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Revalidation – a Blessing or a Curse?

Revalidation is the new process by which nurses and midwives will renew their registration.

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Revalidation is the new process by which nurses and midwives on the Nursing and Midwifery Council (NMC) register will renew their registration, starting in April 2016. 

As in previous years, renewal of registration takes place every three years and on the past was achieved through the completion of a Notification of Practice (NOP) Form (now an online form).  At that time, the registrant declared that they had met the requirements for continued registration and were of good health & character and they paid their (now) annual fee.  The answer to all questions on revalidation can be found in the NMC ‘bible’ ‘How to Revalidate’ – and I would encourage all registrants to become familiar with this document.  The NMC Website has and links to PowerPoint presentations, mandatory and suggested templates / forms, guidance documents, and much more – everything you need to become an expert and controller of your own Revalidation destiny!  The following sections outline the processes in which Revalidation will take place.

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NMC Online

The first step is to set up an account via NMC Online.  This will be the only way in which your revalidation application can be made.  It is now the process in which NOP applications are being made too (last time I did mine in August 2013 it was paper form via the post).  Here is the guidance document on how to set up your account if you have not done so by now!  The NMC will keep you updated on your own revalidation and other important issues via your NMC Online-registered email address.  They will also use this email address to contact you for verification / audit, so I always advise NOT using an email address that you can only access whilst at work.

The Code

The new NMC Code was approved in March 2015 and a copy of this was sent to every registrant in April.  The Code underpins everything within the Revalidation process and is a living guide to every registrant and their practise. Many aspects of the process will require reference to pillars and sections of the code, so I advise all registrants to have their copy of the Code handy (either the leaflet version that was posted to us, a printout of the PDF referenced above, or via the e-edition) when working through the steps below.

To e- or not to e-:  Your Revalidation Portfolio

The NMC recommends that you maintain a portfolio (and this recommendation has not changed from the previous requirements in Post Registration Education & Practice (PREP).  All of the resources discussed below (and any associated evidence) could / should be maintained within the portfolio.  There is no requirement to upload anything to the NMC.  There will be some who might choose to use an electronic portfolio as a handy way to store things.  Please note that due to issues related to data protection and information management, some forms used for Revalidation cannot be scanned and uploaded electronically.  They will need to be maintained in a paper-based portfolio only.  I will explain in detail where this is relevant.  All other forms, documents, evidence etc. that you choose to upload must NOT contain any data which can identify another person, patient etc.   The NMC has produced a Guidance Document on Portfolios which some registrants have found useful.

Practice Hours

Every nurse registrant and every midwife registrant requires to have worked a minimum of 450 hours of nursing practice relevant to their area / scope of practice within the 3-year renewal cycle.  If you are a nurse and a midwife, you will require 900 hours of practice.  The NMC have provided a handy Practice Hours Template Log that you may choose to use for recording of your practice hours.  It is unlikely that you will need actual proof or evidence of the hours, but if you do, copies of job description, work plan, work rota and other documents may assist in this process.

Continuing Profession Development

Every nurse registrant and every midwife registrant requires to have completed a minimum of 35 hours of CPD relevant to their area /scope of practice within the 3-year renewal cycle.  At least 20 of the 35 hours must have been conducted with other professionals (‘participatory CPD’).  The NMC have provided a handy CPD Log that you may choose to use for recording of your CPD.  You may want to have some evidence of your CPD handy also – such as notes from your training / study, copies of hand-outs / presentations, a certificate of attendance and other items as may be applicable.  A certificate of attendance, on its own is not sufficient as you need to evidence how you used this learning / development to improve your practice.

Practice Related Feedback

Every nurse registrant and every midwife registrant requires to have documented at least 5 sources of practice-related feedback within the 3-year renewal cycle.  The feedback should come from a variety of sources, some of which could include patients, service users, students and colleagues. Feedback can also be obtained through reviewing complaints, team performance reports and serious event reviews.  Feedback can be informal or formal, written or verbal.  Feedback does not need to be specific to you as an individual it can be about a whole ward, team or organisation (such as an inspection / audit report).  The information should be recorded anonymously so as not to identify a person or patient and the NMC have not recommended or suggested a template form.  My suggestion for a template would be to include details as below:

DateSourceAction Taken to improve Your Practice
01/01/1990 Patient 1 Patient commented that…

Refection & the Reflective Discussion

Every nurse registrant and every midwife registrant requires to have completed a minimum of 5 Reflective Accounts relevant to their area /scope of practice within the 3-year renewal cycle.  The NMC have provided a Reflective Account Form that you must use to document each of your reflective accounts.  You can choose to reflect on a range of issues, chosen from your Practice Related Feedback (see below) and/or a session of CPD (see above) and/or an event or experience in your practice.  I’ve done a few already and it does not take that long to do one (30 minutes on average?).  I would encourage each workplace to have spares of the Reflective Account Form handy, as ideas and opportunities for reflection will occur on an almost daily basis.  I am a natural reflective practitioner and use my own ‘model’ of reflection.  The NMC suggests that you can use any model you wish as long as you can take your documented reflection and fit it into / onto the mandatory form.

