Nursing in the United Kingdom

Nursing in the United Kingdom has a long history, but in its current form probably dates back to the era of Florence Nightingale, who initiated schools of nursing in the latter part of the 19th and early 20th centuries. During the latter part of the 20th century, increases in autonomy and professional status changed the nursing role from "handmaiden" to the doctor to independent practitioners.

The profession has gone through many changes in role and regulation. Nurses now work in a variety of settings in hospitals, health centres, nursing homes and in the patients' own homes. Nearly 400,000 nurses in the United Kingdom work for the National Health Service (NHS). To practise, all nurses must be registered with the Nursing and Midwifery Council (NMC).

History

The history of nursing dates back to ancient times, where medical folklore was associated with good or evil spirits, the sick were usually cared for in temples and houses of worship. In the early Christian era nursing duties were undertaken by certain women in the Church, their services being extended to patients in their homes. These women had no real training by today's standards, but experience taught them valuable skills, especially in the use of herbs and drugs, and some gained fame as the physicians of their era. Remnants of the religious nature of nurses remains in Britain today, especially with the retention of the term "Sister" for a senior female nurse.^[1]

Florence Nightingale

Florence Nightingale is regarded as the founder of modern nursing profession.^[2] There was no real hospital training school for nurses until one was established in Kaiserwerth, Germany, in 1846. There, Nightingale received the training that later enabled her to establish, at St Thomas' Hospital in London, the first school designed primarily to train nurses rather than to provide nursing service for the hospital.

In the Crimean War against Russia, Nightingale was appointed to oversee the introduction of female nurses into the military hospitals in Turkey due to criticisms in the British press. In November 1854, Nightingale arrived at the Barrack Hospital near Constantinople, with a party of thirty-eight nurses. Initially the doctors did not want the nurses there and did not ask for their help, but within ten days fresh casualties arrived from the Battle of Inkermann and the nurses were fully stretched.

When Nightingale returned from the Crimean War in August 1856, she hid herself away from the public's attention. For her contribution to Army statistics and comparative hospital statistics in 1860, Nightingale became the first woman to be elected a fellow of the Statistical Society.

1858–1902

When state registration of the medical profession had begun in 1858, many observers pointed to the need for a similar system for nursing. That year, the Nursing Record (renamed the The British Journal of Nursing in 1902), a nursing journal, called for "... the whole question of the Registration of trained nurses to be set forth in a succinct form before the profession and the public". Support for the regulation of nursing began to become more widespread following the establishment of organised nurse training in 1860.

By the 1880s, the Hospitals Association (an early version of the NHS Confederation) was committed to the principle of registration for nurses. The Matrons' Committee, comprising the matrons of the leading hospitals, agreed with registration, but differed in their views of the required length of training, arguing for three years as opposed to the one supported by the Hospitals Association. In 1887, the Hospitals Association over-ruled the matrons and established a non-statutory voluntary register. At this the Matrons' Committee split between one group which supported the Hospitals Association and another faction, led by Ethel Gordon Fenwick, which opposed the new register and sought to align themselves more closely with the medical profession. Florence Nightingale, incidentally, supported neither group and was opposed to any form of regulation for nursing, believing that the essential qualities of the nurse could neither be taught, examined nor regulated.

In 1887, the group of nurses associated with Ethel Gordon Fenwick formed the British Nurses' Association (BNA), which sought "... to unite all British nurses in membership of a recognised profession and to provide for their registration on terms, satisfactory to physicians and surgeons, as evidence of their having received systematic training".

Therefore, two separate voluntary registers now existed. Whereas that maintained by the Hospitals Association was purely an administrative list, the register established by the BNA had a more explicit public protection remit.

1905–1920

• National Council of Nurses formed.
• The First World War results in large numbers of unmarried women, many of whom devote their lives to nursing.
• College of Nursing founded in 1915. (See entries on Cooper Perry and Royal College of Nursing)
• 1919 sees the Nurses Registration Act and the establishment of the Ministry of Health.^[3]

The pressure for state registration grew throughout the 1890s but was undermined by disagreements within the profession over the desired form and purpose of the regulatory system. In 1902, the Midwives Registration Act established the state regulation of midwives and, two years later, a House of Commons Select Committee was established to consider the registration of nurses.

