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Exclusive: Revalidation pilots reveal raft of unresolved issues

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Nurses have said they need clearer guidance about how to complete the new process of checks for renewing their registration in order to reduce confusion and avoid potentially falling off the register.

Nursing Times has carried out research into the experiences of nurses taking part in the pilot schemes for the Nursing and Midwifery Council’s new revalidation system.

Following testing of the proposed system – due to replace post-registration education and practice (PREP) from next year – nurses have highlighted particular problems around finding an appropriate person to sign them off and how to deal with fitness to practise issues along the way.

“You could end up producing the work and it could be to a really basic standard compared to somebody else, but they still get signed off”

Julia Hagger

Others who took part in piloting the new revalidation system have questioned whether draft guidance is too weak in places and risks there being varying standards of acceptance for sign off.

It has also been claimed the guidance has been composed with large NHS organisations in mind and that more should be done to address the difficulties registrants working in smaller or private organisations will likely face.

While the introduction of revalidation was welcomed by all pilot organisations Nursing Times spoke with, participants say clarity is now needed from the NMC across a range of areas ahead of its launch in April 2016.

Under the new arrangements, every UK registrant will be required to submit evidence to the NMC demonstrating how they are maintaining their fitness to practise every three years when they are due to renew their registration.

The system introduces additional standards that state registrants must gain feedback on their practice, reflect upon and discuss the NMC code of conduct, their practice and development, and also obtain confirmation from a third party that they have met all requirements.

Draft guidance released earlier this year confirmed that nurses and midwives will continue to have to complete at least 450 hours of practice in the three years prior to renewing their registration, as well as provide evidence of continuing professional development.

“I can’t go to somebody who doesn’t practise what I’m practising otherwise they are not able to be my confirmer”

Jackie Atkinson

But the additional standards have caused some concern for pilot sites, especially around third party confirmation.

Nurses leading the revalidation pilot at Central Manchester University Hospitals Foundation Trust said smaller and non-NHS organisations would benefit from clearer guidance on the role of the “confirmer” – the person who vouches that a registrant has compiled all the necessary revalidation documentation – who it is recommended should be a line manager.

Provisional guidance from the NMC states that while most nurses will have a reflective conversation about their practice as part of their confirmation, in some cases it will be possible for a non-registrant confirmer to sign someone off as long there is evidence a reflective discussion has taken place.

In this instance, the Manchester pilot leads – who saw 299 people complete the process – believe registrants should include a summary of their reflective discussion to avoid confirmation becoming a “tick-box exercise”.

Andrea Boland, head of professional development at the trust, questioned whether people would understand that the confirmer was clarifying the quality of the portfolio or just saying the person has done 450 hours of practice, 40 hours of CPD and other requirements.

“There needs to be an area [for a summarised account] so the confirmer can see there has been a reflective discussion and what that entailed,” she said.

Nursing Times has learnt from another source that during the pilot, to save time, two nurses at the trust got themselves signed off by someone who was not their line manager, despite the guidance recommending this is the preferred person.

“Our recommendations were about making sure they provide clear and appropriate guidance to all areas of practice so everybody feels they are a part of it”

John Lee

The situation raises the risk that nurses could get a friend or other sympathetic colleague to sign them off as a favour.

However, Ms Bowland and deputy director of nursing Dawn Pike told the Nursing Times it would not happen at their trust in future, because internal systems would alert managers when staff are due to be signed off for revalidation.

Nottinghamshire Healthcare Foundation Trust’s senior matron for offender health said it was unclear whether third party confirmers should sign a registrant off if they had fitness to practise issues.

Eddie Alder, the lead for piloting revalidation at the trust, said it did seem possible somebody could meet the revalidation requirements even if they were already being looked into for an FtP concern.

“The bit we are still unclear about…is there a period of time where things [revalidation] can almost be paused while FtP is being dealt with,” he said.

Mr Alder said that while his organisation – which saw 41 registrants complete the pilot – had not been affected by this issue, his experience had alerted him to this as a potential problem.

Julia Hagger, a clinical matron for HM Prison Lincoln at the same trust, said there was “quite a bit of confusion” about how much information should be included within the reflective accounts and what evidence was required.

“There needs to be an area so the confirmer can see there has been a reflective discussion and what that entailed”

Andrea Bowland

Ms Hagger, who acted as a “confirmer” during the pilot, pointed out that this could lead to wide variations in documentation that are signed off. She said: “You could end up producing the work and it could be to a really basic standard compared to somebody else, but they still get signed off.

“I wonder if that needs being made more rigid in terms of what is suitable and how much should be in the logs to reduce the risk of people still revalidating when they haven’t particularly improved their scope of practice,” she said.

Ms Hagger added that she knew “a huge amount” of nurses outside her trust that either did not know about revalidation at all, or were unsure what it entailed. She said better publicity and communication was needed from the NMC.

Meanwhile, Jackie Atkinson, who took part in the pilot as a member of the British Association of Cosmetic Nurses, also warned of problems around the role of the “confirmer”.

While provisional NMC guidance states it is not essential for the confirmer to have a similar scope of practice to the person revalidating, it requires that as a minimum they need to have a discussion about the registrant’s practice.