For each of the Reflective Accounts, you must have had a professional discussion with a reflective partner (who must be on the NMC register).  The NMC have provided a Reflective Discussion Form that you must use to document your discussions.  You can use one form for one or more discussions and it is the reflective partner who is expected to complete the detailed parts of the form.  The NMC has produced a Guidance Document on conducting reflective discussions which some registrant have found very useful.  Because the Reflective Discussion form(s) contain(s) details that can identify another individual (your reflective partner), you cannot save this document electronically.  You will need to print it off and have the reflective partner complete the form(s) manually and save it (them) in your ‘paper-based’ portfolio.

I feel that reflection and the ensuing discussion are the most important and potentially powerful vehicles for development and improved practice.  I wold suggest that you choose your reflective partner according to who you think will be effective or you; and to use one form /partner for each discussion / reflection.  I would also encourage you to complete these as you move through your triennial renewal cycle and not save them up and rush through them when you realise revalidation is imminent!

Confirmation

No more than 12 months in advance of your Revalidation Date, you should arrange to have a Confirmation Discussion. This cannot be arranged until you have gathered the evidence above and have the required forms filled in and ready for review.   The Confirmer should be the person who normally does your appraisal / supervision (e.g. your line manager) and it does not matter if this person is not an NMC registrant.  The NMC has produced an Information for Confirmers guide that is very useful.  In the main, the confirmer’s role is to act as a third party to confirm that the requirements set above have been met.  They are not there to grade or assess the elements of revalidation that you present to them nor are they there to assess your fitness to practice; simply to confirm that they have seen them.

At the completion of the confirmation discussion, the Confirmer will then be asked to complete and sign a declaration that they have confirmed your readiness to revalidate.  The NMC have provided a Confirmation Form that must be used to document your discussions.  Because this form contains details that can identify another individual (your confirmer), you cannot save this document electronically.  You will need to print it off and have the confirmer complete the form manually and save it in your ‘paper-based’ portfolio.

Revalidation Application

Once the confirmation process has been signed off, you are effectively ready to revalidate.  Your Revalidation Date is a fixed date (e.g. 18th May 2015).  In this example, your registration would expire on the 31st May 2015.  Your deadline to revalidate (your Revalidation Application Date) is therefore the 1st of the month (1st May 2015).  The NMC will send you a notification you that you can revalidate 60 days before your Revalidation Application Date (e.g. 1st March 2015).  From this notification date, you then have that 60-daty window in which to complete the Revalidation Application.

In completing the Revalidation Application, in addition to declaring that the requirements above have been completed and subsequently confirmed by a third party, you will also require to make a declaration that you are of good health & character and that you have an appropriate level of professional indemnity (as you would through NOP).  Once you have completed the online Revalidation Application, you should receive a confirmation soon thereafter that your revalidation has been successful and that your registration has been renewed.

I would recommend that every registrant logs in to their NMC Online account to verify (well in advance of the registration expiration date) to ensure that their statement of entry has been successfully updated; a printed copy of which could be  retained within the portfolio and provided to your line manager / confirmer for their records.

Verification / Audit

As with the PREP portfolios, the NMC will select a small percentage of registrants for verification / audit.  It is envisaged that if you are selected, you (and your confirmer) will be sent an email within 24 hours of your Revalidation Application submission.  You will both be required to follow the link provided by the NMC in order to provide additional information to support the verification / audit process.  There is no set timescale for you (and your conformer) responding to this request, but remember that (either of you) not responding can put your registration at risk!

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A lack of proper breaks is leaving tired nurses driving dangerously

Tired and overworked nurses feel they are putting their lives in danger just to ensure patients get the care they need.

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Driving Home from Work

The majority of staff admitted they often felt unsafe driving home.

Tired and overworked nurses feel they are putting their lives in danger just to ensure patients get the care they need, according to a survey by NursingNotes.

A survey of 2,660 healthcare workers prompted by the recent deaths of two nurses, sought to examine how safe staff felt driving home from their place of work after a night shift.

