The National Health Service Knowledge and Skills Framework and its implications for continuing professional development in nursing

The National Health Service Knowledge and Skills Framework has been introduced as part of the Agenda for Change Reforms in the United Kingdom to link pay and career progression to competency. The purpose of this paper is to consider the implications for nurses, their managers and the impact on university departments delivering continuing professional development for nurses. The new system has the potential to increase the human resources management aspect of the clinical nurse managers' role and could have legal implications, for example if practitioners perceive that their needs for continuing professional development have been overlooked to the detriment of their pay and career aspirations. The new system also has implications for providers of continuing professional development in the universities and is likely to demand closer liaison between education providers and trust staff who commission education and training. The Knowledge and Skills Framework is of interest to nurses and nurse educators internationally because the system, if effective, could be introduced elsewhere.     

Employment experiences of older nurses and midwives in the NHS

AIM: To examine the employment experiences of older nurses and midwives working in the NHS. METHOD: A total of 27 semi-structured telephone interviews were conducted with nurses and midwives to identify positive and negative aspects of their working lives in the NHS. The interviewees were selected from a potential pool of 87 nurses and midwives who had consented to be involved in an earlier part of the study. Data were analysed using QSR NVivo 7.0. FINDINGS: Positive and negative issues were identified as having an impact on the quality of working life. These included: access to training, change and Agenda for Change (AfC), quality of management, work demands, patient/colleague contact and nursing and midwifery as a career. CONCLUSION: This study highlighted a number of issues relevant to older nurses and midwives that warrant further study and attention. These include access to training and continuing professional development, issues relating to change and AfC, and general work demands including workload, resources and morale. The ability of staff to remain healthy, committed and able to deliver quality care can be compromised in cases where the staff experience is negative.     

Effects of Case Management on the Nursing Context-Perceived Quality of Care, Work Satisfaction, and Control Over Practice

Purpose: To examine in 1995 the effects of case management on the context of nursing practice-perceived quality of care delivered, work satisfaction, and control over nursing practice-rather than the commonly studied effect on fiscal outcomes.
Design: Prospective quasi-experimental. Sampled were nurses on four units at one community hospital where patients with DRG 107 (Coronary Artery Bypass Graft, with no cardiac catheterization) were traditionally hospitalized.
Methods: Registered nurses on these units completed quality of care, satisfaction, and practice-control scales before and 1 year after implementation.
Findings: Significant positive differences were found in several aspects of perceived quality of care for both staff nurses and case managers, with specific increases found in nurses' perceived ability to develop relationships with patients, ability to be therapeutic, and support for good care from the institutional structure and administration. A significant decrease in nurses' satisfaction with their pay and other rewards as well as respect from colleagues was found. Case managers were found to have significantly increased perceptions of control over their practice.
Conclusions: Case management was found to have a primarily positive effect on nurses-staff and case managers alike. There were significant increases in several aspects of the nurses' perceptions of the quality of care delivered. Additionally, case managers were more satisfied with the administration, the respect they received, and their pay and rewards in the institution. Most strikingly, case managers perceived themselves to have more control over their practice. Some negative effects of the program were a decrease in satisfaction with the pay and rewards by the staff who were not case managers.     

Agenda for Change: the knowledge and skills framework

This article examines a range of issues associated with role redesign and pay modernisation in the light of Agenda for Change (DoH 1999a). It is argued that the Knowledge and Skills Framework is central to Agenda for Change and should not be seen in isolation, but needs to be considered alongside other changes that are being introduced as a result of GP practice and consultant contracts.     

Implementing clinical education for phlebotomists

Change is a regular occurrence in the healthcare system, but individuals might see it as difficult, stressful and frustrating. Implementing change with strategic planning and support for staff is an effective method. This article describes the change process for introducing a formal education programme for phlebotomy staff in an acute paediatric and maternity NHS trust hospital.     

The use of rewards for employees in the National Health Service

This paper examines the purpose of rewards and explores their theoretical base. The implications to managers are identified and an examination of intrinsic and extrinsic rewards for nursing and other staff within the National Health Service NHS is undertaken. Job content and context are explored. The limitations imposed on a public sector organization are identified as well as some of the resulting national benefits. Job design is seen as crucial, both as part of a reward system and as a means of enabling health services to respond flexibly through current changes.     

