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Professional context

There are many factors influencing the professional context of nursing in 2020. The two highlighted here are patient safety and quality of care, and new roles required to respond to the increasing demand for services.

Patient safety and quality of care

Core to nursing, wherever it takes place, is the commitment to caring for individuals and keeping them safe, so wherever the procedures are used, they are to be carried out within the framework of the Nursing and Midwifery Council's Code (NMC [23]).
One of the original purposes of The Royal Marsden Manual of Clinical Nursing Procedures was to promote patient safety through standardized and evidence‐based approaches to care. Patient safety is an essential part of nursing care that aims to prevent avoidable errors and patient harm. The Royal College of Nursing (RCN) ([35]) highlights four key factors that are important in patient safety:
  1. Developing a culture of safety: this involves promoting attitudes and behaviours that encourage staff to learn from preventable incidents, which will make it less likely that the incident will happen again. Organizations fostering a proactive approach to patient safety should be open, just and informed, and reporting and learning from error should be the norm (Carthy and Clarke [2]).
  2. Designing for reliability: this involves making healthcare more reliable – that is, taking a standard approach to patient care, agreeing to ways of working based on research and evidence where it is available, and agreeing at an organizational level to apply that knowledge to practice.
  3. Taking a systemic approach to work: the system of work – which includes equipment, devices, medication and information systems – makes a considerable difference to quality and safety. Changes to the design of physical things can make a big difference to how well people work. For example, the interfaces of devices, control panels, packaging and lighting levels can improve the speed, accuracy and reliability of a procedure.
  4. Human factors: this refers to the way teams work together and the culture that influences how they act. The discipline of human factors can be defined as enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organization of human behaviour and abilities, and application of that knowledge in clinical settings (Clinical Human Factors Group [3]). To paraphrase Ives and Hillier ([17]), nurses within healthcare are one of healthcare's greatest sources of strength and the science of human factors and ergonomics is about providing a system which allows them to work to the very best of their ability to provide safe, high‐quality care for patients.
Adapted by the RCN, the consultancy Leadership Management and Quality's Human Factors Model (Figure 1.2) illustrates the interaction between the direct factors (dexterity (mental or physical), awareness/memory, distraction/concentration and decision – in the orange circle) that impact performance and therefore the patient experience and the potential factors (stress, fatigue, safety culture, communication, teamwork, leadership and work environment – in the teal circle), which have the potential to make the situation either better or worse. The interventions or managing factors (green circle) manage the effect of the potential factors and improve the direct factors (RCN [35]). The interventions or managing factors are many, both at the organizational and the individual levels. The Royal Marsden Manual of Clinical Nursing Procedures has a role at the organizational level, providing standardized procedures on which training can be based, and at the individual level, supporting the development of problem prevention and problem solving through the acquisition of knowledge associated with clinical processes.
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Figure 1.2  The Human Factors Model. Source: Adapted from RCN ([35]) with permission of the Royal College of Nursing.

Professional competency

The development of clinical competency is an integral part of delivering safe care; the Nursing and Midwifery Code states that nurses must:
  • have the knowledge and skills for safe and effective practice without direct supervision
  • keep their knowledge and skills up to date throughout their working life
  • recognize and work within the limits of their competence (NMC [23]).
The Nursing and Midwifery Council (NMC) ‘has a duty to review the standards of proficiency it sets for the professions it registers on a regular basis to ensure that standards remain contemporary and fit for purpose in order to protect the public’ (NMC [28], p.3). In fulfilling this duty, it published Future Nurse: Standards of Proficiency for Registered Nurses (NMC [28]) (Figure 1.3). This document details the knowledge and skills that all registered nurses must demonstrate when caring for people of all ages and across all care settings, reflecting what the public can expect nurses to know and be able to do in order to deliver safe, compassionate and effective nursing care. These proficiencies have a legal standing, fulfilling Article 5(2) of the Nursing and Midwifery Order 2001, which requires the NMC to establish standards of proficiency necessary for nurses to be admitted to each part of the register and for safe and effective practice under that part of the register (NMC [28]). The proficiencies are designed to apply across all fields of nursing practice (adult, child, mental health and learning disabilities), ‘because registered nurses must be able to meet the person‐centred, holistic care needs of the people they encounter in their practice who may be at any stage of life and who may have a range of mental, physical, cognitive or behavioural health challenges’ (NMC [28], p.60).
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Figure 1.3  Future Nurse: Standards of Proficiency for Registered Nurses. Source: Reproduced from NMC ([28]) with permission of the Nursing and Midwifery Council.
The proficiencies are grouped around seven platforms (Box 1.3). These reflect what the nursing profession expects a newly registered nurse to know and be capable of doing safely and proficiently at the start of their career (NMC [28]).
Box 1.3
The seven platforms of Standards of Proficiency for Registered Nurses
  1. Being an accountable professional
  2. Promoting health and preventing ill health
  3. Assessing needs and planning care
  4. Providing and evaluating care
  5. Leading and managing nursing care and working in teams
  6. Improving safety and quality of care
  7. Co‐ordinating care
In addition, there are two annexes that describe what registered nurses should be able to demonstrate they can do at the point of registration in order to provide safe nursing care. Annex A specifies the communication and relationship management skills required, and Annex B specifies the nursing procedures that registered nurses must demonstrate that they are able to perform safely (NMC [28]).
Many of the chapters in this edition of The Royal Marsden Manual of Clinical Nursing Procedures map onto the NMC proficiencies in Annex B of the Standards of Proficiency for Registered Nurses (NMC [28]); these are detailed in the Appendix in this edition of the manual. The manual provides theory and exploration of anatomy and physiology related to nursing procedures, recognizing that competence is not just about knowing how to do something but also about understanding the rationale for doing it and the impact it may have on the patient.
The revision of the standards for nursing also has implications for the education and training of nurses – specifically, ensuring they are prepared for the future roles they will be fulfilling (Figure 1.4).
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Figure 1.4  Summary of key changes to the standards for nurses. Source: Reproduced from NHS Employers ([19]) with permission of the NHS.

