The UK’s most widely-used safe staffing tool will need to evolve to take into account different types of nursing role, according to one of its architects, who says the profession must embrace the opportunities provided by new job titles and routes into nursing.
In an exclusive interview with Nursing Times, Professor Dame Hilary Chapman said the Safer Nursing Care Tool needed to reflect the changing nature of the workforce including new roles such as nursing associate.
“We know we have got to make this tool work for the changes in the workforce”
Meanwhile, she said it was time to “think a bit differently” when it came to looking at ways to address staffing shortages including making the most of new nursing support roles.
One of the UK’s most prominent nursing leaders, Dame Hilary is currently chief nurse at Sheffield Teaching Hospitals NHS Foundation Trust but has announced she will be stepping down this summer.
Together with Professor Katharine Fenton, she co-led the development of the Safer Nursing Care Tool, which went on to be endorsed by the National Institute for Health and Care Excellence and is now used in acute hospitals across the UK to determine nursing establishments.
Initially developed for adult inpatient wards it has since been adapted for other types of ward and healthcare setting.
However, Dame Hilary said developers would also need to factor in increased variety in the make-up of nursing teams.
“We know we have got to make this tool work for the changes in the workforce so if we’re going to be having nursing associates in our ward teams then the tool needs to reflect this,” she said. “We know we have some development work to do around that.”
“You’re part of a big team and respecting people within that team is mission critical”
The tool has already been adapted for assessment units and children and young people’s wards and a version for emergency care was recently piloted in a number of A&E departments.
This was praised in a recent report by the Care Quality Commission on the way emergency departments coped with winter pressures, which found it had led to an increase in nursing staff numbers.
“In my own unit it has been really helpful in determining what nurses we need for the patients who go through our department and we have seen an increase here,” said Dame Hilary, who said the emergency care version should be ready to be rolled out more widely later this year.
Meanwhile, work is under way to refine the tool for mental health settings and develop a version for care for older people in acute settings – and possibly care homes.
While the tool has been widely adopted across the UK, Dame Chapman said there was further work needed to help trusts understand how to use it to best effect.
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She said she was therefore “really excited” about new specialist training funded by NHS Improvement under the new National Safe Staffing Fellows programme.
“I am really excited about the faculty that NHS Improvement is setting up which will help us to support people in the correct use of the tool,” she said.
“It will be an England-wide approach that includes opportunities for people to be seconded into the faculty to learn how to use the tool and then to help others learn how to use it.
“I think that’s fantastic and I suppose it’s what I’ve worked for over the last 20 years since we started developing the tool,” said Dame Hilary.
“It’s what I’ve worked for over the last 20 years since we started developing the tool”
She said one thing that had been really important to the tool’s developers was to ensure it was free of charge for NHS organisations.
“We fought really hard for that. The thought of somebody marketing this – trying to sell it for the benefit of patients – does not get my head off the pillow,” she said. “We want it to be free of charge to every NHS organisation and then help them to roll it out and use it correctly. I think that’s a win-win really.”
While there was still a “lack of understanding” in some places around how to use the tool correctly, she said guidance was being strengthened based on feedback from nurses on the ground.
“One of the main misunderstandings is this tool is to set establishments – it’s not for monitoring hour in, hour out,” she said. “Every question we get helps us to strengthen the guidance we give with the tool.”
In 2016 Wales became the first UK nation – and first country in Europe – to enshrine safe staffing in law. Meanwhile, staffing legislation has now been promised in Scotland, with the recent introduction of a bill.
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Dame Hilary said she would support some form of legislation around safe staffing in England as long as it was “realistic”, adding that the work under way in Scotland looked particularly promising.
“I think the law has to be sufficiently sophisticated for the application of that law to be realistic,” she told Nursing Times.
“They have done a huge amount of work on safe staffing in Scotland and I’m hopeful that the legislation that emerges there will be really positive because it will be based on a realistic premise, which would be great.”
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She said one of the key challenges facing nursing at the moment was the fact demand for services was changing with an ageing population, more people living with complex conditions and higher expectations all round.
“I think we have got to be very clear on what our demand is now and what our emerging demand is and that is about working with the public, working with patients and their carers,” she said.
While supply of nurses was also a challenge she said “there are solutions” including new roles such as nursing associate and assistant practitioner roles.
“Clearly there are challenges with the supply of staff but I think that’s where we need to be a bit more creative, look differently – there are loads of new roles emerging,” she said.
“We want it to be free of charge to every NHS organisation and then help them to roll it”
Overall, she said was “excited and positive” albeit still somewhat cautious about new nursing roles and what they had to offer.
“Our role is to ensure they sit within a framework where we can be accountable for the care that’s delivered,” she said. “And that is for us to develop with our teams and organisations be they acute trusts, mental health, community, primary care.”
Meanwhile, she also welcomed the development of new routes into becoming a registered nurse because it was bringing a wider range of people into the profession.
“We’re moving away from that linear pathway into nursing which was you get A-levels, come in, do your training, and come out – into this much wider gateway into nursing, which I think is a real benefit because we then get the bonus of having a really mixed workforce,” she said.
“Some of the people who have gone through say the Open University programme in my organisation or support workers who’ve been supported to do the training – have become fantastic registered nurses,” she said.
“There are challenges but there are also opportunities that I think we need to embrace, including thinking a little bit differently about workforce,” she said. “It’s not about diluting at all, it’s about looking for the opportunities and grasping them.”
“We need to be a bit more creative, look differently – there are loads of new roles emerging”
She said there was a need for the profession to work closely with education providers “to develop those educational routes that will give us the professionals we need in the future”.
