Nursing in the United Kingdom – Wikipedia, the free encyclopedia

The Nursing and Midwifery Council

The core function of the NMC is to establish and improve standards of nursing and midwifery care in order to serve and protect the public. Its key tasks are to:

  • maintain a register listing all nurses and midwives;
  • set standards and guidelines for nursing and midwifery conduct, performance and ethics;

provide advice for registrants on professional standards;

  • quality assure nursing and midwifery education;
  • set standards and provide guidance for local supervising authorities for midwives;

consider allegations of misconduct, lack of competence or unfitness to practice due to ill health.

The powers of the NMC are set out in the The Nursing and Midwifery Order 2001.

The council consists of twelve registrant members, twelve alternate registrant members and eleven lay members. The registrant members consist of equal numbers of nurses, midwives and specialist community public health nurses. The lay members include people from education, employment and consumer groups (who are appointed by the Privy Council. The former president and vice-president were Sir Jonathon Asbridge and Mary Hanratty respectively.

The NMC held its first elections of registrants for its governing council, with all members. The new council came into being in July, 2006. The first elected President of the council is Sandra Arthur, with the vice-president position vacant.

[edit] Regulation

To practise lawfully as a registered nurse in the United Kingdom, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council. The title “registered nurse” can only be granted to those holding such registration, this protected title is laid down in the Nurses, Midwives and Health Visitors Act 1997.

[edit] The register

As of August 2005, the NMC register split into three parts: nurses, midwives and specialist public health nurses. Previously, it only contained 15 “sub-parts”, a list of which can be viewed here

According to the NMC, there are 672,897 registered nurses on the register, as of 2005. Of these:

  • Over 10% of registrants are male.
  • Over 53% are on part 1 of the register (Adult).
  • Over 60% are under the age of 40.
  • There are only two male School nurses registered with the NMC.

[edit] Employment of nurses

The National Health Service is the provider of almost all healthcare in the United Kingdom, and employs the vast majority of UK nurses and midwives which number 386,000 according to the Department of Health.

The nursing staff is split into two main groups:

  • Non-registered staff
– e.g. auxiliary nurses and healthcare assistants.
  • Registered staff (split into four further groups)
– First level nurses.
– Second level nurses.
– Specialist nurses.
– Managers.

[edit] Non-registered staff

These staff can be found carrying out a number of roles, attracting various titles such as auxiliary nurse, healthcare assistant (HCA), clinical support worker, care assistant and nursing assistant. These titles all describe workers who work in direct patient care (often on wards), performing tasks such as personal care (washing and dressing), social care (feeding, communicating to patients and generally spending time with them) and more specialised tasks such as recording observations or vital signs (such as temperature, pulse, respirations TPR) or measuring blood pressure, urinalyisis, blood sugar monitoring, waterlow score, catheterisation, or canulisation).

Some unregistered staff can work in other roles, for example as phlebotomists (taking blood samples) and ECG technicians (recording electrocardiograms). Others can expand their ward-based role to include these tasks and others. Technically, there are few areas of nursing practice that cannot be legally performed by suitably trained non-registered staff, although they cannot fully replace them, as they legally must be supervised (either directly or indirectly) by a fully qualified registered nurse.

[edit] Registered staff

[edit] First level nurses

First level nurses make up the bulk of the registered nurses in the UK. They were previously known by titles such as RGN (registered general nurse), RSCN (registered sick children’s nurse), RMN (registered mental nurse), RNMH (registered nurse mentally handicapped N.B. Not to be confused with the more modern abbreviation for Mental Health Nurses i.e. Registered Nurse in Mental Health – see table to the right), RFN (registered fever nurse) and SRN (state registered nurse) etc.

Sub-part Level Branch Title Country
1 First General RGN UK-Wide
2 Second General EN(G) England and Wales
3 First Mental illness RMN UK-wide
4 Second Mental illness EN(M) England and Wales
5 First Learning disabilities RNLD UK-wide
6 Second Learning disabilities EN(LD) England and Wales
7 Second General SEN Scotland and NI
8 First Children RSCN UK-wide
9 First Fever (obsolete) RFN UK-wide
10 N/A Midwife RM UK-wide
11 N/A Health visitor HV UK-wide
12 First Adult RN/RNA UK-wide
13 First Mental health RN/RNMH UK-wide
14 First Learning disabilities RN/RNLD UK-wide
15 First Child RN/RNC UK-wide

The majority of first level nurses are employed as staff nurses with the minority in management and specialised roles.