Ms Atkinson said self-employed nurse would be forced to use someone from outside their clinic who worked in a similar line of business in order to have a meaningful conversation about their practice – which meant risking sharing commercial information.

student nurse observing

“We are all in business – so I have to go along to somebody, maybe not my direct opposition – but somebody who does the same as me, because I can’t go to somebody who doesn’t practise what I’m practising otherwise they are not able to be my confirmer,” said Ms Atkinson.

Ms Atkinson, who owns Medi-Laser Solutions in London, said she welcomed the “positive forward-thinking” from the NMC around including cosmetic nurses in the pilot scheme, but said the draft guidance focussed too much on NHS organisations.

John Lee, head of undergraduate studies in the school of nursing and midwifery at the University of Dundee, led the pilot at his organisation which included 50 registrants.

He said clearer guidance was needed for academic settings. He said it may not be easy for those who have not been through the pilot to understand what sort of reflection is required, the role of the confirmer and what counts as practice hours in non-clinical settings.

“[Our recommendations to the NMC from the pilot] were about making sure they provide clear and appropriate guidance to all areas of practice so everybody feels they are a part of it,” he said.

In response to the points raised, the NMC said it was unable to provide clarification in time before Nursing Times went to press.

The regulator is due to publish a report on its own findings from the pilot schemes later this month.

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Readers' comments (10)

  • I wonder if this milarky is the same for doctors!

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  • Contrary to the comment made by Ms Hagger I think there has been ample publicity regarding revalidation with nurses 'not knowing' having more to do with 'ignorance being bliss'. The information is out there it just requires nurses to take time out to read it otherwise we all could plead the same cause. Whether we agree with the change or not (& I am not particularly enamored by it) it is going to happen & if we value our profession & our jobs we need to show we are committed to ensuring our practice is safe & up to date. I do however agree that there needs to be total clarity of the portfolio content & that of the confirmer's role so those staff who may not cut the mustard are not allowed to slip through the net just because they happen to be held in favour by the manager signing them off as fit to practice. Having known (& still knowing) many nurses who have not kept up to date with PREP with this never being discussed or addressed at their annual review, it is not surprising to hear of staff raising concern over revalidation. I'm concerned despite having already started preparing for the change & having more than adequately demonstrated my fulfilling of PREP previously. This change will hopefully ensure that those staff who were never committed to maintaining fitness to practice (given the expectation is often this needs to be done in your own time), will have as much extra work to do as the rest of us who have demonstrated more pride in our role by been committed to proving continuous learning. If they still choose not to bother then they run the risk of removal from the register & in my opinion that is no bad thing.

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  • What do you do if you are an Agency Nurse and your manager isn't a nurse but just runs the office?
    Also I am already hearing conversations between managers,deputy managers and clinical lead nurses about signing each other off 'no problem'.
    I know of one nursing home where the manager has done less than 50 hours practice and the deputy manager is going to sign her off because they're friends! Also her job would be at risk if she didn't!

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  • I know a nurse who feels like they are being bullied by their manager and according to HR this nurse doesn't have enough evidence to put forward a bullying case. who would sign hers??

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  • The focus has always been on large hospitals - the NMC doesn't seem to recognise that there are thousands of nurses in other areas of practice, not least care homes. I find it astonishing that there were no pilots in care homes or CCG's - our local CCG has at least 20 nurses in posts which require current registration and I presume that pattern is mirrored across England. Likewise, this needs testing with a whole range of posts - safeguarding nurses, Continuing Healthcare nurses, quality improvement nurses, nurse commissioners, practice nursing - there is a whole world of nursing outside hospitals.

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  • As with everything else in today's NHS/DH, "the process" and the generation thereof (not forgetting the graphic design, of course) has substituted actual "thinking". Nobody thinks any more - as long as the output is a nifty-looking document with the appropriate buzz-word density then somebody can update their CV and wait to moved up the ladder.

    This lot couldn't organise a kids tea party! - even though the invitations will look great.

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  • It is not clear to me whom is able to sign you off .. What happens if your line manager is not a nurse .. or if you have not had an appraisal for 4yrs .. peer signing is that possible then ??
    Does generic training apply for updates .. I ask this because of working in a carehome .
    The NMC cant even organise monthly direct debits to pay fees !!!
    Surely all the information is with them if yearly direct debits are collected ???
    Boo hoo NMC .. get your act together!!

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  • michael stone

    'Nursing Times has learnt from another source that during the pilot, to save time, two nurses at the trust got themselves signed off by someone who was not their line manager, despite the guidance recommending this is the preferred person.'

    If you want clarity, you do need to be clear - the words 'recommended' and 'preferred' are not the same thing as 'must', and guidance/rules must be taken to mean what they say, or else it is chaotic.

    Guidance and rules become 'unclear' because they try to cover every possibility - that can lead to a remarkable amount 'of confusion' !

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  • Surely reflective discussions should be taking place in supervision. That's the one place it should be happening but how much real Clinical Supervision actually takes place in the busy settings nurses are working in these days?

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  • apart from doctors who already have revalidation do other health care professionals apart from nurses have to be revalidated?

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