1 1 : Past, Present and Future 2

2 The Professional Nurse and UnitUnit 1 Contemporary 25

3 Health Promotion 50 Contextualising the Art 4 Public Health 72 and Science of Nursing

COPYRIGHTED MATERIAL 1

Nursing: Past, Present and Future K a r e n W i l d University of Salford, UK

Learning Outcomes Competencies On completion of this chapter you will be able to: All nurses must: • Understand how nursing has evolved through history 1. Understand the nurses’ roles, responsibilities and • Have an awareness of some of the philosophical theories functions to meet the changing needs of people, that shape nursing today groups, communities and populations • Be aware of the values that underpin nursing 2. Be self-aware and recognise how your own values, • Be aware of the drivers that shape nursing policies and principles and assumptions may affect practice guide contemporary nursing practice 3. Facilitate nursing students to develop competence, using • Understand how is regulated in the a range of professional and personal development skills United Kingdom (UK) 4. Be able to respond autonomously and confi dently to • Have an insight into the various roles that nurses planned and uncertain situations undertake in different settings 5. Create and maximise opportunities to improve service 6. Work effectively across professional and agency boundaries

Visit the companion website at www.wileynursingpractice.com where you can test yourself using fl ashcards, multiple-choice questions and more.

Unit 1 image source: LTH NHS Trust / Science Photo Library Nursing Practice: Knowledge and Care, First Edition. Edited by Ian Peate, Karen Wild and Muralitharan Nair. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wileynursingpractice.com

2 Chapter 1 Nursing: Past, Present and Future 3

Table 1.1 Mapping the 6Cs against the basics of the Introduction RCN ’ s Principles of Nursing Practice. (Source : Watterson 2013 ) In their report to the Prime Minister ( DH 2010 ), the Commission on the Future of Nursing and Midwifery stated that: THE 6CS OF NURSING RCN ’ S PRINCIPLES OF NURSING PRACTICE England ’ s nurses and midwives are the lifeblood of the NHS and other health services and have always been at the heart of good Compassion Principle A health care. In 2009 there were well over half a million nurses and • relationships based on • dignity, equality, diversity empathy, respect and dignity and humanity midwives on the Nursing and Midwifery Council (NMC) register residing in England. As the largest group of registered professionals Courage Principle B in the NHS, they are a huge workforce with great power and • doing the right thing, • ethical and legal integrity, speaking up if concerned, accountability, potential to infl uence health and health care. Th ey are ideally strength and vision to responsibility placed to improve the experiences of service users and families, innovate Principle C and they infl uence health in a wide range of health, social care • safety, the environment, and community settings. organisational health and In the last decade nurses have acquired greater responsibility safety, risk management as autonomous interdependent practitioners: they lead pro- Care Principle D grammes of care, act as partners and employers in general prac- • the core business of nursing, • advocacy, empowerment tice, and also lead their own services and run their own clinics. which helps the individual and patient-centred care ( Department of Health 2010 , p. 16) and improves the health of • patient involvement in Th is chapter will explore the evolution of nursing as described the whole community care earlier and highlight the unique roles that nurses play in contem- • caring defi nes nursing porary society. It will look at past and current structures of the NHS Communication Principle E and health provision in the UK and describe the legislation that • central to successful caring • communication, handling supports the professional status of Nursing. relationships; listening is as feedback, recording, important as what is said reporting and monitoring and done. ‘ No decision about Principle G Jot This Down me without me ’; • interdisciplinary and When you refl ect on your role as a nurse, what would communication key with multi-agency working; you say was your motivation to care? patients and staff teamworking, continuity of care Competence Principle F I n t h e ‘ J o t Th is Down’ exercise, you may have identifi ed certain • the ability to understand an • evidence-based practice, traits in your behaviour or personality that motivate you to care. individual’ s health and social education, technical skill, Th e need to help others and to respect an individual ’ s dignity and needs clinical reasoning independence can infl uence the desire to care. You may see yourself • expertise, clinical and as a naturally caring person, so-called altruistic traits. Work that is technical skill to deliver challenging and varied might appeal to you; job satisfaction and effective care based on the ability to work in a team may also help to motivate you as a research and evidence nurse. You may have considered the characteristics of the role that Commitment Principle H you have, such as autonomy, feedback (people saying thank you), • to patients and populations • leadership which the variety of skills that you have developed and satisfaction in • to build on and improve care contributes to an open seeing the completion of an aspect of care. You may also relate your and patient experiences and honest culture motivation to care in terms of the value that you hold in society • nurses leading by example and the opportunities you have for personal development and growth within the profession. Some may relate the motivation to the relative job security that nursing brings; its salary and peer light the core professional values and behaviours that underpin support may be signifi cant too. Th e intellectual basis of nursing and nursing. Th e CNO is the government ’ s most senior nursing adviser the continued development of knowledge, skills and profi ciency and has the responsibility to ensure that the government’ s strategy may also feature on your list. for nursing is delivered. Th e CNO leads over 597 625 nurses, mid- Th e fundamental basis of nursing is associated with caring and wives, health visitors, other allied health professionals. helping, and nursing can be described as both an art and a science. Th is chapter is concerned with the professional values that Caring defi nes nurses and their work, and as such, there are many underpin nursing practice. An overview is provided of the devel- facets associated with the role and function of the nurse. Th e role opment of nursing, from what was an unstructured, ad hoc is constantly evolving and is diffi cult to classify. approach to caring, to a regulated profession. Recent developments have infl uenced the guidance developed Care has been claimed to be an essential human need for the by the chief nursing offi cer ’ s (CNO) 6Cs ( DH 2012 ) and the RCN ’ s full development, health maintenance and survival of human ( 2010 ) Principles of Nursing Practice (rcn.org.uk/nursing princi- beings in all world cultures (Leininger 2002 ), yet care throughout ples). In Table 1.1 you can see the links that can be mapped between history has not been awarded the same importance as cure. Leinin- the 6Cs and the RCN ’ s Principles of Nursing Practice. ger poses the question: does cure gain more attention because of In Table 1.1 , there is clear evidence from both the RCN and the the public recognition of dramatic new technologies, and because CNO that nursing encompasses many roles, and it serves to high- it is associated with males? In contrast, the tradition of caring has 4 Chapter 1 Nursing: Past, Present and Future

