As nursing and healthcare roles have undergone significant change over the last two decades, two grades are needed to reflect levels of care, argues Maggie Nicol.
Keywords: Clinical skills, Education, Training, High-quality care
Clinical skills are the heart of nursing and therefore must be delivered by, or at least supervised by, nurses. Education and training are needed to be able to see beyond the task itself. These are also needed to see the person as an individual and safely deliver holistic care effectively and with compassion.
Lord Darzi’s NHS Next Stage Review (Department of Health, 2008) rightly concluded that compassion, safety and effectiveness of nursing care lie at the heart of quality nursing. Nurses have a big impact on patient safety and well-being as they provide the bulk of patient care - or rather they did.
Now the majority of fundamental care is provided by the increasing number of healthcare assistants (also known as healthcare support workers or nursing assistants) who often have little training apart from mandatory sessions and learning ‘on the job’.
However, nurses should be giving this care; providing a blanket bath is the perfect opportunity to observe the patient’s hydration, nutrition, pressure areas and skin condition, and to respond to their concerns. It is also the perfect opportunity to teach these skills to student nurses and junior staff.
Recent media reports suggested the RCN was dismayed to find that ward managers were spending time delivering fundamental patient care. I would argue that is exactly what they should be doing, working alongside their junior staff, teaching and demonstrating high standards of care.
Until relatively recently there were two levels of nurses; it was recognised that some nurses preferred the ‘hands-on’ aspects of care and a job that stopped at the end of the shift. They did not want (and sometimes did not have the ability) to be leaders of care with responsibility that continued even when not on duty.
Following two years’ training, enrolled nurses (ENs, now known as second-level registered nurses) were well prepared to provide all aspects of fundamental care and were regulated by the UKCC and therefore required to abide by the code of conduct.
The EN grade was phased out in the 1990s and most became first-level registered nurses (RNs), but since then the ratio of nurses to HCAs has changed. In many clinical areas HCAs and student nurses now provide most fundamental care.
Nurses are not ‘too posh to wash’ - they are just busy doing other things. It is HCAs with minimal training and often minimal supervision who are doing the washing.
However, if these practitioners do not have sufficient training to appreciate the consequences of not turning patients regularly, patient care will suffer. If they do not have sufficient training to recognise that observations are abnormal, patient care will suffer.
If HCAs are doing nursing, why don’t we call them nurses? Why don’t we reinstate a second level of nursing called ‘practical nurses’ and provide proper education and training?
But let’s learn from the past. All students should start the same education programme; practical nurses can then ‘step off’ after 18 months unless they choose (and have the ability) to continue to become RNs. This would enable practical nurses to continue their education to become RNs at a later date if they chose to do so.
It would mean that all those providing nursing care would be governed by the NMC’s code of conduct and all would have sufficient education and training to provide compassion and safe and effective nursing care.
Maggie Nicol is professor of clinical skills, School of Community and Health Sciences, City University London
Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report. London: DH.