Other key challenges included getting to grips with new integrated models of care. “For me this is about putting the patient at the centre and working in partnership around them with colleagues across the board – primary care, community, acute, mental health, social services, housing,” she said.
During a nursing career spanning more than 30 years, Dame Hilary, who is a visiting professor at Sheffield Hallam University and honorary doctor of medicine at the University of Sheffield, has made major contributions to health policy, healthcare delivery and system reform.
Having trained as a nurse in Sheffield in the 1980s she went on to work at the Northern General Hospital as a staff nurse in cardiothoracic surgery and a critical care sister.
She was chief nurse at Kettering General Hospital and University Hospitals Coventry and Warwickshire NHS Trust before her career came full circle and she returned to Sheffield Teaching to take up the role of chief nurse in 2006.
“I wanted to keep my practice fresh but it is also about the privilege of that interface between nurse and patient”
She said one of the biggest things that had changed since she started nursing was the sheer breadth and depth of roles for nursing professionals – including when it came to being at the cutting edge of research that helped transform care.
“There have always been opportunities if you wanted to seek them but the opportunities now are amazing,” she told Nursing Times.
”There is breadth of opportunity but there is also the depth of opportunity in terms of the skilled roles nurses can now do,” said Dame Hilary, who was awarded a CBE for her services to nursing in 2012 and was made a Dame Commander of the Order of the British Empire in the Queen’s New Year Honours.
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“If I think back to when I registered as a nurse, it was an extended role to take blood or give IV drugs. Now people can wrap all that up into the role of the nurse caring for that patient. It’s not about a series of skills that you gather like certificates, it’s about holistic care.
“Some of the advanced and specialist roles we have now are amazing but the nurse at the bedside or in the community also do so much more than the role I first did when I was a staff nurse.
“It is more fulfilling now. Rather than almost having to hand off part of the care you wanted to deliver, you can pretty much do most of the care for that patient.”
“There are challenges but there are also opportunities that I think we need to embrace”
However, she said there was a need to do more to showcase all nursing had to offer and this was partly down to nurses. Health Education England recently launched a campaign to promote nursing to 16 to 18-year-olds but Dame Hilary said it was also important to also spread the word among younger children.
“I think we need to start earlier than 16. We need to be out in schools talking to young people before they are making career choices, when they are talking about choosing GCSEs,” she said.
“I go out into schools and FE colleges locally and talk about what nursing has given me in terms of opportunities and a career. Having organisations like Health Education England and all the arms length bodies promoting nursing is one thing but I think it is for us as nurses to advocate the strengths, benefits and opportunities our profession can bring.”
She recalled how she was first drawn to nursing through an inspirational conversation – and reading Nursing Times. “I’m not one of those people who wanted to be a nurse from being a little girl. I actually met somebody in my later years at school who was going to be a nurse and it was from talking to her,” she said.
“I actually started buying the Nursing Times way back and I remember reading it – not as a nurse – and thinking ‘Wow – this is a career I would really love’,” she said. ”And as soon as I came into nursing I knew I had made the right choice.”
“I started buying Nursing Times way back and I remember reading it and thinking this is a career I would really love”
Despite her long and distinguished career and many achievements she said one of her highlights was still the day she became a registered nurse.
“I can remember it now – it was one of the proudest days of my life to register to be a nurse,” she said. “Another was when I became a sister in critical care. I remember getting that job and I remember the interview even though it is a long time ago and the pride at being a sister.”
Throughout her career she said she had benefited from the support of some fantastic nursing leaders and this had made all the difference.
“The education I did was essential because it opens your eyes to a different world and enables you to place nursing in a wider context,” she said. “But the thing that made the difference in my career was the people – the teams I have worked with and the leaders who spotted some potential in me.”
She said it was vital nurses at all levels were given the help they needed to develop in their chosen field or role and good staff development was not simply about helping nurses move up the career ladder.
“There’s nothing I value more than the nurse who wants to stay in his or her role but have an opportunity to do something a bit different,” she said.
“Not everybody wants to be a chief nurse, so it’s about valuing the things that midwives and nurses want to do and enabling them to do that – it might be sideways moves, opportunities for education and development, shadowing,” she said. “All those things can be very motivating.”
Professor Dame Hilary Chapman
As a nursing leader Dame Hilary said it had been important to her to continue working clinically, doing one shift in uniform each month.
“I can’t imagine being in this job and not doing clinical shifts,” she said. “I wanted to keep my practice fresh but it is also about the privilege of that interface between nurse and patient – that’s when you see and when you feel it – when you are in uniform and at the bedside or in the community in somebody’s home – and it’s very powerful and very precious,” she said.
“It also keeps you up to date not only with your own practice but the world of nursing and the world of healthcare and you get to meet staff you wouldn’t normally meet,” she said.
When it came to advice for other chief nurses, Dame Hilary stressed that no nursing leader could hope to succeed without the support of nurses on the ground and all other members of the multi-disciplinary healthcare team.
“You’re not a one man band, you’re part of a big team and respecting people within that team is mission critical,” she said.
“When I go out and work clinically people can sometimes be nervous or anxious because the chief nurse is around,” she said. “But they always know more than me because it’s their job, their work setting, their patients.
“You don’t know the answer to everything and you don’t have the monopoly on good ideas – you are hugely dependent on the people you work with and respecting them for their knowledge, expertise and skill is the cornerstone of these jobs,” she added.
Dame Hilary’s last day at Sheffield Teaching Hospitals will be on 15 August, when she will be celebrating her retirement with current and former nurses and midwives who have played a key role in her career.