[edit] Second level nurses

Second level (still referred to as EN’s) nurse training is no longer provided, however they are still legally able to practice in the United Kingdom as a nurse and also by law may refer to themselves as a registered nurse NMC. EN’s trained for a period of 24 months in England and Wales whilst training in Scotland was normally 18 months in duration. Many have now either retired or undertaken conversion courses to become first level nurses.

[edit] Specialist nurses

The NHS employs a huge variety of specialist nurses. These nurses have many years of experience in their field, in addition to extra education and training (see below).

They split into several major groups:

  • Nurse Practitioners – these nurses carry out care at an advanced practice level. They often perform roles similar to those of Doctors. They commonly work in primary care (e.g., GP surgeries) or A&E departments, although they are increasingly being seen in other areas of practice.
  • Specialist Community Public Health Nurses – traditionally known as District Nurses and Health Visitors, this group of practitioners now includes many School nurses and Occupational Health Nurses.
  • Clinical Nurse Specialists – undertaking these roles commonly provide clinical leadership and education for the Staff Nurses working in their department, and will also have special skills and knowledge which ward nurses can draw upon.
  • Nurse Consultants – these nurses are similar in many ways to the clinical nurse specialist, but at a higher level. These practitioners are responsible for clinical education and training of those in their department, and many also have active research and publication activities.
  • Lecturer-Practitioners – these nurses work both in the NHS, and in universities. They typically work for 2–3 days per week in each setting. In university, they may train pre-registration student nurses (see below), and often teach on specialist courses for post-registration nurses (e.g. a Lecturer-practitioner in critical care may teach on a Masters degree in critical care nursing). Lecturer-Practitioners are now more often referred to by the more common job title of Practice Education Facilitators (shortened by student nurses to PEFs).
  • Lecturers – these nurses are not employed by the NHS. Instead they work full time in universities, both teaching and performing research. Typically Lecturers in Nursing are qualified to a minimum of Masters Degree and some are also qualified to PhD level. Some senior lecturers also attain the title of Professor. This title is more often the School/Department Dean e.g. Dean/Vice Dean School of Health & Social Care.

[edit] Managers

Many nurses who have worked in clinical settings for a long time choose to leave clinical nursing and join the ranks of the NHS management. This used to be seen as a natural career progression for those who had reached ward management positions, however with the advent of specialist nursing roles (see above), this has become a less attractive option.

Nonetheless, many nurses fill positions in the senior management structure of NHS organisations, some even as board members. Others choose to stay a little closer to their clinical routes by becoming clinical nurse managers or Modern Matrons.

[edit] Nurse education

[edit] Non-registered staff

There is no mandatory training for most people undertaking these roles. The majority of NHS employers however, have created “in-house” training for these members of staff, both in the form of induction programmes and ongoing education to achieve a recognized qualification. Some work collaboratively with local further education colleges to provide theoretical input, and may award a recognised qualification. It is becoming more common for NHS employers to ask for some type of health or social care qualification for potential new members of staff for example, an SVQ/NVQ or HNC/HND with various qualification names including health care, social care and health & social care.

Many trusts and health boards create opportunities for these staff members to become qualified nurses, this is known as secondment (whereby the trust/health board continues to pay them for the duration of their training, and often guarantees employment as qualified nurses following the completion of their training).

[edit] Pre-registration

In order to become a registered nurse, and work as such in the NHS, one must complete a programme recognised by the Nursing and Midwifery Council. Currently, this involves completing a degree or diploma, available from a range of universities offering these courses, in the chosen branch speciality (see below), leading to both an academic award and professional registration as a 1st level registered nurse. Such a course is a 50/50 split of learning in university (i.e. through lectures, essays and examinations) and in practice (i.e., supervised patient care within a hospital or community setting).

These courses are three (occasionally four) years long and must be 4600 hours in length to meet the requirements of the NMC. The first year is known as the common foundation programme (CFP), and teaches the basic knowledge and skills required of all nurses. The remainder of the programme consists of training specific to the student’s chosen branch of nursing. These are:

  • Adult nursing.
  • Child nursing.
  • Mental health nursing.
  • Learning disabilities nursing.