New roles

The changes in demand for healthcare and the limited resources (particularly staff) available to provide it have prompted government, employers and the profession to consider new roles. These new roles could potentially provide a faster route to solving staffing problems and offer career development opportunities that could also help to improve retention. These include expanding physician associate and advanced nurse practitioner roles and the new nursing associate roles (King's Fund [18]).

Nursing associates

The report Raising the Bar: Shape of Caring – A Review of the Future Education and Training of Registered Nurses and Care Assistants (Health Education England [15]), led by Lord Willis, made recommendations for the education of nurses and care assistants. One of the key areas it identified was the skills gap between care assistants and registered nurses (NMC [29]). The nursing associate role, announced by Ben Gummer, Health Minister, in 2015, was developed to address this gap:
The new nursing support role is expected to work alongside healthcare support workers and fully qualified nurses to deliver hands on care, ensuring patients continue to get the compassionate care they deserve. Nursing associates will support nurses to spend more time using their specialist training to focus on clinical duties and take more of a lead in decisions about patient care.
(Department of Health and Social Care [5])
The NMC is the regulator for these new roles and has set out standards of knowledge and skills expected of a nursing associate for safe and effective practice (NMC [29]). The Standards of Proficiency are structured in a similar way to those for registered nurses and are based around six platforms (Box 1.4).
Box 1.4
Standards of Proficiency for Nursing Associates
  • Platform 1: Being an accountable professional
  • Platform 2: Promoting health and preventing ill health
  • Platform 3: Provide and monitor care
  • Platform 4: Working in teams
  • Platform 5: Improving safety and quality of care
  • Platform 6: Contributing to integrated care
The procedures that it is expected a nursing associate will be able to undertake competently on registration are defined in Annex B of the Standards of Proficiency, which states: ‘Nursing associates are expected to apply evidence‐based best practice across all procedures. The ability to carry out these procedures, safely, effectively, with sensitivity and compassion is crucial to the provision of person‐centred care’ (NMC [29], p.15). It is hoped that this manual will be a resource for nursing associates in helping them to develop the understanding necessary to apply evidence‐based practice to all the procedures they undertake. The procedures specified in Annex B of the Standards of Proficiency for Nursing Associates are mapped against the chapters in this manual in the Appendix.

Advanced nurse practitioners

‘New solutions are required to deliver healthcare to meet the changing needs of the population. This will need new ways of working, new roles and new behaviours’ (NHS England [22], p.1). Advanced clinical practice roles are seen as an essential part of these solutions (Nuffield Trust [30]). A multi‐professional advanced clinical practice framework has been developed to define advanced clinical practice and set out the core capabilities expected across professions and care settings to foster the development of these new roles in a consistent way to ensure safety, quality and effectiveness (NHS England [22]) (see Box 1.5).
Box 1.5
Definition of advanced clinical practice
Advanced clinical practice is defined as follows:
Clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterized by a high degree of autonomy and complex decision making. This is underpinned by a master's level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence.
Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people's experience and improve outcomes.
(NHS England [22], p.7)
Source: NHS England ([22]). Reproduced with permission of the NHS.
Developing new roles and taking responsibility for new procedures have obvious risks attached and, although every individual nurse is accountable for their own actions, every healthcare organization has to assume vicarious liability for the care, treatment and procedures that take place. An organization will have expectations of all of its nurses in respect of keeping patients, themselves and the environment safe. There are obvious ethical and moral reasons for this: ‘Nurses have a moral obligation to protect those we serve and to provide the best care we have available’ (Wilson [44], p.118). Clinical governance has therefore become an integral part of day‐to‐day nursing work; for this reason, the clinical governance implications of the areas of practice have been integrated into each chapter of this edition of the manual.
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