tended to be a female activity, focussing on the individual, the were caused naturally and not because of superstition or the inter- family and groups of people. She asserts that there can be no curing vention of gods. without caring, and that the culture of care can be embedded in Th e fi rst hospitals were established in the Byzantine Empire, our history, through examples such as religious (or spiritual), which was the fi rst part of the Roman Empire. As the Roman social, political, educational and economic contexts. Th e next Empire expanded, hospitals were erected. It was Fabiola, a wealthy section will provide a snapshot of that history and tradition. Roman, who was responsible for the introduction of hospitals in the West. She dedicated her immense wealth to the sick and served as a role model, nursing the sick herself, despite the repulsive A Glance at the wounds and sores of the inmates. Th e primary carers in these hos- pitals were young men on the verge of adulthood, who were called Almost unanimously, the history of nursing will tend to focus on contubernales. Aft er the Roman invasion in approximately ad2, the works and publications of Florence Nightingale; however, slave girls were known to assist Roman physicians. Valetudinariums nursing has been shaped and formed throughout history and has – civilian hospitals – were kept clean and aired by bailiff s ’ wives, been infl uenced by a global perspective. To appreciate the develop- who would also watch over the sick. ment of contemporary nursing in the UK, it helps to take a look at In the Middle Ages, medical knowledge and development where nursing has come from, and how it continues to develop and slowed and many of the infl uences of the Ancient Greeks and in grow. particular the Romans in this country were destroyed. Rome and Health and disease is a constant factor of the human state, and the Catholic Church dominated the direction of medicine, and the need for some form of support and care of individuals and throughout the Middle Ages, military, religious and lay orders of populations throughout history varies greatly. What follows is a men provided most of the health care. Some of these orders of men review of the evidence that supports the idea of people helping included the Knights Hospitallers, the Order of the Holy Spirit and other people in times of need, through history, and the develop- Teutonic Knights. While these men provided care, charlatans and ment of systems of care and the fundamental beginnings of nursing ‘quacks’ provided treatment for money; examples are diagnoses as we know it today. made by the use of astrology and the widely practised treatment of bloodletting, oft en doing more harm than good. Th e Black Death Pre-history was to kill two-thirds of England ’ s population between 1348 and Paleopathology is the study of diseases in past populations, and 1350, and the commonly held doctrine from the church that disease archaeologists have retrieved ancient human remains which dem- was a punishment from God for sinful behaviour did little to help onstrate that fractured limbs have been healed; this signifi es that the poor and uneducated. Figure 1.1 depicts the experience of birth some form of care provision occurred. In addition, evidence of and the support given to a woman in labour during this time. infectious diseases such as tuberculosis and syphilis has also been identifi ed in bone remains. Indicators that some form of treatment was given exists in the skull evidence of ancient man, where the practice of trepanation (or drilling holes in the cranium) has been seen. In some skulls, there is evidence of more than one hole with partial healing, indicating that the treatment was oft en survived. Cave paintings illustrate life events such as birth and death, and there are images that suggest female interaction. Th ose who lived in the prehistoric period suff ered similar conditions to those expe- rienced by society today, and according to Hallett ( 2010 ), tribes in those early years took part in caring for their sick and wounded. Th e role of spirituality and health linked to strange occurrences, such as sudden fl ooding or times of drought, have helped shape beliefs around supernatural interventions, for example the visita- tion of evil spirits. Healers or Shamans would employ various brews and magical potions to heal the sick. Th ose responsible for feeding and cleaning the sick were predominantly females. Evidence to support the evolution of nursing has been gathered and interpreted from hieroglyphic inscriptions, cuneiform writ- ings, papyri and documented histories in the forms of drawings, ancient objects and oral traditions. Ancient History In Ancient Greece, temples were erected to honour the goddess of health, Hygeia. Care at the temples was related to bathing and this activity was overseen by priestesses. No mention is made of nurses as a separate entity, but temple attendants probably assisted the physicians by ‘caring’ for their patients. Babylonian civilisations from around 3000 BC acknowledged the role of public health measures, such as large stone drains, to cope with human waste. Th e foundation of modern medicine was laid down by Hippoc- Figure 1.1 Early engraving depicting the support of a woman in rates in Ancient Greece, who is credited with the belief that diseases labour. Reproduced with permission of Everett Collection Historical/Alamy. Chapter 1 Nursing: Past, Present and Future 5