Evaluating the impact of a new pay agreement on New Zealand nursing

Aim: This paper examines the labour market impact of a new national pay award for nurses implemented in New Zealand in 2004/5 – the Multi‐Employer Collective Agreement (MECA). Background: The health system in New Zealand is unusual in that, while retaining a public sector system, the focus of pay determination for nurses over the last 20 years has shifted first from national to local pay determination, and then more recently reversed this trend, moving back to a national level pay determination. The shift back to a national pay determination approach in 2004/5 is therefore worthy of examination, both in terms of its labour market impact, and as a case study in the use of national level pay determination. Methods: The research was conducted in 2007–8. A rapid appraisal method was used, based on key stakeholder interviews, a document and literature review and a review and analysis of available data on the New Zealand nurse labour market, and trends in application rates to schools of nursing were assessed. In addition, interviews with managers of two District Health Boards, and interviews with five non‐government employers of nurses, were conducted. Results: Indicators pointing to improvements included: steady (though not rapid) growth in staff numbers; reduced difficulty in recruiting; reduced vacancy rates; and increased application rates to schools of nursing. Managers interviewed in the study supported these positive indications, but some health‐care employers not covered by the pay award reported negative knock‐on effects (e.g. needing to match DHB rates, increased retention and recruitment difficulties). Conclusions: Available nurse labour market data provide an incomplete but compelling picture of the positive impacts of the MECA in a period of a very tight labour market. While much of the content of the 2004/5 agreement could be characterized as a ‘normal’ pay bargaining contract, there were also issues that differentiated it from the norm. In particular, it included an agreement to establish a safe staffing commission to assess the impact and implications of low staffing levels, nursing workload, and to establish guidelines on safe staffing and healthy workplaces.     

Go the extra mile--use the Delphi Technique

AIM: The Delphi Technique is reviewed and its potential contribution to the management of change assessed. BACKGROUND: Change management is an essential skill required, not just by managers, but by all staff working in health care. Modern theories advocate participation and free communication to engender commitment and ensure successful change. Data collection methods associated with surveys--interviews and questionnaires--are regularly used to obtain information for service development. Indications of likely resistance are more difficult to obtain. KEY ISSUES: The Delphi Technique is critiqued and found to incorporate many attributes that can produce information which would be otherwise difficult or impossible to obtain. A recently published study performed by the author illustrates this potentiality. An indication of the impact of the findings on the subsequent implementation of change by service managers is provided. CONCLUSION: The Delphi Technique is a useful management tool that can provide data that are difficult to obtain by other means.     

The problem and management of sickness absence in the NHS: considerations for nurse managers

AIM: This paper examines the topic of sickness absence management in the context of the healthcare sector. BACKGROUND: National Health Service (NHS) employee absenteeism is an expensive and difficult problem. Nurse managers need to assess the extent and characteristics of absenteeism, be aware of their organization's sickness policies, evaluate the effectiveness of these policies and contribute to the development of related initiatives to ensure prudent management of sickness absence. METHOD: A literature review has been undertaken, providing a broad conceptual context by which the problem of sickness absence in the NHS can be examined. The focus of this paper is to examine the accumulation of research based knowledge to provide a healthcare perspective on the problem of sickness absence management. CONCLUSION: Sickness absence management within the NHS is challenging but provides opportunities to improve the working lives of NHS employees. Sickness absence cannot be eradicated but it can be reduced by a selection of measures that reflect the uniqueness of the NHS. The many and diverse causes of sickness absence need acknowledgement, when devising strategies that can effectively provide solutions to the problems of sickness absence.     

Implementing KSF competency testing in primary care. Part 2: Evaluation of the pilot of an appraisal tool

Assessment of competence is a way of measuring if staff are fit for purpose. Clinical competences, against which performance is measured, have been developed in a wide range of clinical settings in recent years (Department of Health (DH), 2008). Several trusts also operate an assessment centre in the recruitment and selection of staff, and these frequently involve competency testing in order to be certain that their new recruits are fit for their post. Agenda for Change (DH, 2004a) firmly links pay to the competences expressed in the Knowledge and Skills Framework (DH, 2004b; c) yet the KSF has not been implemented in all trusts. In part 1 of this article (Bentley and Dandy-Hughes, 2010), the process of Southwark PCT's competency project was described. This involved the process of writing measurable, manageable competences from the KSF, in order to develop staff to be fit for purpose. Part 2 evaluates the use of the appraisal tool that was developed from the KSF, and examines the role of the nurse consultant in education who led the competency project.     

Purchasing post-qualifying professional education in the health care sector

The National Health Service (NHS) is proposing to establish local consortia for educational contracting, with a wider involvement and responsibility being devolved to service managers. This paper addresses the educational issues of purchasing post-qualifying professional education for a cross-section of NHS hospital professionals. The professions chosen for comparison were clinical staff and include nurses, doctors, and as an example of paramedical professions', physiotherapists.     

