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Exclusive: Court case over care home payments 'reveals urgent need to define nursing'


A court case involving a dispute over care home payments between local councils and the NHS has exposed a serious lack of understanding about the definition of nursing, which must be tackled urgently, a leading nurse has told Nursing Times.

Dame June Clark, former president of the Royal College of Nursing who is now retired, said the four-year case, which was brought to an end earlier this month, had shown NHS health boards in Wales wrongly believed personal care was not a part of nursing.

“[If we] allow basic nursing care to be taken out of the concept of nursing… we diminish our whole underpinning of the role”

June Clark

She warned that if the profession allowed the “concept of basic nursing care to be taken out of the concept of nursing… we diminish our whole underpinning of the role”.

Dame June told Nursing Times the lack of a clear definition needed to be addressed immediately by the nursing profession – and in particular by the RCN, which had a duty to do so – to ensure nursing was not reduced to a series of tasks.

Otherwise, she said there was a “danger” that policymakers would believe new roles, such as nursing associates in England, could be allocated these tasks, potentially removing the need for a nurse.

The case, which concluded at the Supreme Court on 2 August, was between all local authorities in Wales – except the County Council of the City and County of Cardiff – and health boards led by Cardiff and Vale University Health Board.

“Either we let external bodies decide what nursing is. Or we take this opportunity ourselves”

June Clark


It centred on how much funding local councils and the NHS should each contribute for the nursing of residents in care homes who required nursing care for only some of the time.

The row stemmed from a decision, made in 2013 by the country’s NHS health boards, to increase the rate they paid for nurses in care homes – but not by as much as local authorities said they should have.

The seven health boards said they should not have to fund nurses’ time spent doing “non nursing” tasks, such as dressing and washing, because it was possible for other staff members to do these instead.

The local councils disagreed and argued that the NHS should pay for everything done by a registered nurse in a care home and that their time should not be “atomised” into different tasks, according to court documents.

Swansea University/RCN

Care home payment row case ‘reveals urgent need to define nursing’

Source: Rodw

June Clark

At the hearing this month, a judge said the relevant legislation – Section 49 of the Health and Social Care Act 2001 – “quite clearly envisages that there will be some circumstances in which care does need to be provided by a registered nurse, even though it is not care which only a registered nurse can provide”.

The Supreme Court  judge, Baroness Hale, concluded that the health boards’ decisions were based on a misinterpretation of the legislation and “must be quashed and re-taken” in light of additional guidance she provided in court.

In this guidance, she stated it was her view that the definition of nursing care provided by a registered nurse included “time spent on providing, planning, supervising or delegating the provision of other types of care, which in all the circumstances ought to be provided by a registered nurse because they are ancillary to, or closely connected with, or part and parcel of the nursing care which she has to provide”.

Baroness Hale said that councils and health boards would, on that basis, now need to renegotiate how far each pays for nurses’ time in care homes.

“There will be some circumstances in which care does need to be provided by a registered nurse, even though it is not care which only a registered nurse can provide”

Baroness Hale

Speaking to Nursing Times after the case, former RCN president Dame June, who is also emeritus professor of nursing at Swansea University, said the dispute had highlighted a lack of understanding about the profession.

She called for action from nurses – and especially the RCN – to avoid external organisations deciding what the profession should or should not do.

“Either we wait for local authorities and health boards – who have shown they know nothing about nursing – and let those external bodies decide what nursing is. Or we take this opportunity ourselves,” she said.

Dame June said the RCN should either promote a previously decided definition of nursing from 2003 – which she led the development of – or it should develop a new version, taking into account new roles such as nursing associates.

“The lead judge repeatedly asked for a definition of nursing, was told there wasn’t one, and recommended that the health boards and local councils should sort it out between them. I believe it is the job of the profession, not health boards or local authorities, to say what nursing is,” she added.

“We will be seeking the support of our members to help inform and progress this work”

Stephanie Aiken

In response, Stephanie Aiken, deputy director of nursing at the RCN, said: “The definition of nursing is publically available on our website and was last updated in 2014. This definition is due for review in December 2017.

“The RCN is actively engaged in work to articulate the value of nursing, which involves a wide range of stakeholders, including the chief nursing officer,” she said.