Several hospitals were opened during this period, for example Alongside the Poor Law acts of the 19th century, medical St Th omas ’ s, St Bartholomew ’ s and Bethlem. Care that had been schools began to emerge, as medical knowledge grew. Th e Royal provided by nuns was now provided by local women, whose College of Surgeons was formed in 1800 and at this time, doctors eff orts were overseen by . Th eir duties centred on domestic were required to carry out some aspects of their training in chores. hospitals. Th e second half of the 18th century saw the evolution of scien- Th e year 1800 brought about the era of social and political revo- tifi c method, the so-called ‘Age of Enlightenment’. Its purpose was lution, and many of the great philosophers, such as Emanuel Kant to reform society using reason, challenging tradition and advanc- brought radical intellectualism into the minds of many. In 1784, ing knowledge. Scientifi c endeavour fl ourished during the Enlight- Kant challenged society to: ‘Dare to know! Have the courage to enment and philanthropists provided the means to open charity use your own understanding’, which became the motto of the hospitals around the UK. Th ese hospitals employed nurses, who Enlightenment. Science and technical development reached new may have been paid or unpaid, who carried out domestic duties. It heights and the Victorian era from 1831 saw the biggest develop- was not unusual for so-called nurses to drink alcohol and take ments in social and scientifi c engagement. During 1853 to 1856, money from patients in order to pay for their alcohol. Charles Britain and France became involved in the Crimean war against Dickens, in his 1843 novel Martin Chuzzlewit , developed the main Russia, and the American Civil war started in 1861. theme related to ‘selfi shness’. One of the characters, the nurse, Mrs Gamp, was an odious individual who was a midwife and ‘layer-out of the dead’ (perhaps one of the fi rst health visitors: ‘from cradle Jot This Down to the grave’). The American Civil War of 1861 was regarded as the fi rst ‘modern war’ because of the large scale use of what was then considered modern technology. The Evidence • Make a list of the developments in health care that The speech-mangling, cucumber-guzzling, gin-tippling, patient- you think have been infl uenced by wars and confl ict brutalising Mrs Gamp could well be Dickens’ s fi nest grotesque, throughout history although he thought of her as highly realistic. In his preface to Chuzzlewit, Dickens wrote that Mrs Gamp was, “four-and-twenty years ago, a fair representation of the hired attendant on the I n t h e ‘ J o t Th is Down’ exercise above, you may have thought poor in sickness,” and she was so popular with Victorian about more recent developments that you are aware of, such as the readers that it took Florence Nightingale’ s efforts in the Crimea hospital at Camp Bastion in Afghanistan, with its innovations in to steer the public perception of nurses away from the Gamp stereotype. Even her weirdest quirks came from real life: her trauma surgery and nursing care; or the development of triage, to habit of standing by the fi replace and rubbing her nose on the assess those most in need of emergency care. Interestingly, triage fender, for example, came from a description of a nurse given was developed in the First World War in France to treat mass casu- to him by his friend Angela Burdett-Coutts. alties. You may have included the use of the tourniquet to limit ( Collin 2012 ) blood loss; this was known in Roman times and has been adapted http://www.telegraph.co.uk/culture/charles-dickens/9044813/Sarah by the military today to be applied, if needed, with one hand. -Gamp-My-favourite-Charles-Dickens-character.html Ultrasound is a product of war, fi rst used to detect cracks in armour in the Second World War, by tank engineers. Your list may also include infection control and the use of antibiotics to treat infec- Sarah Gamp was immoral, self-indulgent, sloppy and generally tions. Modern infection control has been infl uenced by the work drunk. A notorious stereotype of untrained and incompetent of Florence Nightingale during the Crimean War, as she pioneered nurses of the early Victorian era, before the reforms of campaigners the cleaning and ventilation of the Scutari hospital, thus reducing such as Florence Nightingale. Mrs Gamp is everything we least mortality rates among the sick and wounded. expect of a good nurse: she was selfi sh, untrustworthy, a bully, nasty to patients and slothful. F lorence N ightingale (1820–1910) Parish nurses and their supposed inadequacies were justifi ca- Known for her pioneering work in the Crimean War, Florence tion of the need to change the way that nurses were employed and Nightingale (Figure 1.2 ) opened the way to bring respectability to governed, and in 1727, two pamphlets were published to support nursing. Born in Italy in 1820, she is now celebrated as a social the creation of a workhouse. Workhouses were established to reformer and statistician. From a professional viewpoint, Nightin- employ and maintain the poor, and nursing duties were generally gale is seen as the founder of modern nursing; she spoke with fi rm performed by elderly female inmates who were illiterate, fond of a conviction about the nature of nursing as a distinct profession, drink and inept in the demands of caring for the sick. Th e develop- allowing young middle-class women an opportunity to make a ment of the workhouse infi rmaries saw a move to the more familiar meaningful contribution to society. At the time, nursing in the set-up of providing a separate annex to the workhouse building; middle and upper classes was defi ned as caring for sick and elderly this allowed segregation of the sick according to the nature of their relatives, for example, a daughter might nurse her ageing and sick illness. It is diffi cult to diff erentiate what history tells us about the father. Nightingale was concerned with what she saw as the all- nature of nursing: that is the diff erence between ‘nursing work’ and encompassing plight of the Victorian woman – on the one hand the ‘work done by nurses’. Nurses began to be employed by work- redundant wives of the wealthy, and on the other women who were house guardians and in 1865, William Rathbone, with the help of poverty stricken and forced to toil for long hours at tedious and Florence Nightingale, fi nanced the introduction of trained nurses unskilled work. to the Brownlow Hill Infi rmary in Liverpool. Interestingly, the Born to a wealthy upper-class family herself, the expectation employment of pauper nurses continued under the supervision of was that she would marry well and produce a family. However, she a trained nurse (White 1978 ). defi ed the wishes of her family and in the fi rst decade of her adult 6 Chapter 1 Nursing: Past, Present and Future

life, fought to use her talents in a productive and helpful way in Aft er the war, she wrote , where she set out the order to benefi t society. basic foundation on which nursing was to be based, and expressed In March 1853, Russia invaded Turkey, and Britain, concerned the proper functions of nursing. Th ese functions in Nightingale ’ s about the growing power of Russia, went to Turkey’ s aid. Th is view included improving the environment of the sick room with confl ict occurred in and around Scutari and became known as the clean air and ventilation, making and recording astute observations Crimean War. Soon aft er British soldiers arrived in Turkey, they of the sick and their environment and developing knowledge began to fall ill with malaria and cholera. Florence Nightingale around the process of recovery. volunteered her services to the war eff ort and was given permission to take a group of nurses to a hospital in Scutari based several miles from the front. Here, she was faced with mass infections, lack of The Evidence How to Ventilate without a Chill medical supplies and poor hygiene. . . . with a proper supply of windows, and a proper supply of fuel in open fi re places, fresh air is comparatively easy to secure when your patient or patients are in bed. Never be afraid of open windows then. People don ’t catch colds in bed. This is a popular fallacy. With proper bed-clothes and hot water bottles, if necessary, you can always keep a patient warm in bed, and well ventilate him at the same time. ( Nightingale 1859 )

Florence Nightingale was seen by many historians as ‘Th e Lady with the Lamp’ aft er a report in Th e Times newspaper from the Crimea, which depicted her as a lone fi gure in the night, a small lamp in her hand, checking on the welfare of the wounded soldiers. Interestingly, the lighting of lamps is documented in the Nursing Mirror pocket diary of 1913, shown in Figure 1.3 , which gives specifi c times for lamps to be lit throughout the year. A ft er returning to England as a national heroine, she began reforming conditions in British hospitals (in the fi rst instance, this was confi ned to military hospitals). Nightingale was able to raise £45 000 in funds to improve the quality of nursing. In 1860, she used these funds to found the Nightingale School and Home for Nurses at St Th omas’ s Hospital. Her philosophy of nursing was based on the belief that there should be a theoretical basis for nursing practice and that nurses should be formally educated. Resolute in her desire to profession- Figure 1.2 Florence Nightingale. Reproduced with permission of alise nursing, she insisted that nursing schools should be controlled Superstock/David Cole. and staff ed by women who were trained nurses. She also wanted to