A ward without walls? District nurses’ perceptions of their workload management priorities and job satisfaction

Aim. To explore district nurses’ workload management, job satisfaction and the challenges they face. Background. This paper reports qualitative findings from a qualitative and quantitative study to identify a district nursing perspective on use of time, challenges and work satisfaction. District nursing is under increasing pressure because of the increasing shift to care in the community, early hospital discharge and changes in demography with an ageing population and more people with chronic illnesses. Design. Qualitive. Method. The study took place in one Scottish Health Board and data were collected in February and March 2005. The qualitative approach involved a total of 31 district nurses and senior managers in focus group discussions or individual interviews. Results. Three main themes were identified: (1) the priorities of district nurses and their views on work unrelated to ‘hands on’ clinical care, (2) aspects of district nursing considered stressful and (3) district nurses’ job satisfaction. Conclusion. District nurses and managers agree that caring work with patients is the priority for the service and provides job satisfaction. Many nurses feel overwhelmed by their workload and have little control over the admission of patients to their caseload; they are mainly demand led and therefore reactive care providers. A culture of long hours has developed as district nurses struggle to meet the needs of patients. Feeling devalued lowers satisfaction and Agenda for Change is perceived as de‐valuing the skills of community nurses. Relevance to clinical practice. More clerical support is required so district nurses can deliver care to patients. District nurses can better represent their workload and how it is managed through expressing the nature of assessing risk and caring for patients as opposed to defining patients care needs by medical diagnoses. Extending the hours of the full district nursing service would benefit patients and staff.     

Valuing 'voices from below'

The publication of Commission for Health Improvement (CHI) reports in recent years have revealed that employees attempted to blow the whistle on abuse, corruption or malpractice but were largely ignored by senior members of staff. The CHI report into the North Lakeland National Health Service (NHS) Trust (November 2000), for instance, states that an initial failure among management to listen to the concerns of student nurses led to the sustained abuse of patients. To protect patients from incompetent and unethical practitioners and improve standards of care, an environment needs to be created where health care professionals feel able to express legitimate concerns openly and honestly to senior staff, safe in the knowledge that senior managers will take their concerns seriously and act accordingly. The government has pledged to create an 'open culture' in the NHS to encourage staff with genuine concerns to speak out. This can only be achieved if the current leadership culture characterized by conflict avoidance, blame and hierarchical control is replaced with openness and accountability. To produce the desired changes in culture and attitudes, the NHS needs strong leaders capable of challenging the existing social equilibrium.     

The management of poor performance in nursing and midwifery: a case for concern

stone k., traynor m., gould d. & maben j. (2011) Journal of Nursing Management 19, 803–809
The management of poor performance in nursing and midwifery: a case for concern Aim(s) To examine the evidence of how poorly performing nurses and midwives are managed in the UK National Health Service (NHS). Background Nurses and midwives form the largest clinical group in the NHS. There is little evidence, however, about poor performance and its management in nursing and midwifery literature. Method(s) The present study comprised a literature search, analysis of recent Nursing and Midwifery Council (NMC) data and observation at NMC fitness to practice hearings. Results Nurses and midwives are the clinical groups most likely to be suspended in the NHS; Trusts do not report data on suspensions therefore no data exist on numbers, reasons for suspensions, managerial processes, gender, area of work, or ethnicity of those suspended; the few major research projects identify variable management practices, the significant financial cost to the NHS and the personal cost to those suspended; there is evidence that inexperienced, poorly trained, or poorly supported managers use suspension inappropriately. Our observation supported this. Conclusion(s) There is a need for robust data gathering and research in the field of NHS managerial practice. Implications for nursing management Managers should refrain from adopting punitive forms of performance management. Frontline staff and management need better training and support for dealing with poor performance.     

Supporting students in practice

This article reports a project aiming to assess the effectiveness of clinical nurses employed in support roles for students in clinical practice in one UK higher education institution and its linked NHS Trusts. Focus groups and telephone interviews were used to collect data from the clinical support nurses themselves, senior nurse managers and pre- and post-registration students. Findings show that personal commitment to the role was high and that these support staff made a valuable contribution to up-to-date clinical input into classroom teaching. Managers also valued the university-clinical link role fulfilled by these staff. Students had mixed opinions, pre-registration students having had little exposure to this kind of support and post-registration students often not regarding clinical support as necessary because of their own existing clinical experience and expertise. For clinical support staff themselves, the role was a busy one and they often experienced conflict and role overload in balancing the education and clinical sides of their work. Necessary improvements for functioning of the roles were identified, including having regular meetings between university and NHS managers and support teachers for liaison purposes, joint appraisal, and formal support mechanisms for role occupants. The overall conclusion drawn is that the roles were successful in bridging the theory-practice gap for the University and NHS Trust managers, but less so for students, and that they did this at some personal cost for role holders.     