The committee reported in 1904 and set out a detailed and persuasive case for registration. However, the government sat on the report and took no action. Over the next decade, a number of Private Member's Bills to establish regulation were introduced but all failed to achieve significant support in Parliament.

The First World War provided the final impetus to the establishment of nursing regulation, partly because of the specific contribution made by nurses to the war effort and also as a reflection of the increased contribution of women more generally in society. The College of Nursing (later the Royal College of Nursing) was established in 1916 and three years later persuaded a backbench Member of Parliament (MP), Major Richard Barnett, to introduce a private members bill to establish a regulatory system. The bill was finally passed in December 1919 and separate Nurses Registration Acts were passed for England/Wales, Scotland and Ireland, which was still part of the United Kingdom at the time. These acts established the General Nursing Council for England and Wales and the other bodies which survived intact until the legislative changes in 1979 which were to create the UKCC and the National Boards of Nursing. Ethel Gordon Fenwick was the first nurse on the English register.

1930s

• Foundation of the National Society of Male Nurses.
• The Royal College of Nursing gains its royal charter.

1940s

• Role of state enrolled nurse formally recognised, with two years' training instead of three.
• Horder Committee recommends fewer nursing schools and the introduction of inspection.
• Penicillin becomes available for civilian use.
• Numbers of male nurses increase as demobilised service men with medical experience join the profession.
• The National Health Service (NHS) is launched, offering comprehensive health care for all, free at the point of delivery, but paid for through taxation.

1950s

• Large influx of Caribbean entrants into British nurse training.
• Introduction of tranquillisers transforms mental health nursing.
• Male nurses join the main nursing register in 1951.
• University of Edinburgh runs the first course for clinical nurse teachers.
• The Mental Health Act 1958 abolishes the legal separation of psychiatric hospitals, allowing those patients to be admitted to any hospital.

1960s

• Availability of sterile supplies brings an end to washing and sterilisation of equipment such as dressings and syringes
• Edinburgh initiates the first degree in nursing.
• The Nursing Homes Act 1963 brings registration and greater control by local authorities.
• The Salmon report calls for reform to nurse grading, initiating the end of matrons.^[4]
• Nurse Dame Cicely Saunders sets up the first hospice in 1967.
• Termination of pregnancy becomes legal under the Abortion Act 1967.

1970s

• Nurses march to Downing Street demanding better pay, and win increases of up to 58 per cent.
• Manchester University appoints the first professor of nursing.
• The Royal College of Nursing (RCN) becomes a trade union.
• The Nursing Process establishes an ethos based on assessment, planning, implementation and evaluation.
• Reform of shift patterns begins

The Briggs Committee was established in 1970 due to pressure from the RCN to consider issues around the quality and nature of nurse training and the place of nursing within the NHS, rather than regulation per se. It reported in 1972 and recommended a number of changes to professional education. Almost as an afterthought, Briggs also recommended the replacement of the existing regulatory structure (involving nine separate bodies across the United Kingdom) with a unified central council and separate boards in each of the four countries with specific responsibility for education. Six years of debate and delay followed before the modified Briggs proposals formed the basis of the Nurses, Midwives and Health Visitors Act 1979. This was due to the need to take account of devolution, Treasury misgivings, lack of consensus within the professions (especially from midwives), and a lack of government will to find the parliamentary time to enact the legislation.

In 1979 the Royal Commission on the National Health Service reported that across the UK in hospitals there were 110,334 Registered Nurses, 63,208 Enrolled Nurses, 66,047 Student Nurses and 25,569 other nurses. In addition there were 10,623 Health Visitors, 15,280 District Nurses, 2,895 School Nurses and 9,240 other nurses in the community, 26,251 Midwives, 2,766 administrative nursing staff and 969 Blood transfusion nurses, a total of 430,506.^[5]

1980s

• Mass meetings are held over pay, the state of the NHS, clinical grading and the abolition of the enrolled nurse.
• United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) becomes the profession's new regulatory body in 1983.