Figure 1.3 Lighting the lamps in 1913. Chapter 1 Nursing: Past, Present and Future 7 develop a systematic approach to the assessment of patients where not always been recognised, and unlike Nightingale, she does not an individual approach to care provision based on individual feature signifi cantly in the established until the patient needs was required. She strongly believed in the mainte- 1970s. It is most certainly the case that Seacole ’ s work in the nance of patient confi dentiality. Crimean War was overshadowed at the time by that of Florence Th e philanthropist, William Rathbone, worked with Nightin- Nightingale; however, there has been a revival of interest in her gale to develop the fi rst district nursing service. Th is was acknowl- contribution, with an introduction to her life and works added to edged by Queen Victoria with the title ‘Queen’ s Nurses’ being the school national curriculum in the UK. awarded to nurses caring for people at home. In the late 1800s, courses were provided to teach women to develop an insight into The d evelopment of e ducation and sanitation in homes. Th ese women had a duty to care for the health regulation for n urses of adults, children and pregnant women (pre- and antenatal), and Th roughout the 1890s, pressure grew for the registration of nurses, the fi rst was employed in Salford in 1862 ( Adams and leaders within the profession were debating the need to pass a 2012 ). public examination just as medical practitioners had been required In the 1870s, America’ s fi rst trained nurse, Linda Richards was to do since 1858. However, Florence Nightingale was opposed to mentored by Nightingale. Richards went on to pioneer the develop- this notion, worried that central examination might undermine her ment of nursing in both America and (Doona 1996 ). In 1883, philosophy of nursing. In 1887, Ethel Bedford-Fenwick (a former Nightingale was awarded the Royal Red Cross by Queen Victoria, at St Bartholomew ’ s Hospital, London) formed the British and became the fi rst woman to receive the Order of Merit. In 1873, Nurses ’ Association, which sought to provide for the registration Nightingale wrote, ‘Nursing is most truly said to be a high calling, of British nurses, based on the same terms as physicians and sur- an honourable calling’. She died in London in 1910. geons, as evidence of their having received systematic training. Bedford-Fenwick was a staunch supporter of professional regula- M ary S eacole (1805–1881) tion. Up until this time, nurses remained relatively free from exter- Daughter of a Scottish soldier with a Jamaican mother, Seacole nal regulation. In 1902, the Midwives Registration Act established (Figure 1.4 ) learned her nursing skills in the family boarding house the state regulation of midwives, and midwives undertook training for invalid soldiers. She was well travelled, visiting the Bahamas, in order to register with the Central Midwives Board. A House of Central America and Britain. Despite the War Offi ce in England Commons Select Committee was established in 1904 to consider refusing her application to be an army nurse in the Crimean War the registration of nurses, and in 1909, the Central Committee for Seacole funded her own visit and arrived in Scutari to off er her the State Registration of Nurses was formed. services to Nightingale, but these were refused. Undeterred, Seacole Th e First World War (1914–1918) provided the fi nal stimulus set up her own services and established the British Hotel near to the creation of nursing regulation, partly because of the contri- Balaclava. Here, she provided comfort and convalescence to the butions made by nurses to the war eff ort. Th e College of Nursing British and Russian soldiers, oft en at the battle front (Anionwu (this later became the Royal College of Nursing in 1928) was estab- 2005 ). lished in 1916. Its principal functions were to: Seacole also became involved in the training of nurses for • Advance the profession of nursing through improved education employment in the workhouses. Her contribution to nursing has and training • Promote consistency of nursing curricula • Recognise approved nursing schools • Create and maintain a register of nurses who were certifi ed profi cient through training • Promote Parliamentary Bills in any way connected with the interests of nursing, education of nurses and the professional recognition of nursing. ( Baly 1995 ) Eventually in 1919, the Nurses Registration Acts were passed for England, Wales, Scotland and Ireland. Th e General Nursing Council (GNC) for England, Wales, Scotland and Ireland and other bodies were established as a result of these Acts. Th e Councils were established in 1921, with clearly agreed duties and responsibilities for the training, examination and registration of nurses and the approval of training schools for the purpose of maintaining a Reg- ister of Nurses for England and Wales, Scotland and Ireland. Th e GNC Register of qualifi ed nurses included a number of ‘parts’: one part contained the names of all nurses who satisfi ed the rules of admission, and there were also supplementary parts for: • Male nurses • Nurses trained in caring for people with mental diseases • Nurses trained to care for sick children. Later additions to the parts of the register included nurses trained to care for ‘mental defectives’ (people with learning diffi culties) and Figure 1.4 Mary Seacole. Reproduced with permission of Nils Jorgensen/Rex. nurses of infectious diseases. 8 Chapter 1 Nursing: Past, Present and Future

Th e GNC had powers to undertake disciplinary procedures and individual. Henderson ( 1966 ) implies that nursing is more than a remove the names of State Registered Nurses (SRNs) from the matter of carrying out doctors’ orders. Instead, nursing involves a register if they were deemed ‘not fi t and proper persons’ having special relationship with the person (and oft en the family). Accord- committed an act of misconduct or ‘otherwise’ – conduct unbe- ing to Henderson, the nurse intervenes with knowledge and skills coming of a nurse. to meet those needs that individuals and family would not nor- Progressively, nursing began to emerge as acceptable work for mally be able to provide. the middle-class woman, no longer labelled as menial duties but Her concept highlights what the nurse ought to focus on; now seen as work that was professional, respectable and valued. however, it has been criticised for its lack of in-depth guidance as In the inter-war years, the image of nursing was associated with to how the nurse assists in meeting the individual components courage and heroism; the First World War had enabled women to (Wills & McEwen 2002 ). She saw nurses as functioning independ- enter new areas of freedom and independence. ently from the physician, promoting the treatment plans prescribed. Th e Register of Nurses was fi rst published in 1922. Th e GNC Her concept encompassed the notion of the life continuum, with and the other bodies survived intact until changes were made in nurses helping both sick and healthy people from the newborn to 1979. Th ese resulted in the creation of the United Kingdom Central those who are dying. Nurses, according to Henderson, should be Council (UKCC) and the four National Boards for the UK. knowledgeable in biological and social sciences and must have the ability to assess basic human need. The d evelopment of m odern n ursing With human need as the central component of Henderson ’ s Despite the TV and media image of the nurse as an attractive concept, it has paved the way for further theories as to individual female, who falls in love with the doctor, the 1960s heralded a seed needs and how nurses can help in meeting these needs. change in the way that nurses viewed their role in terms of account- ability and the consequences of their actions. Th eories to support D orothea O rem (1914–2007) the art and science of nursing began to emerge, and models of Orem developed the ‘Self-Care Th eory’ based on the premise that nursing were introduced to help describe nursing in a variety of people should be self-reliant and responsible for their own care and care settings and roles. Chapter 7 within this book explores these the care of others in their family. Her philosophy focussed on the developments in detail. distinct individuality of the person, and the interaction of the Many of the theories that relate to nursing have a philosophical person with the nurse, based on the need to meet self-care. In this foundation and will include ideas about the nature of nursing, the way, she developed the idea of a health continuum, where the nature of the person, the nature of society and the environment patient moves from dependency to independency. Th e nurses ’ role and the nature of health. Some examples of the key infl uencers in in the continuum is to help the achievement of independence, act relation to this are highlighted in the next section. as an advocate, redirector, supporter and teacher, and to provide an environment that contributes to the therapeutic environment. V irginia H enderson (1897–1996) Orem ’ s philosophy is that nursing is the ability to care for another, Known as the ‘modern day mother of nursing’, upon graduation, especially when they are unable to care for themselves (Orem Virginia Henderson began her nursing career in Washington DC 1991 ). in 1921, working as a nurse in the community. She soon entered the education arena and wrote about her early experience as a nurse teacher. In the 1940s, she began to develop her personal defi nition H ildegard P eplau (1909–1999) Peplau was the fi rst published nurse theorist since Florence Night- of nursing, her so-called ‘concept’, which focussed on the impor- ingale. Her work focussed on the therapeutic nature of nursing, tance of independence for the patient, helping with rehabilitation asserting that the nurse–patient relationship is the foundation of and progress from hospital to home. She identifi ed 14 nursing nursing practice. She wanted to revolutionise the established components based on human need and geared towards the nurses’ approach to care, where the nurse passively acted out the doctor’ s role: orders and the patient passively received the treatment. She saw a • Substitutive – doing for the person human dynamic in the shared experience of caring and being cared • Supplementary – helping the person for, where each party experiences personal growth through learn- • Complementary – working with the person. ing and coping. Th is dynamic is achieved through developmental stages in the nurse–patient relationship, and relies on the distinct character The Evidence H enderson’ s Defi nition of Nursing roles typical of the nurse. Typical character roles include: the nurse The unique function of the nurse is to assist the individual, as a resource, answering questions and interpreting data; nurse as sick or well, in the performance of those activities contributing a technical expert, providing physical care through clinical skills; to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or nurse as a teacher, providing instruction and facilitating under- knowledge and to do this in such a way as to help him gain standing (Peplau 1952 ). independence as rapidly as possible. Th e developmental stages are mapped out as follows: ( Henderson 1966 ) Orientation Phase • Establish rapport • Set parameters Th e 14 components are, in the main, physiological and focus • Understand roles and begin to establish trust on physical aspects such as breathing, eliminating, maintaining Identifi cation Phase hygiene and nutrition. However, Henderson also acknowledged • Patient identifi es problems the importance of spiritual, moral and sociological needs of the • Nurse helps patient to recognise their own role in self-care Chapter 1 Nursing: Past, Present and Future 9