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The majority of staff (73%) said they felt unsafe driving home. Over half (58%) said this was because they did not have the time to take their unpaid allocated rest break. When staff do take breaks, most staff (77%) said their employer did not allow them to sleep during this unpaid period. One respondent said; “When I drive home from a night shift I feel like I am drunk. It sounds odd but I feel dazed and out of it and have slower reactions.”

An overwhelming amount of staff (96%) admitted to feeling stressed or tired during the drive home and nearly all of all those surveyed said they were often forced to leave late because they still had patient care to provide – only further compounding tiredness.

Numerous respondents cited chronic understaffing and high patient acuity as the reason for leaving late.

Falling asleep at the wheel.

Respondents often described driving home after a night shift as like being on “autopilot” and the majority (80%) admitted to not always remembering how they got home. One respondent said; “I find myself drifting easily between lanes. A lot of my nights I run with very short staffing levels and get no breaks and I never remember driving home after these. I have almost drifted into cars in other lanes.”

Around two thirds (65%) of respondents admitted to being involved in one or more ‘near-miss’ while driving home after a night shift. Nearly a quarter (23%) admitted to being involved in at least one minor road traffic collision and twelve staff said they had been hospitalised as a result.

One respondent said; “A colleague of mine died in an RTC after a night shift,” adding “the coroner concluded she fell asleep and went headfirst into a lorry.”

A significant proportion of staff (40%) admitted having fallen asleep at the wheel with one nurse admitting; “I was driving back from work on the motorway after a stressful day and had an accident – swerved across the 3 lanes and the hard shoulder, somersaulted onto a trailer”. Another added, “the rumble strip has woken me up more than once”.

Driving tired is like driving drunk.

Dr Michael Farquhar, a Consultant in Sleep Medicine at Guy’s and St Thomas’ NHS Foundation Trust, said that while the NHS provides 24/7 emergency care “we all too often ignore the consequences on NHS staff themselves of working around the clock”.

He added; “Working long shifts, often under considerable pressure, inevitably leads to fatigue, especially when that work is being carried out overnight. Fatigue not only increases the risk of harm to our patients, but it puts every single member of staff driving home after a long nightshift at significantly increased risk of a road traffic accident – the levels of fatigue commonly seen after a normal NHS nightshift produce a similar effect on driving as if we are at or over the legal drink-drive limit.

“Driving tired is like driving drunk and when we ignore or forget that, we will continue to see NHS staff dying on the roads just trying to get home after a shift.

“A proper focus on regular rest and breaks during shifts, and strategies to reduce risk of harm when driving home after shifts, is essential, and every NHS Chief Executive has a responsibility to their staff and patients to do this.”

Employers must not normalise missed breaks.

Kim Sunley, Royal College of Nursing National Officer said: “Nursing staff are sounding the alarm on the dangers they face driving home from work after long shifts caring for patients. Staff say they are leaving work exhausted from being unable to take rest breaks and as a result are almost crashing their vehicles, in some cases with tragic and fatal consequences – this is an unacceptable position to put health and care staff in.

“Employers have a requirement to provide an uninterrupted break, however, in practice we know that staffing shortages can mean that health and care staff are unable to take breaks, eat or even or drink during their shift.“But despite the lack of staff, employers must not normalise missed breaks. This would not be acceptable in any other area where safety was critical and a lack of staff must not be used as an excuse for denying nursing staff the breaks they are entitled to.

“The corrosive effect of short staffing on patients and nurses has now never been clearer, but with a record 43,000 empty nursing posts in England alone it threatens to worsen. As well as employers upholding their duty give staff the break they are entitled to, the government must invest in the nursing workforce for the long-term and then change the law so that from the health secretary down, decision makers are held responsible for ensuring there are enough nurses to provide safe and effective care.”

Pushing exhausted nurses to burn out.

Jonathan Ashworth, Labour’s Shadow Health Secretary, said; “These two deaths are heart-breaking. We know that years of cuts, failures to address staff shortages and mounting pressures are pushing our exhausted nurses to burn out putting their lives at risk. It’s totally unacceptable.

“Our NHS ought to be the very best employer anywhere and that means caring properly for our staff just as much as they care for our loved ones. As a start we need to properly fund the NHS, bring back a decent bursary to train more nurses and midwives and invest properly in professional development.

“Ministers are taking our nurses for granted, it has to stop.

“My pledge is to be a champion for our nurses and midwives working together to improve care for staff and patients.”