In 1983, the UKCC was set up. Its core functions were to maintain a register of UK nurses, midwives and health visitors, provide guidance to registrants, and handle professional misconduct complaints. At the same time, National Boards were created for each of the UK countries. Their main functions were to monitor the quality of nursing and midwifery education courses, and to maintain the training records of students on these courses.

This structure survived with minor modifications until April 2002, when the UKCC ceased to exist and its functions were taken over by a new Nursing and Midwifery Council (NMC). The English National Board was also abolished and its quality assurance function was taken on board by the NMC. The other National Boards were also abolished, but new bodies were created in each country to take over their functions, for example, NES in Scotland.^[6]

1990s

• Reforms to training under Project 2000 begin to be implemented.
• Post-registration education is introduced.
• Nurse-led helpline NHS Direct is founded.

2000–2010

• Health care reforms set out in The NHS Plan.
• The Nursing and Midwifery Council takes over from the UKCC in 2002.
• Agenda for Change paves the way for a new pay structure for nurses.
• Nurse employers inspected for staff-friendly policies under Improving Working Lives and Investors in People.
• In 2005 nurse numbers hit 397,500 – an all-time high.
• Nursing students are given supernumary status throughout their three years of training.

2010-

Widespread reports of shortages of nurses after nurse training places were reduced by the Cameron government, and later nurse to patient rations improved in the wake of the Stafford Hospital scandal. Shortages were particularly acute in London where Barts Health NHS Trust reported 1200 vacancies - 1/5 of the nursing workforce in July 2015.^[7]

In August 2014 there were 325,000 nurses working in the NHS. Health Education England proposed to train 23,000 extra nurses by 2019. It expects around 31,000 Full Time Equivalent nurses to retire over 2014-19.^[8]

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.^[9]

The Nursing and Midwifery Council

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

• register all nurses and midwives and ensure that they are properly qualified and competent to work in the UK.
• set the standards of training and conduct that nurses and midwives need to deliver high quality healthcare consistently throughout their careers.
• set the standards for pre-registration nursing education
• ensure that nurses and midwives keep their skills and knowledge up to date and uphold the standards of their professional code.
• ensure that midwives are safe to practise by setting rules for their practice and supervision.
• use fair processes to investigate allegations made against nurses and midwives who may not have followed the code.

The powers of the NMC are set out in the Nursing and Midwifery Order 2001.^[10]

Membership of the council comprises 6 lay and 6 registrant members appointed by the Privy Council, including one member from each of the four UK countries. The registrant members consist of nurses and midwives. The lay members currently include people with diplomatic, legal and business backgrounds.

The NMC register

The NMC register is split into three main parts: Nurses, Midwives and Specialist Community Public Health Nurses (SCPHN). Within the registration it contains several "sub-parts" and qualifications e.g. sub part 1, sub part 2.^[11]

There are 618,187 registered Nurses, Midwives and SCPHNs. Of these:

• Over 53% are Adult Nurses.
• Over 60% are under the age of 40.
• 11.9% of registrants are male (74038).
• There are 132 male midwives representing 0.0002% of the NMC register of which 63 are in England, 7 in Scotland, 3 in Wales, 2 are in Northern Ireland with the remainder based outside of the UK.

Revalidation

Revalidation^[12] is a new requirement for all NMC registered members to revalidate every three years in order to ensure their registration can be renewed. Revalidation will be introduced from April 2016. Revalidation replaces Prep.

Revalidation Requirements

• 450 practice hours, or 900 if renewing as both a nurse and midwife
• 35 hours of CPD including 20 hours of participatory learning
• Five pieces of practice-related feedback
• Five written reflective accounts
• Reflective discussion
• Health and character declaration
• Professional indemnity arrangement
• Confirmation

Code of Conduct

A new NMC Code was introduced in March 2015,^[13] this replaced the 2008 NMC code. The NMC code presents the professional standards that nurses and midwives must uphold in order to be registered to practise in the UK.