Exploitation Phase Table 1.2 Theoretical and conceptual philosophies of • Patient trust is established, makes full use of nursing service nursing. • Problem-solving • Setting future goals THEORIST CONCEPTUAL PHILOSOPHY Resolution Phase Florence Nightingale Concepts of society and environment: • Patient needs met major emphasis on the environment • Relationship ends on mutual basis of care, light, noise, smell and warmth • Patient less reliant on nurse, more self-reliant. Virginia HendersonConcepts of the person: the mind and body are inseparable; individuals are unique; individual needs are mirrored P atricia B enner in 14 components of basic nursing Benner was contemporary theorist who introduced the concept care that expert nurses develop skills and understanding of their craft Concepts of health: values through the experience and education of caring. She described fi ve independent function levels of nursing experience and coined the phrase: ‘from novice to Dorothea Orem Concepts of the person: the individual expert’ in her publication in 1982. Her work is signifi cant, as it as a whole made up of physical, changed the perception of the term ‘expert nurse’ from the most psychological and social structures highly paid and prestigious, to encompass the notion of the expert with an element of self-care ability as one who provides the ‘most exquisite care’, and that practise itself Hildegard Peplau Concepts of the person: the human could inform the theory of care ( Benner 1982 ). dynamic and therapeutic relationship; the stages of that relationship Patricia BennerConcepts of the person: person is M argaret N ewman self-interpreting and engaged, In 1979, Newman presented her ‘theory of expanding conscious- learning, concern, cultural ness’. She presents the notion that disease (ill health) and the appreciation, direct involvement in absence of disease (health) in the individual are equally important caring in the human lifespan. She asserts that consciousness is a healthy Margaret Newman Concepts of health: expanding state; the more individuals interact with their environment and the consciousness through the experience world around them, the more conscious they are. Crisis such as of illness health breakdown increases consciousness – she relates to this as the total response that the individual makes to that crisis: physio- logical, psychological and social. In this way, no matter how disor- Child and Family Nursing The Platt Report 1959 dered or hopeless a situation may seem, the process of becoming more of oneself and fi nding meaning in the situation is a demon- Acknowledged that: stration of expanding consciousness (Newman 1979 ). • The emotional care of children was important and Th e theoretical and conceptual philosophies of nursing pro- that separation could be damaging moted by the theorists are highlighted in Table 1.2 . • Children should not be admitted to adult wards • Physical environment should be cheerful • Nurse in charge should be a trained children’ s nurse • Paediatricians should have concern for all admitted The Beginnings of the NHS • Nursery nurses for children under 5 and Nursing • Children should be prepared for admission • Education provision should where possible continue Th e National Health Service was established on 5 July 1948 with • Parents should be able to visit freely and to stay with children the aim of health care being free at the point of delivery. Th e 1949 under 5 years Nurses Act allowed that the constitution of the GNC be amended; • All staff should be trained in the emotional needs of children the general and male nurse parts of the register were amalgamated. ( Davies 2010 ) Nurses welcomed the development of the NHS, as they recognised through fi rst-hand experience of caring, the suff ering that resulted Some signifi cant dates in the history of the NHS are shown in from having to pay for medical care. Figure 1.6 . Figure 1.5 shows a copy of the state examination that was taken in 1963 to demonstrate the principles and practice of nursing. Interestingly, there is no reference to any evidence base to underpin Early the answers that are given, nor are the candidates asked to critically analyse the care that they give. Th e Briggs Committee, a working group, was set up in 1976 to Workforce planning was crude and with the development of review the training of nurses and midwives, and set the expectation new hospitals and services came the need for a greater number of that nurse education would incorporate the latest fi ndings of evi- nurses. Sadly at the time of the development of the NHS, no real dence to underpin practice. Th e work of this committee led to provision for the education of nurses had been established en-masse , the Nurses, Midwives and Health Visitors Act of 1979, which and there was no recognition for nurses to help shape the develop- dissolved the GNC. Th e GNC was replaced by the UKCC for ment of services. Services were isolated, in particular the provision Nursing, Midwifery and Health Visiting, with four National Boards of mental health care. Children were isolated from their families for England, Wales, Scotland and Northern Ireland. Th e UKCC had with visiting restricted to weekends only in many wards. a specifi c responsibility for the quality of education of nurses, the 10 Chapter 1 Nursing: Past, Present and Future