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It all starts with attraction: building the nursing workforce

While retention is clearly an issue, attracting new nurses into the profession is also a significant problem.

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Student Nurse Lecture Theatre

Six per cent of places on pre-registration nursing degrees across the UK are going unfilled.

When it comes to managing the nursing workforce the focus is often on retention, with recent figures from the Labour party revealing that more than 160,000 nurses have left the NHS for reasons other than retirement since 2010. This is undoubtedly worrying for industry leaders, with departing staff members adding to the strain on the health service from budget cuts and the ageing population.

While retention is clearly an issue, attracting new nurses into the profession is also a significant problem. The number of EU nurses joining the Nursing and Midwifery Council register since the UK voted to leave fell from 10,000 in 2015/16 to just 800 in 2017/18, which means that NHS trusts need to find nursing talent elsewhere in order to ensure that they can continue to provide excellent and efficient patient care.

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Developing homegrown talent presents the most sustainable solution to the nursing numbers crisis, yet new data from The Open University’s Breaking Barriers to Nursing report six per cent of places on pre-registration nursing degrees across the UK are going unfilled – the equivalent of over 1,450 vacancies each year.

Barriers to nursing.

Despite many young people considering nursing as a potential career, there are a number of barriers that are deterring them from pursuing this route – and it is essential that educators and NHS employers work together to ensure that everyone who wants to become a nurse has the opportunity to do so.

The barriers to studying nursing are vast – and for most prospective students there will be two or more of these factors at play. The cost (and associated costs) of study is the most prevalent concern, particularly for those in England, but many are also put off by travel or entry requirements, workload, and even the advice made available at school or college. While some of these barriers are difficult to remove or reduce, there are a number of potential solutions that could help improve both recruitment and retention in the sector.

The removal of the nursing bursary in England has certainly made studying for a nursing degree a greater financial commitment, but the associated costs of studying – course materials, relocating, commuting – are problematic for prospective students across the UK. For many, this makes traditional nursing study prohibitively expensive, especially when the costs are compared to relatively low salary expectations.

One solution that could help to address the cost concerns faced by potential nursing students in England, and bring myriad benefits to the NHS as a whole, is the new Registered Nurse Degree Apprenticeship. The ability to earn while you learn is undoubtedly appealing, but it also provides a new route into the profession, offering a tool for continuous professional development to those already in the NHS workforce.

Technology-enabled learning.

In addition to the cost of relocating and commuting, many prospective students struggle with merely the idea of this. For some, this can be an exciting opportunity, but for others the commitment is too much, especially for mature students, who may have other commitments or roots in an area.

With new technology, there is no longer any need for students to travel in order to study, particularly for the lecture-based portion of their degree. Through technology-enabled learning, educators can make course delivery more flexible, so that students can study wherever, whenever and however suits them. And because they have not had to relocate, fewer nurses will leave their training hospitals to return home upon qualification.

Furthermore, some universities’ entry requirements exclude many would-be nurses from entering the profession. The Nursing and Midwifery Council requires candidates to have just GCSE-level Maths and English (or equivalent) when they begin their course, but as it stands, nine in 10 Higher Education Institutions that offer pre-registration nursing degrees in the UK require the 96 UCAS points (equivalent to three A-levels at or above a C-grade) for entry.  And grade requirement vary depending on where you are in the UK – in Wales all universities require at least 120 UCAS points at A-level (3 ‘B’s), while in Scotland half require only 64-72 points.

Remove unnecessary entry requirements.

These additional entry requirements limit an already diminished pool, and at a time when talent is in short supply, they represent an unnecessary barrier into the profession. These requirements also stand in the way of the NHS goal of widening participation and increasing diversity, as many of those who were not afforded good educational opportunities are effectively excluded, even if they have all of the other qualities required to become a nurse.

For some, it is not the practicalities of studying that presents the issue, but concerns about the career at the end. One in five of those who considered becoming a registered nurse were deterred because they were worried about the working hours and stress they might face. However, those working as registered nurses would argue that the rewards far outweigh any challenges – so it’s crucial that NHS trusts work with local communities and media to promote the benefits and counter any negativity, in order to bring in new recruits.

So, there are a number of barriers preventing prospective nurses from entering the profession, but there are also a number of ways in which industry stakeholders – educators and NHS employers – can start to address them.

By removing unnecessary entry requirements, promoting the positive, embracing technology-enabled learning and opening up new routes to the profession, we can develop a more sustainable pipeline of talent, which is essential for future-proofing the NHS, and ensure that it can continue to provide a safe service for years to come.

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