“This will consider how we define the scope and contribution of contemporary nursing, and how we communicate this to professional and public audiences,” she said. “We will be seeking the support of our members to help inform and progress this work.”



Readers' comments (11)

  • Essential rather than basic nursing care.
    Henderson defined nursing in functional terms: "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 a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.

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  • Who is the person who must ensure that the 'basic nursing care' is carried out correctly by supervision?
    The RN on duty.
    Who is referred if the resident is found in a neglected state?
    The RN on duty.
    For years social workers have been assessing residents to ensure they did not get classified as nursing so nursing was done 'on the cheap'

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  • karen Webb

    Absolutely! Thank you Dame June for advocating for our patients in care homes, who deserve skilled nursing care! Residential placements House people living with multiple complex comorbidities, balancing medications and ongoing health changes. When I assist a resident with their personal care as a nurse my assessment, planning, implementation and evaluation of interventions is wholly more rigorous and informed than the kind and caring task performed by my colleague care assistants.
    There is a big difference that the professional bodies and trade unions supposedly speaking for us totally fail to advocate - older people deserve nurses every bit as much as other members of the public. Yes that costs money, but the alternative costs more and makes us the poor relation of every civilised society. Shame on us - nurses, nurse leaders and government along with the commissioners. When we are 87 we need to expect the care we are silently allowing now do we? kind hopefully, but not nursing. Collective Dereliction of our regulated activity is what Dame June is saying

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  • Rosemary Gondwe Mazhandu

    We do not need to define what nursing is. We should pay more attention on the care each individual client needs. We can not all be bosses. Roles have to be singled out to who does what, not with this issue of that we work as a team, as this way I find at the end no one is accountable for their actions. People are getting away with so much laziness and uncaring attitudes because the system allows it. I am a nurse on duty, its my overall respossibility to see to the proper care of my clients, I deligate to my subbordinates according to capabilities and skill mix. We did away with bedside nurses who were brilliant in delivery of basic care which is very very important as this meant being with the client longer and knowing their needs. We need more staff that are committed to delivery of basic care. Its a shame that one feels rushed when delivering care as you have to go through alot with a limited number of staff at your disposal.

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  • A 5 minute search for a definition ....

    Definition of Nursing 2 (short version) Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. (International Council of Nurses, 2002)

    The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death. (RCN, 2014)

    Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people. (WHO, 2017)

    Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. (American Nurses Association, 2017)

    There are more than I have listed but they all carry the same message!
    How many definitions of nursing do they want?

    Haven't they learnt that you get the level of service you pay for ... pay for a nurse and you get nursing care. Don't and you won't.

    Health is not a business ... never has been and never will be!

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  • Dame June is to be congratulated for raising this issue.

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  • "Washing a patient requires skill, patience, an ability to assess, communicate, evaluate and treat – it is not just giving someone a rub with a flannel." Until I can get a student nurse interested in learning this 'skill' the future of Nursing is in peril! It was the bedrock of my training years before P2K those of us with these skills are dwindling with no one to take our place. The reinventing of the SEN via a University route is not the answer!

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  • "Dame June’s belief is that it is the job of the profession, not health boards or local authorities, to define nursing." I thought that would have been part of the excitement around Nursing becoming a Degree led profession. Casting away from the GNC and moving forward to NMC via UKCC. That this definition is not there is a mockery of this process towards our 'Professional' status!

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  • Since the implementation of the New Care Act there is no longer a defined "Nursing Home" as there was under the Old Act . All homes are now " Registered Care Homes" with defined numbers of beds being designated for specific usages. The Provider has to staff each home to meet the needs of the Residents , which is ,obviously, rather ambiguous.
    The role and responsibilities of Nurses needs to be defined.

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  • I am just returning to practice.
    My Husband is in a care home with Alzheimers. On admission there was no assessment done for daily individual care and his usual daily routine . Not using the information from me .I was trying to give it. I ended up writing it down but still 7 months later I have staff saying 'he is self care'. far from it. They are not meeting the codes of practise requirements of assessment. This isn't the only home i have had this experience with. They just do not want to listen to the spouse/carer who knows them best.

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