Figure 1.5 Copy of the state examination taken in 1963. Chapter 1 Nursing: Past, Present and Future 11

Table 1.3 Comparison of Project 2000 curriculum to 1948 – The NHS is born, traditional nurse training. ‘good care available to all regardless of wealth’ PROJECT 2000 TRADITIONAL NURSE TRAINING 1952 – Prescription charges introduced Education in Higher Took place in schools of 1953 – DNA structure is revealed allowing the study of Educational Institutions nursing, most likely disease caused by defective genes (HEIs) hospital-based

1954 Supernumerary status, not Part of the workforce, included – Link establised between smoking and lung cancer counted as ‘numbers’ on on the team ‘off duty’ rota – Children allowed daily visits wards 1960 – First kidney transplant Increase of theory content to Practice component represent 50% of the signifi cantly outweighs time 1961 – Contraceptive pill is introduced three-year course spent in classroom

1962 – First hip replacement Includes a minimum HEI No fi nal award but eligible for award (Diploma) along with nurse registration 1968 – First heart transplant nurse registration Focus on health rather than Illness model focus 1972 – CT scans introduced ill health with emphasis on 1980 – The Black Report is published the life sciences – Keyhole surgery is introduced Common Foundation No foundation programme Programme (CFP) of 18 1986 – The AIDS health campaign months for all student nurses 2000 – NHS walk-in centres introduced Four specialist pre- No branches, nurses start on 2008 – Free choice introduced: patients can choose from registration branches of 18 specifi c programme at any hospital or clinic that meets NHS standards months to follow CFP: beginning of three-year training Adult 2012 – Health and Social Care Act: the most extensive Child health reorganisation of the NHS since its introduction Mental health in 1948 Learning disabilities

Figure 1.6 Some signifi cant dates in the history of the NHS. While presenting a radical change to the way that nurses were educated, Project 2000 had many critics, not least from the estab- maintenance of student training records, the provision of profes- lished workforce in nursing in the wards and departments. Many sional guidance and a remit to handle professional misconduct. found the transition from students as part of the workforce to Th e fi rst code of conduct for nurses, midwives and health visi- supernumerary status diffi cult to adapt to. tors was developed in 1984 by the UKCC, setting out standards of professional behaviour and accountability. Th is was an eff ort at Jot This Down transparency to provide the public with standards that they could The introduction of Project 2000, while embraced by expect and to guide the profession with regard to their duty of care some, was a cause of concern to many nurses. to their patients and clients. • Why would this radical change in the way that nurses Much of the work of Briggs in the 1970s paved the way for were educated cause so much anxiety? reform in relation to nurse education. In 1984, the UKCC set up a project to consider reforming nurse education, which became known as Project 2000. Th e UKCC ’ s report, published in 1986, I n t h e ‘ J o t Th is Down’ exercise above, you may have made the provided the Council’ s strategy (UKCC 1986 ). Th e strategy was same conclusions that the professional bodies and nurse educators implemented by the mid-1990s and up to this point, nurse educa- were investigating as Project 2000 began to develop. tion worked on the apprenticeship model, where students were Researchers began to look at the experience from Project 2000 salaried, part of the workforce and in the majority of cases, had ( Hamill 1995 ), and just as importantly the outcome, in relation to their education based in one local hospital. Examinations were newly qualifi ed nurses ( UKCC 1999 ). What they found was concern both hospital and nationally set. Until Project 2000, the whole over the fi tness to practise of some qualifi ed nurses following the model of education for nurses was geared towards the needs of the fi rst round of Project 2000. local health services and provided hands on, practical approaches Th e Peach Report was published in response to the UKCC’ s to clinical practice ( RCN 2007 ). desire to conduct a detailed examination of the eff ectiveness of pre-registration nurse education and determine if students were ‘fi t P roject 2000 for practice’ and ‘fi t for purpose’ ( UKCC 1999 ). Th e report outlined Project 2000 introduced a framework for pre-registration nurse several recommendations, for example: programmes which was to radically change the experience of • A reduction in the common foundation programme from 18 student nurses in practice and in education. Table 1.3 shows a months to one year comparison between the traditional style of nurse education and • An increase in the branch programme from 18 months to two the revolution in education that was introduced with Project 2000. years 12 Chapter 1 Nursing: Past, Present and Future