Representation

Many nurses are members of the Royal College of Nursing (RCN) which has over 400,000 members: nurses, midwives, students and healthcare assistants. ^[14] The RCN has a duel role as both a Royal College and a union, this duel role was the subject of debate in 2013 and voted on dividing to form two organisations, 99.4% of voters did not want to divide. ^[15]

Other Trade unions that represent healthcare workers are Unite the Union ^[16] and Unison.^[17]

Nursing Values

The 6Cs

The 6Cs are Care, Compassion, Courage, Communication, Commitment and Competence.^[18]

The 6Cs began with the concept of 'Energise for Excellence for nurses, midwives and other care staff' ^[19] which was began by Jane Cummings and Katherine Fenton. Following the Francis report compassion within nursing was revisited and 'Compassion in Practice' became a key phrase which helped to introduce and formalise the idea of the 6Cs. The 6Cs were rolled out in December 2012.^[20]

#Hellomynameis

Started by Dr Kate Granger after an experience in hospital where a member of staff did not introduce themselves, the 'hello my name is...' campaign became part of the 6Cs where staff are encouraged to introduce themselves by name.^{[21] [22]}

The campaign operates on twitter using the hashtag #Hellomynameis.^[23]

Government Publications on Nursing

There have been a number of governmental publications on Nursing in the United Kingdom.

Committee on Nursing chaired by Professor Asa Briggs (1972)

Following the pay disputes and nurses strikes in the 1970s which included over 90,000 nurses The Briggs Committee was established. It reported in 1972 and recommended a number of changes to professional education. The focus was mostly on education and training but also included professional regulation. The report was accepted in 1974.^[24]

Front Line Care (2010)

Front Line Care and the government's response were published in 2010.^[25] The Chair of the Commission was Ann Keen MP who trained as a nurse.

Shape of caring review (2015)

The Shape of Caring Review, (Raising the Bar) was published in March 2015.^[26]

Employment

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. clinical support workers and healthcare assistants.
• Registered staff

Nursing Shortages

See also Nursing Shortages

In January 2016 the RCN stated that more than 10,000 nursing posts went unfilled in 2015.^[30] This represented a 3% increase year on year from 11% in 2013, 14% in 2014 and 17% in 2015 of all London nursing positions and 10% as an average nationwide.^[31] According to a BBC article the Department of Health said it did not recognise the figures.^[32]

Migration

An Organisation for Economic Co-operation and Development survey in December 2015 showed that 21.7% of NHS nurses, were born abroad compared with 26.9 in Ireland, 9.8% in Italy, 14% in Germany and 5.9% in France. The UK was the highest exporter of nurses, with more than 50,000 British nurses working in other OECD nations.^[27]

Non-registered staff

These staff can be found carrying out a number of roles, attracting various titles such as 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 and respiratory rate, or TPR) or measuring and assessing blood pressure, urinalysis, blood glucose monitoring, pressure sores (see waterlow score) and carrying out procedures such as catheterisation or cannulation).

Some unregistered staff can work in other roles, for example as phlebotomists (taking blood samples), ECG technicians (recording electrocardiograms) or smoking cessation therapists, a scheme currently being employed in a number of local G.P. Surgeries. 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.

Nursing Associate

Following the spending review of November 2015, where NHS student bursaries were to be removed MP Ben Gummer introduced the role of Nursing Associates who would work alongside healthcare support workers and fully qualified nurses focusing on patient care.^[28]

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:

• Staff Nurses – the first grade of qualified nursing staff. These nurses are responsible for a set group of patients to which they are responsible (e.g. administering medications, assessing, venepuncture, wound care and other clinical duties). Clinical grading, these nurses were usually employed at D grade, under Agenda for Change they are most likely to attract a band 5 salary.
• Senior staff nurses – these nurses carry out many of the same tasks, but are more senior to, and more experienced than the staff nurses. Employed at E or F grade under clinical grading, and may be assigned band 5 or 6 under Agenda for Change. Not all NHS Trusts have Senior Staff Nurses. Other areas may refer to them as Junior Sisters/Charge Nurses. And in other areas, there will be no rank between the Staff Nurses and the Sisters/Charge Nurses.
• 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. In some NHS Trusts, these will be known as Sisters/Charge Nurses
• 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 – developed 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.^{[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).