Midwifery training is similar in length and structure, but is sufficiently different that it is not considered a branch of nursing. There are shortened (18 month) programmes to allow nurses already qualified in the adult branch to hold dual registration as a nurse and a midwife. Shortened courses lasting two years also exist for graduates of other disciplines to train as nurses. This is achieved by more intense study and a shortening of the common foundation programme.

Student nurses currently receive a bursary from the government to support them during their nurse training. Diploma students in England receive a non-means-tested bursary of around £6000 per year (with additional allowances for mature students or those with dependant children), whereas degree students have their bursary means tested (and so often receive less). Degree students are, however, eligible for a proportion of the government’s student loan, unlike diploma students. In Scotland and Wales, however, all student nurses regardless of which course they are undertaking, receive the same bursary in line with the English diploma course. All student nurses in Wales study, initially, for a degree, but may chose to remain at Level 2 for their third year, therefore achieving a diploma in place of a degree.

Before Project 2000, nurse education was the responsibility of hospitals and was not based in universities; hence many nurses who qualified prior to these reforms do not hold an academic award.

[edit] Post-registration

After the point of initial registration, there is an expectation that all qualified nurses will continue to update their skills and knowledge. The Nursing and Midwifery Council insists on a minimum of 35 hours of education every three years, as part of its post-registration education and practice (PREP) requirements.

There are also opportunities for many nurses to gain additional clinical skills after qualification. Cannulation, venepuncture, intravenous drug therapy and male catheterisation are the most common, although there are many others (such as advanced life support) which some nurses will undertake.

Many nurses who qualified with a diploma can choose to upgrade their qualification to a degree by studying part time. Many nurses prefer this option to gaining a degree initially, as there is often an opportunity to study in a specialist field as a part of this upgrading.[citation needed] Financially, in England, it is also much more lucrative, as diploma students get the full bursary during their initial training, and employers often pay for the degree course as well as the nurse’s salary.

In order to become specialist nurses (such as nurse consultants, nurse practitioners, etc.) or nurse educators, some nurses undertake further training above bachelors degree level. Masters degrees exist in various healthcare related topics, and some nurses choose to study for PhDs or other higher academic awards. District nurses and health visitors are also considered specialist nurses, and in order to become such they must undertake specialist training (often in the form of a top up degree (see above) or post graduate diploma).

All newly qualifying district nurses and health visitors are trained to prescribe from the Nurse Prescribers’ Formulary, a list of medications and dressings typically useful to those carrying out these roles. Many of these (and other) nurses will also undertake training in independent and supplementary prescribing, which allows them (as of May 1, 2006) to prescribe almost any drug in the British National Formulary. This has been the cause of a great deal of debate in both medical and nursing circles.[5]

[edit] Hierarchy and nursing roles

Traditionally, on completion of training, nurses would be employed on a hospital ward, and work as staff nurses. The ward hierarchy consists of:

  • Healthcare Assistants etc. (see above for other titles) – Unregistered staff responsible for providing direct patient care, under the supervision of qualified nurses (often staff nurses). Under clinical grading (see below), these staff usually attracted A or B grades, and are now employed in Bands 2-3 under Agenda for Change (see below) although some roles are continuing to be developed and warrant a position at band 4 perhaps with a different title and involves more experience and/or qualifications. These positions at band 4 can often be referred to as Associate Practitioners and provide a more complex support role to the Registered Practitioner and/or Physician.
  • Staff Nurses – the basic grade of qualified nursing staff. These nurses are responsible for a set group of patients (e.g. one bay of a ward) or tasks (e.g. administering medications). In clinical grading, these nurses were usually employed at D grade, under Agenda for Change they are most likely to attract a band 5 salary. Level two nurses often hold positions anywhere between C and E grades, but are now banded exactly the same as first level staff nurses.
  • Senior staff nurses – these nurses carry out many of the same tasks, but are more senior to the staff nurses. This difference is usually academic, although it is evident occasionally when a senior staff nurse is in charge of the ward or department area during a shift. Employed at E or F grade under clinical grading, and may be assigned band 5 or 6 under Agenda for Change.
  • Junior/Deputy Sister; Charge Nurse; Ward Manager – responsible for the day-to-day running of the ward, and may also carry specific responsibilities for the overall running of the ward (e.g., rostering) in accordance with the wishes of the ward manager. These nurses were usually employed at F grade under clinical grading, and now are most likely to be assigned band 6, although some have attracted a band 7 salary.
  • Sister/Charge Nurse; Ward Manager – this nurse is responsible for running a ward or unit, and usually has budgetary control. He/she will employ staff, and be responsible for all the local management (e.g., rostering, approving pay claims, purchasing equipment, delegation duties or tasks). These nurses were previously employed at G grade, and now usually attract a band 7 salary (occasionally band 6, e.g. in the case of a small ward/ department, or if responsibility is shared).
  • Senior Sister; Charge Nurse; Senior Ward Manager – if there is a need to employ several nurses at a ward manager level (e.g. in A&E), then one of them often acts as the senior ward manager. These nurses were previously graded G or H, and now attract a banding anywhere between 6 and 8c.