• To ensure that students experienced at least three months ’ super- increase from 62.3 million in 2010 to 73.2 million in 2035; this is vised clinical practice towards the end of the programme in part due to the projected natural increase based on more births • Longer student placements than deaths: people are living longer and surviving the chronic • Th e introduction of practice skills and clinical placements early illnesses that at one time would prove fatal. Th e provision of care on in the common foundation programme will see a continued growth and an increasingly diverse role for the • Greater fl exibility in entry to nursing programmes. Th ird Sector, as well as reliance on the commercial sector to make Subsequent revisions included more focus on clinical skills acquisi- available considerable aspects of secondary care provision ( Longley tion, a closer link between theory and practice, and the develop- et al . 2007 ). ment of roles that support mentors in practice such as practice International migration has necessitated health care to adapt education facilitators (PEFs). ways of working to support cultural diff erences. Isolation of the elderly is a common feature; stress and the breakdown of the Drivers for Change extended family are examples of factors aff ecting the population ’ s Nurse education can be seen as an organic element, responding to health. changes within society, the healthcare setting and the educational Patterns of health and disease are infl uenced by lifestyle, less system. As such, there are a number of so-called ‘drivers’ that have physical activity and sedentary lifestyles, and coupled with the ‘fast been identifi ed to help identify the kind of health care that will be food’ culture have contributed to a rise in the incidence of obesity. needed in the future and subsequently, the type of nurse needed to Cigarette smoking accounts for around 18% of all deaths of adults support that health care (RCN 2004 ). over the age of 35 years ( Th e Health and Social Care Information Examples of the drivers include: Centre 2012 ). Th e same study highlighted that in England in • Demographic changes, we live in an ever-ageing population 2010/2011, there were approximately 1.5 million hospital admis- • People living longer with chronic disease and long-term illness sions with a primary diagnosis of a disease that can be caused by • Lifestyle dictating health, e.g. obesity smoking. Th is is a steady rise from 1996/1997, when the number • Th e public expectation of quality care was 1.1 million admissions. • Focus on prevention and health promotion Th e rise of consumerism has led to a more informed user of • Primary care and a move away from hospital care delivery healthcare services. Expectations of the care received are high, for towards a community focus example in Islington in 2009, 40% of respondents to the Citizens • Supporting patients and carers to self-manage their conditions. Panel that investigated Health and Social Care, said that better provision of opportunities to take up health screening, e.g. breast Such drivers infl uence the type of care that can be expected in cancer, would improve the health of residents. the future and determine the preparation of the future nursing Th e ethical component of care is another example of the drivers workforce. for development in nursing. Acknowledgement of individual rights Technological advances continue to shape the way that nurses and nursing responses to this and the consideration of mental work, and the need to be computer literate to cope with managing capacity are discussed in Chapter 3 of this book. Diversity and patients ’ records and data is a constant feature of the nurses ’ role. equity and the maintenance of a fair and non-discriminatory health Advances in telehealth and remote patient monitoring are being service in which everybody can participate to reach their potential developed, particularly in the community setting, and telehealth are important drivers for nursing. has been seen as an eff ective tool for telephone triage, an example being ‘NHS 111’ in England. Telecare is the use of electronic equipment, sensors and aids Jot This Down in a person ’ s home to support independent living. Geared towards From examples of the ‘drivers’ in health care above, home care, the technology can help people with a range of long- what would you say were the important components of term conditions to avoid unnecessary hospital admis sions. nursing programmes of study to equip the nurse of the Technological developments will continue, with an increased future to support excellent health care? understanding and use of new applications associated with bio- technology, bioengineering and robotics. F r o m t h e ‘ J o t Th is Down’ exercise above, you may have con- sidered the need to include a signifi cant placement within the The Evidence Telehealth, the Use of F lorence (F lo) community setting, the ability to assess complex needs and to Practice nurses can use the ‘Flo telehealth system’ to convey respond appropriately, work eff ectively within teams, work in interactive and positive health messages to selected patients partnership with people and their families to promote health to enhance clinical management. An example is an interactive and support self-care, and to recognise opportunities for health mobile phone texting service with blood pressure (BP) promotion. management. Patients measure their BP, text their readings to Florence, receive an immediate automatic response and have Modernising Nursing Careers their results reviewed by the GP or practice nurse at least weekly. In 2006, the four UK chief nursing offi cers created a vision for the ( Cottrell et al . 2012 ) nursing profession in the 21st century, setting the direction for modernising nursing careers (DH 2006 ). Similar to the RCN in Th e demographic pattern of the UK population also has an 2004, it too considered the drivers for change in relation to: infl uence on nursing today. According to UK National Statistics, Th e context of nursing: diversity in society, demographics, health life expectancy at birth in the UK in 2008–2010 was 78.1 years for patterns, inequalities, expectations of health care, advances in males and 82.1 years for females. Th e population is calculated to technology, economics of care. Chapter 1 Nursing: Past, Present and Future 13

Changing health care: putting the patient fi rst, integrated care, • General Pharmaceutical Council patient choice, care of people with long-term conditions, health • Health Professions Council promotion, community focus of care, new ways of working. • Nursing and Midwifery Council • Pharmaceutical Society of Northern Ireland Th e report highlighted that wherever nurses work, there are four Under the NHS Reforms and Health Care Professions Act 2002 elements that are key to the role. and the Health and Social Care Act 2008, the CHRE has a number of powers, for example it carries out checks on how healthcare regulators carry out their work as well as providing The Evidence Elements for All Nurses advice to the regulators concerning policy. • Practice • Education, training and development • Quality and service development Th e fundamental concern of the NMC is the protection of the • Leadership, management and supervision public. Its duties to society are to serve and protect by: ( DH 2006 ) • Maintaining a register listing all nurses and midwives • Setting standards and guidelines for nursing and midwifery edu- cation, practice and conduct Th e vision for the future is for nurses to be able to respond to • Providing advice for registrants on professional standards the complexity of a modern society with all of its demands for • Ensuring quality assurance related to nursing and midwifery quality, cost-eff ective, technological care. Th e report identifi ed a education need for nurses to be able to meet the elements identifi ed in the • Setting standards and providing guidance for local supervising evidence box: in practice, the ability to work in diverse care set- authorities for midwives tings; in development, be able to pursue education and training • Considering allegations of misconduct or unfi tness to practise when needed; in service development, be both generalist and spe- due to ill health. cialist skilled as required; in leadership, be able to take on changed In maintaining the professional register, the NMC provides the roles and responsibilities. profession and public with a database of all and midwives. Th e information shared includes the name and registra- The N ursing and M idwifery C ouncil ( NMC ) tion status of the nurse on one or more of the three parts of the and N urse E ducation register; nursing, midwifery and/or community public health nurse. Th ere are currently over 650 000 qualifi ed nurse registrants In 1998, the government initiated a major review of how the in the UK. nursing profession was regulated. Th e outcome of this review resulted in consultation with nurses and midwives regarding professional regulation and areas that needed to be addressed. Professional and Legal Issues Recommendations were suggested and acted upon regarding self- professional regulation, regulatory mechanisms and procedural • To stay on the professional register, the nurse must rules. Th e United Kingdom Central Council (UKCC) and the four renew their registration every three years. This is national boards were abolished; quality assurance elements were known as periodic renewal. An annual retention fee is incorporated into the work of the Nursing and Midwifery Council also required at the end of the fi rst and second year of (NMC). the registration period. • Nurses must be able to demonstrate that their skills and Th e NMC was set up by Parliament to safeguard the public and knowledge are suitable for their work. Currently, a nurse is to ensure that nurses and midwives provide high standards of care required to undertake a minimum of 35 hours of learning to their patients. Th e Nursing and Midwifery Order 2001 (SI 2002/ relevant to practice over a three-year period. 253) established the Council and it came into being on 1 April 2002.

