidence for revalidation.

Educationalists and trainers have also been involved in linking learning outcomes to the Code. On completing training sessions staff are helped to reflect on their learning and how it links to the Code and professional practice. Many have commented on how this informal approached has reduced their anxiety about revalidation. The requirements of the Code have also been used to identify specific training needs – for example, use of social media and protecting patient confidentiality have been included in education sessions.

The mediation process

During the preparation sessions, staff identified as confirmers voiced some concerns about being responsible for signing off staff as being fit to revalidate. There was a general feeling that they required additional support. With the help of the external consultant, the role of the mediator was developed as a point of contact for confirmers experiencing problems with the process. Mediators were selected from the group of confirmers.

The mediator is defined as: “a senior nurse or midwife with substantial experience of appraisal, mentoring, reflection and goal setting. The mediator demonstrates and role models excellence in leadership and professional practice through the NMC Code”.

Confirmers can approach a mediator if they need help, want to escalate concerns, discuss approaches to managing performance or feel a nurse or midwife is failing to engage in the revalidation process. Mediators can also be used as a confidential sounding board, as the role is separate from the formal leadership structure; however, major concerns or potential NMC referrals must always be escalated via the chief nurse.

The main purpose of the mediator role is to provide support, but it also helps ensure implementation of the revalidation process and evaluation of revalidation evidence is consistent across the bailiwick. There are plans for mediators to meet on a quarterly basis to discuss specific issues arising from confirmers. The mediation process has been used approximately six times to date to support confirmers while ensuring fairness and integrity with the process.

Reflecting back and forward

As the date for revalidation to go live approached, extra training sessions were offered, specifically aimed at staff due to revalidate between April and June. These:

  • Focused on putting together portfolios;
  • Allowed participants to experience a mock confirmation session;
  • Provided assistance with the online revalidation application;
  • Gave time for questions and answers.

The sessions, delivered by the revalidation lead, will be repeated every three months for as long as necessary. They have attracted registrants from a diverse range of settings, resulting in staff ‘buddying up’ with others facing the challenge of revalidation. This form of support has been a valuable mechanism for staff to share their experiences and ideas on constructing portfolios.

A revalidation policy has also been developed, demonstrating the organisation’s commitment to supporting staff so they can successfully complete the process. It also cross-references other related policies with which registrants need to be familiar as they prepare for revalidation, such as the duty of candour policy.

In the initial stage of our work information from the NMC was limited so we developed supporting documents, including:

  • Advice on putting together a revalidation portfolio;
  • Confirmer guides;
  • Pro formas to document reflections, learning activities and practice hours.

We also created revalidation promotional materials, including mugs and mouse mats, which helped to promote professional discussion on the system, as well as a badge for registrants who have successfully revalidated (Fig 2); this demonstrates that the organisation and NMC have confidence in the wearer. Wearers of the badges can be identified by other staff as a point of contact as someone who has successfully “been through it”.

Conclusion

Developing the revalidation system has been exciting for our nurses and midwives; several have now revalidated. The success of this initative has been due to early support from senior leaders, resourcing a revalidation lead role, investing in an external consultant and the commitment of the bailiwick’s registrants to rise to this challenge.

Key points

  • Revalidation has caused anxiety among some nurses and midwives
  • Training across a mixed health economy can ensure nurses and midwives engage with the process in a consistent manner  
  • Training can also help to clarify how the Nursing and Midwifery Council’s Code relates to daily practice and the revalidation process
  • Confirmers benefit from training to make sure revalidation evidence is assessed consistently
  • Revalidation mediators can support confirmers if they have specific questions about revalidation or the process in general
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Readers' comments (1)

  • A highly commendable and fascinating initiative deserving congratulations. This is what happens when sensible people can see the relevance of what lies ahead and do something tangible about it. Registrants in Guernsey are fortunate to have this level of real support through the revalidation process. Most of the rest of the rest of us are own our own with minimal/zero support from our employers.

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