Infection control nurses' perceptions of the Code of Hygiene

randle j. & clarke m. (2011) Journal of Nursing Management 19 , 218–225
Infection control nurses’ perceptions of the code of hygiene Aim The aim of the study was to understand senior infection prevention and control nurses’ experiences and perceptions of implementing the day to day aspects of the Code of Hygiene. Background The Code of Hygiene is legislative and sets out compliance standards in order to reduce infection rates. It details standards by which health-care providers failing to comply with infection control standards can be subject to improvement notices and actions. Methods Senior nurses from five infection prevention and control teams in England participated in taped, qualitative interviews which were analysed. Findings Two themes emerged from the data: ‘Interventions’ and ‘Barriers to compliance’. Interventions were driven by senior NHS managers and necessitated organizational change. It was senior NHS managers who were considered as being the force for change and who intervened and took responsibility for implementation. Change was achieved by a top-down approach and was driven by senior managers’ fear of external censure. At the same time, participants felt they had more authority as a consequence of these changes as they too, felt they could enforce change. Barriers to compliance were identified as: a lack of facilities, specifically a lack of side rooms and isolation facilities, and the non-engagement of medical staff. Implication for nursing management Compliance was achieved by organizational change and senior managerial intervention. Barriers to compliance must be addressed to meet the Code of Hygiene’s compliance criteria.     

The shadowing experience for nursing students

The shadowing scheme supports nursing students in learning how to manage and identify the characteristics of good leadership. Derby Hospitals NHS Foundation Trust and the University of Nottingham offered nursing students the opportunity to shadow service leaders and managers during their final semester. This initiative promotes an effective service, takes account of students' needs and interests and supports the government's modernisation agenda and the NHS Plan (Department of Health (DH) 2000).     

Clinical governance in practice: closing the loop with integrated audit systems

Clinical governance has been acknowledged as the driving force behind National Health Service (NHS) reform since the government white paper outlined a new style of NHS in the UK in 1997. The framework of clinical governance ensures that NHS organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will develop. A major component of a clinical governance framework requires utilizing audit procedures, which assess the effectiveness of current systems and ultimately direct continual quality improvement. This paper describes the audit component of a local clinical governance framework designed for a unit based within an NHS trust, which has utilized a multidisciplinary approach to assess the effectiveness of a newly commissioned service and its impact on the residents and staff. The unit is a 12-bedded, low-secure-intensive rehabilitation unit for clients with severe and enduring mental illness. Using recognized and standardized psychometric outcome measures, information was collected on clinical symptoms, social functioning, social behaviour, quality of life, relationship quality with named nurses and medication side-effects. Additionally, confidential staff measures were included to assess levels of burnout, identify expressed emotion and assess staff perception of models of illness. The paper includes a comprehensive account of how managerial commitment, teaching processes and application of technology ensured prompt data collection and maintained the momentum through the audit timescale. Data analysis and presentation of data in both clinical reviews and in senior management meetings within the unit are discussed. Findings highlight the full integration of the audit system into the processes of the unit. Clinically, the paper highlights the enhancement of the knowledge base of the client group and the influence on clinical decision-making processes and care delivery as a result of the audit. Brief clinical examples are given. In conclusion, the impact of the audit on unit strategy and organizational efficiency are discussed to highlight the importance of closing the audit loop and completing the cycle of clinical governance. The audit system has positive implications for replication in other services.     

Turnover, age and length of service: a comparison of nurses and other staff in the National Health Service

Using information collected from more than 100 district health authorities in England for the year 1989–1990, this paper examines turnover rates amongst a range of nursing and other staff groups in the National Health Service (NHS), and their relationship to the age and length of service characteristics of the labour force. The evidence collected suggests that the NHS employs a significantly younger workforce than is found in the economy as a whole. The age profile of nurses is even more skewed towards younger age groups than that of non-nursing staff working in the NHS. Nurses tend on average to have longer lengths of service than non-nursing staff groups, and it would seem that the average length of service has increased over the last 20 years, certainly amongst registered nurses. Overall, the study found an annual turnover rate amongst all NHS staff of 13.6%. Turnover rates were significantly higher among full-time staff than part-time, and amongst non-nursing staff groups compared with nurses. Broadly, turnover rates decline with age then rise close to retirement. However, there is a more complex relationship between length of service and turnover: turnover rates tend to be high in the first year of service, and to remain high or even rise during the second year of service, before declining. Turnover remains a poorly understood issue in the NHS. The evidence presented here should move some aspects of debate onto a more solid empirical foundation.