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 master's 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 master's 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.
• 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 and independent care sector 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 and independent healthcare organisations, some even as board members or directors. Others choose to stay a little closer to their clinical roots by becoming regional managers, service managers, clinical nurse managers or Modern Matrons.

Nurse education

Non-registered staff education

There is no mandatory training for most people undertaking non-registered staff roles such as a Healthcare Assistant. 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 recognised 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).

Pre-registration education

To become a registered nurse one must complete a nursing degree programme recognised by the Nursing and Midwifery Council from an approved provider i.e. universities offering these courses.

Education format

A Nursing course is a 50/50 split of learning in university (i.e. lectures and examinations) and in practice (i.e. supervised patient care within a hospital or community setting). Nursing courses are usually three years long and are 4,600 hours in length, which is split 50%/50% between theory and clinical placements as set out as a requirement of the NMC. Graduate courses are provided and are two years in length. Graduate courses often require prior learning and relevant healthcare experience this can be referred to as APEL (Accreditation of Prior and Experiential Learning). ^[29]

There are four different branches of nursing offered at university level (not including midwifery):

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

Nursing Diploma

State Enrolled Nurses (SENs) were formally recognised in the 1940s and training took place in hospitals. Nursing education remained closely linked to the hospital where nurses were placed and often lived.

Project 2000; The Nursing degree

Project 2000 was a project which began in the early 1990s was designed to move nursing education from hospitals into universities. Prior to 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.

From September 2013, all nurse training programmes must be at degree level, with no option to study instead for a diploma.

Midwifery education

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.

NHS Student Bursary

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 £6,000 – £8,000 per year (with additional allowances for students with dependant children), whereas degree students have their bursary means tested (and often receive considerably 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.

From 2017, it was announced in the chancellor's Spending Review of November 2015 that the NHS bursary would be removed for all future nursing, midwifery and Allied health Professionals.^[30]

Post-registration education

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. 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. However, from September 2013 onwards all students will only be able to study at degree level while diplomas are gradually being phased out permanently.^[31]

To become specialist nurses (such as nurse consultants, nurse practitioners, etc.) or nurse educators, some nurses undertake further training above bachelor's degree level. Master's 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 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 1 May 2006) to prescribe almost any drug in the British National Formulary. This was the cause of a great deal of debate in both medical and nursing circles.^[32] However, as of 2012 there were over 25,000 Nurse prescribers. Nurse Prescribing had become a mainstream role within nursing, accepted by not only healthcare professionals but also patients. After a historic change in legislation (which came into force in England on 23 April 2012) nurse prescribers were now able to prescribe exactly the same medicines as Doctors (including Controlled Drugs). A common set of prescribing competencies were published in May 2012 by the National Prescribing Centre for all prescribing professionals.

Nursing Students

Until the 1990s nurse training took place in schools attached to hospitals or within hospitals themselves. Nursing students were considered as NHS employees and paid a salary. Project 2000 was a project which began in the early 1990s was designed to move nursing education from hospitals into universities. Prior to 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. From September 2013, all nurse training programmes must be at degree level, with no option to study instead for a diploma.

NHS Student Bursary

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 £6,000 – £8,000 per year (with additional allowances for students with dependant children), whereas degree students have their bursary means tested (and often receive considerably 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.