There are also positions which exist above the ward level:

  • Clinical Nurse Manager/ Nurse Lead – A nurse who is responsible for an entire directorate/department (i.e. Surgical, Medical Diagnostic & Imaging etc.) or at least more than one ward, is often referred to as a clinical nurse manager. Depending on both the inclination of the NHS trust and themselves, they may be more or less involved in actual clinical nursing or management on a clinical level. Often employed at H grade, these nurses now attract band 8a (or occasionally 8b/8c) under Agenda for Change.
  • Modern Matrons – brought in in response to patients’ perceived detachment of nursing from its vocational history, the modern matron is responsible for overseeing all nursing within a department or directorate. Modern matrons used to be employed at H or I grades, and are now most commonly employed on bands 8a-c, occasionally on band 7. See Matron for more details of this role and its historical roots. Modern matrons were poorly received by the majority of nursing staff and their imposition was not called for by any professional group within the health service leading to many seeing the role as a waste of money and a professional step backwards especially as there is no clear role for them across the health service.[citation needed]

The status in the hierarchy of specialist nurses is variable, as each specialist nurse has a slightly different role within their respective NHS organisation. They are generally experienced nurses, however, and are employed at least on band 6 (previously F grade).

[edit] Pay scales

Until recently October 2004, all nurses in the NHS were employed on a scale known as clinical grading (see below). Agenda for Change was developed by the NHS in response to criticisms that the old scale reflected length of service more than knowledge, responsibility and skills.

Whilst developed by the NHS for its own use, both of these systems are in widespread use throughout the private sector.

[edit] Clinical grading

Also known as the Whitley system. This placed nurses (and some other hospital staff) on “grades” between A and I (with A being the most junior, and I the most senior).

Unregistered staff were employed on grades A and B (and occasionally C). Second level nurses were employed on various grades (usually between C and E), with first level nurses taking up grades D-I.

This system is still very popular amongst nurses, who will often refer to themselves by their old clinical grade than their Agenda for Change band (see below).[citation needed]

[edit] Agenda for Change

This system puts nurses (and most other non-medical/dental staff) on “bands” between 2 and 9. Unregistered staff take up bands 2-4, with qualified staff taking bands 5-8. Band 9 posts are for the most senior members of NHS management, currently there are no such positions in existence for nurses, although there will probably be such a position in future nursing in the UK.

The idea of this system is “equal pay for work of equal value”. There was a perceived discrepancy, under clinical grading, between ones grade (and therefore pay) and the work which one actually did, which Agenda for Change aimed to fix. Most NHS staff are now on the AfC system which took quite a long time to implement across the UK. A small percentage of staff are still going through an appeal procedure as they disagree with the band that they have been placed on.

Agenda for Change pay bands starting 1 April 2010, for the period of 2010/11. Pay for nurses on each of the bands is as follows:

  • Band 2: £13,653 – £16,753
  • Band 3: £15,610 – £18,577
  • Band 4: £18,152 – £21,798
  • Band 5: £21,173 – £27,534
  • Band 6: £25,472 – £34,189
  • Band 7: £30,460 – £40,157
  • Band 8a: £38,851 – £46,621
  • Band 8b: £45,254 – £55,945
  • Band 8c: £54,454 – £67,134
  • Band 8d: £65,270 – £80,810
  • Band 9: £77,079 – £97,478 [6]

Most nurses in England and Wales are now employed under Agenda for Change terms, however there are some still employed on clinical grades, especially in Scotland where only 9%[7] of the workforce has been assimilated. The government has set numerous targets for the transition to be complete (all now passed), but a full transition is yet to take effect.

There have recently been complaints of Agenda for Change being a sexist system, as nurses, who are mostly female, claim that, as a profession, they are under-valued using this system.



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