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Part 4.3: The contribution of nurses

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VOL: 97, ISSUE: 17, PAGE NO: 45

Petra Kopp

Mary Ward, Assistant clinical editor and Good Practice Network Coordinator, Nursing Times;Mark Radcliffe, Features editor, Nursing Times

The government has stressed the important role nurses have to play in improving the quality of health care through their contribution to the achievement of the six quality parameters set out in The NHS Performance Assessment Framework (NHS Executive, 1999).

The government has stressed the important role nurses have to play in improving the quality of health care through their contribution to the achievement of the six quality parameters set out in The NHS Performance Assessment Framework (NHS Executive, 1999).

It has set this out in its white paper, Making a Difference: Strengthening the nursing, midwifery and health visiting contribution to healthcare. (Department of Health, 1999), which acknowledges that nurses, midwives and health visitors are the largest professional group in the NHS. The white paper highlights a number of issues that health care organisations need to address to enable nurses to play their role in clinical governance.

In addition to the self-regulation and development areas discussed last week (Nursing Times, April 19, p43-46), these include:

- Research appraisal skills;

- Access to guidelines and clinical information;

- Sharing best practice;

- Managing and minimising risk;

- Complaints management;

- Reporting of clinical incidents and poor practice.

In Wales, the document Realising the Potential. A Strategic Framework for Nursing, Midwifery and Health Visiting in Wales into the 21st Century outlines the Welsh approach to developing the role of nursing. Published in 1999 by the National Assembly for Wales, it is available at:

A separate document published in 1998, Valuing Diversity - a Way Forward: a Strategy for Nursing, Midwifery and Health Visiting, describes the strategy for Northern Ireland.

Scotland's nursing strategy for the next 10 years is set out in Caring for Scotland, which foresees a major expansion for nursing (Scottish Executive, 2001).

- Fit for Practice is compiled by Petra Kopp

Mary Ward and Mark Radcliffe discuss the practical aspects of the nursing contribution
Mary: One of the reasons The NHS Plan has placed so much importance on the role of nurses, health visitors and midwives is because of their dynamic response to the earlier government white paper, Making a Difference.

Nurses are seen as the major agents for change. The demise of the corrosive NHS internal market has been a liberating experience for practitioners around the UK, who genuinely wish to improve patient care and share best practice. They refuse to constantly reinvent the wheel - in isolation - at the whim of the next Department of Health statement.

By actively embracing clinical governance and making it work for them, they can improve the quality of patient care and their own working lives in the process. The NHS is over 50 years old but we had to wait for clinical benchmarking (Department of Health, 2001) to establish national baselines in clinical practice.

Nurses can no longer sit back and wait for 'them' to improve the quality of the service on offer to patients. They have to find the solutions themselves and, if these are unacceptable, work with managers to find acceptable, effective compromises.

Mark: But what does that mean in reality? I don't want to trot out the old excuses for why nurses do not dynamically lead the health service to the promised land. But when we say we expect nurses to be finding solutions, turning policy into practice and revolutionising the health service, which nurses do we mean?

Are they E grades running wards with agency staff and health care assistants, or practice nurses working in professional isolation? It is vital that nurses are at the forefront of establishing standards and good practice, but in reality many are responsible for holding things together. How might they free themselves from the sense of defending a service that is close to crisis and start developing quality?

Mary: I think everyone working in the NHS holds it together on a daily basis. We do not have a government-approved audit tool to measure the enormous volume of goodwill and enthusiasm that practitioners on every grade bring to the workplace every day.

Rather than exploiting it we can harness it to create positive change. E grades running busy wards on a wing and a prayer cannot be expected to change the face of nursing overnight. However, as qualified practitioners they are professionally accountable and have a duty to ensure a safe environment for patients. If that safety is compromised by a lack of staff, equipment or time to find evidence, they have a duty to inform their line managers.

This is where nurses must start making clinical governance work both for them and for patients. Stoicism will bring few benefits: nurses need to be clear about what they need to enable them to perform the duties demanded of them professionally.

Ultimately, the clinical governance buck stops with the trust chief executive. He or she is the person who needs to be fully aware of what is happening at the patient's bed. Nurses must communicate this information upward and demand support in return.

Mark: But what does that mean in practice? Nursing is first and foremost an activity. So as someone goes about their day what can he or she do to implement positive change?

Mary: Let's start with the average shift, whatever one of those is. Thousands of days a year are taken up by nurses sitting in handovers that are not patient focused, wasting precious time repeating information that most staff could recite by heart.

Why not look at how essential patient information can be shared and time saved. Handovers are not mini case conferences: use them to discuss with your team what they consider to be relevant information. Some units use tape recorders to pass on information to the next shift, others have a brief ward round. What would work in your unit? Why do you hand over the way you do? Could you improve it? What information can you find in the literature?

Are there skills your team is desperately in need of, but you have no funding for training? Perhaps it is time to think about what you do well and advertise your skills in your trust newsletter in exchange for those you want. You may be surprised at how keen others are to offer intravenous-access training, for example, in return for your knowledge in tissue viability. No money need change hands, but each team will benefit as a result of the training and so will the patients in your care.

It is time to work smarter not harder.

Useful websites
Department of Health:

Consultative documents:

National Assembly for Wales:

NHS Executive:


Northern Ireland Department of Health, Social Services and Public Safety:

Scottish Executive:

Scottish Health on the Web:

The Stationery Office

UK parliament:

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