From 2017, it was announced in the chancellor's Spending Review of November 2015 that the NHS bursary would be removed for all future nursing, midwifery and Allied health Professionals.^[30]

NHS Student protests #BursaryorBust

In the November 2015 Spending review,^[33] George Osbourne stated that he would remove the NHS Student Bursary from 2017 prompting NHS Student nurses, midwives and Allied Health Professionals to protest outside the Department of Health in December 2015.^[34]

January 2015 Protest

NHS Students marched on Downing Street in January 2016.^[35]

Placement walkout

In February, NHS students walked out of placement in solidarity with the Junior Doctors strike^[36]

Nursing Research

For the full article see also (Nursing Research)

Nursing research is research that provides evidence used to support nursing practices. Nursing, as an evidence-based area of practice, has been developing since the time of Florence Nightingale to the present day, where many nurses now work as researchers based in universities as well as in the health care setting.

Pay scales

Until 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.

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

Agenda for Change

This system puts registered staff on bands 5–8, unregistered staff such as Healthcare Assistants take up bands 2–4. Band 9 posts are for the most senior members of NHS management. Each band contains a number of pay points.

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 went through an appeal procedure as they disagreed with the band that they have been placed on.

In 2015-16 the minimum starting salary for a registered nurse will be £21,692 in England, Wales while in Scotland it will be £21,818.^[37] As of 4 June 2015 Northern Ireland have yet to announce their pay rates for 2015-16.^[37]

Pay disputes

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.^[38]

In 2015 the RCN stated that Nurses had suffered a drop in pay equivalent to 9.8% in real terms since 2008.^[39]

Agency Nurse Pay Cap

In 2015 the government announced that there would be a gradual introduction of pay caps for agency nurses working under NHS England. Starting in November 2015, further caps came in February 2016 with the final cuts introduced in April 2015. The aim of the cap was to save £1bn over three years. The implications of the pay cap means that trusts will not be able to pay staff who work for an agency including doctors and nurses, more than 55% more for a shift than a permanent member of staff.^[40] Jeremy Hunt in his capacity as the Health Secretary said it would stop agencies "ripping off the NHS".^[41]

In response a petition started on the government website which received over 10,000 responses.

NHS Pension

The NHS pension is the main pension offered to NHS staff. There have been three distinct changes made to the NHS pension. The type of pension someone is enrolled onto is referred to by the year that it was introduced or changed 1995, 2008 & 2015.^[42]

See also

• History of Nursing
• History of Nursing in the United Kingdom
• National Health Service
• Nursing and Midwifery Council
• Royal College of Nursing
• Matron
• Nurse
• State Enrolled Nurse
• Men in Nursing
• History of Nursing in the United States
• History of Philippine nurses in the United States
• Nursing in Australia
• Nursing in Canada
• Nursing in Germany
• Nursing in Hong Kong
• Nursing in India
• Nursing in Islam
• Nursing in Japan
• Nursing in Kenya
• Nursing in Pakistan
• Nursing in the Philippines
• Nursing in Taiwan
• Nursing in the United States

References

Nursing Levels of practice Generalists Clinical nurse leader Licensed practical nurse Registered nurse Advanced practice APRNs by role Clinical nurse specialist Nurse anesthetist Nurse midwife Nurse practitioner NPs by Population Family Adult-Gerontology Pediatrics Women's health Neonatal Psych/Mental health Education and licensure Associate of Science in Nursing Bachelor of Science in Nursing Diploma in Nursing Doctor of Nursing Practice Master of Science in Nursing Board of nursing Nurse Licensure Compact Nursing credentials and certifications Nursing school Nurse registry NCLEX TEAS Specialties and areas of practice Ambulatory care Cardiac Critical care Education Emergency Faith community Flight Forensic Geriatrics Holistic Home health Hyperbaric Legal consultation Management Matron Medical-surgical Midwifery Military Neonatal Nursing informatics Obstetrics Occupational health Oncology Orthopedics Pediatrics Perianesthesia Perioperative Psychiatric and mental health Private duty Public health School Space Telenursing WOCN Nursing process Assessment Diagnosis Planning of care Classification systems NANDA Nursing Interventions Classification Nursing Minimum Data Set (NMDS) Nursing Outcomes Classification Category Commons Portal WikiProject

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