Professional and Legal Issues When in 2002 the UKCC ceased to exist, its function was taken over by the NMC which looked to the future of nurse educa- The NMC maintains a register of nurses and midwives, tion in the UK. Th e NMC mapped the standards of profi ciency setting standards for education and practice and offering for pre-registration nursing education, producing its latest version guidance and advice to the professions. An overarching in 2010. aim is to inspire confi dence by ensuring that those on the As established earlier, as health care changes, so too does the professional register are fi t to practise and by dealing speedily role of the nurse and as such, so must the education required to and fairly with those who are not. prepare the student for the new roles and responsibilities (Carvalho The Council for Healthcare Regulatory Excellence (CHRE) et al. 2011 ). Aft er extensive consultation, the NMC have introduced promotes the health, safety and well-being of patients and other members of the public in the regulation of health professionals new standards for nurse education (NMC 2010 ) and students must and has the job of scrutinising the work of the nine health meet these standards to be eligible to enter the professional register. profession regulators: Th e standards help to ensure parity throughout the UK for any fi eld • General Chiropractic Council of nursing (fi elds replace branches). • General Dental Council Th e standards identify what students must demonstrate at • General Medical Council the point of registration with the NMC, and guide the Approved • General Optical Council Education Institutions (AEIs) and partners in the delivery of nurse • General Osteopathic Council education programmes. Registration conveys a message to the 14 Chapter 1 Nursing: Past, Present and Future

public that the nurse who is admitted to the register has reached and possesses a satisfactory level of competence along with a Nursing Field Child and Family: Nursing Practice and certain standard of behaviour – good character and good health. Decision-Making Th e latest NMC 2010 guidelines are specifi cally geared to new Children’ s nurses must be able to care safely and effectively programmes of study, which began in September 2011, and set out for children and young people in all settings, and recognise standards for competence and standards for education. their responsibility for safeguarding them. They must be able to deliver care to meet the essential and complex physical Standards for competence identify the specifi c knowledge, skills and mental health needs informed by deep understanding of and attitudes the student must acquire by the end of the pro- biological, psychological and social factors throughout infancy, gramme within the context of their particular fi eld of nursing, and childhood and adolescence. are arranged in four domains: ( NMC 2010 ) • Professional values • Communication and interpersonal skills • Nursing practice and decision-making Th e last domain is comprised of Leadership, management and • Leadership management and teamworking. teamworking competency, which highlights the importance of Th e fi rst domain, Professional values , emphasises the need for holis- accountability in practice and endeavour for improving nursing tic, non-judgemental caring and sensitive practice. Here, the nurse practice and standards of health care. Self-management and the is reminded of the obligation to respect the rights of individuals, management of others is also a feature alongside ongoing leader- with particular attention to equality and diversity and the needs of ship skills development. an ageing population. Nursing Field Adult: Leadership, Management and Teamworking Nursing Field Mental Health: Professional Values Adult nurses must be able to provide leadership in managing Mental health nurses must work with people of all ages, adult nursing care, understand and coordinate utilising values-based mental health frameworks. They must interprofessional care when needed and liaise with specialist use different methods of engaging people, and work in a way teams. They must be adaptable and fl exible, and able to take that promotes positive working relationships focussed on the lead in responding to the needs of people of all ages in a social inclusion, human rights and recovery, that is, a person ’s variety of circumstances, including situations where immediate ability to live a self-directed life, with or without symptoms, or urgent care is needed. They must recognise their that they believe is meaningful and satisfying. leadership role in disaster management, major incidents and ( NMC 2010 ) public health emergencies, and respond appropriately according to their levels of competence. ( NMC 2010 ) Th e Communication and interpersonal skills domain, highlights the need for excellence, making safe and eff ective, compassionate Standards for education provide the framework from which and respectful communication with people. Th e use of communi- programmes of study are approved and delivered. Th ere are 10 cation technologies to inform patient choice, and the skilled use of standards that institutions and service providers must meet. therapeutic principles to engage in caring relationships is empha- sised. In addition, maintaining accurate records and supporting Professional and Legal Issues The 10 Standards for confi dentiality features in the competencies. Pre-registration Nursing

1. Safeguarding the public: nursing and midwifery Nursing Field Learning Disabilities: Communication education must be consistent with The code: and Interpersonal Skills Standards of conduct, performance and ethics for nurses and midwives ( NMC 2008 ) Learning disabilities’ nurses must use complex communication 2. Equality and diversity: education must address key aspects of and interpersonal skills strategies to work with people of all equality and diversity and comply with current legislation ages who have learning disabilities and help them to express 3. Selection, admission, progression and completion: must be themselves. They must also be able to communicate and open and fair negotiate effectively with other professionals, services and 4. Support of students and educators: programme providers agencies, and ensure that people with learning disabilities, must support students to achieve the programme outcomes, their families and carers, are fully involved in decision-making. and support educators to meet their own professional ( NMC 2010 ) developmental needs 5. Structure design and delivery of programmes: to meet NMC standards and requirements, e.g. 4600 hours in no less than three years Th e third domain, Nursing practice and decision-making , 6. Practice learning opportunities: must be safe, effective, reminds the nurse that practice should be autonomous, compas- integral to the programme and appropriate to programme sionate, skilful and safe and must be dignifi ed and promote health outcomes and well-being. Th e competency stresses the need for evidence- 7. Outcomes: must ensure that NMC standards for competence based care delivered through systematic nursing assessments, rec- are met and that students are fi t for practice and for award ognising risk and evaluating care. on completion Chapter 1 Nursing: Past, Present and Future 15

8. Assessment: programme outcomes must be tested using valid • Safely delegate to others and to respond appropriately when a and reliable assessment methods task is delegated to them 9. Resources: the educational facilities in academic and practice • Safely lead, coordinate and manage care settings must support delivery of the approved programme • Work safely under pressure and maintain safety of service 10. Quality assurance: programme providers must use effective users at all times assurance processes in which fi ndings lead to quality • Enhance the safety of service users and identify and actively enhancement. manage risk and uncertainty in relation to people, the ( NMC 2010 ) environment, self and others • Prevent and resolve confl ict and maintain a safe environment • Select and manage medical devices safely. Infection prevention and control Essential Skills Clusters People can trust a newly registered to: In addition to the standards set, students must engage in essential • Identify and take effective measures to prevent and control skills clusters that are incorporated into the programme of study infection in accordance with local and national policy throughout the three years; these are common to all fi elds and • Maintain effective standard infection control precautions and include: apply these to needs and limitations in all environments • Care, compassion and communication • Provide effective nursing interventions when someone has an • Organisational aspects of care infectious disease, including the use of standard isolation • Infection prevention and control techniques • Comply with hygiene, uniform and dress codes in order to limit, • Nutrition and fl uid management prevent and control infection • Medicines management. • Safely apply the principles of asepsis when performing invasive procedures and be competent in aseptic technique in a variety Professional and Legal Issues Essential Skills Clusters of settings • Act in a variety of environments including the home care Care, compassion and communication setting, to reduce risk when handling waste, including sharps, People can trust a newly registered graduate nurse to: contaminated linen and when dealing with spillages of blood • Provide collaborative care based on the highest and other body fl uids. standards, knowledge and competence Nutrition and fl uid management • Engage in person-centred care empowering people to make People can trust a newly registered graduate nurse to: choices about how their needs are met when they are unable to • Assist them to choose a diet that provides an adequate meet them for themselves nutritional and fl uid intake • Respect them as individuals and strive to help them to • Assess and monitor their nutritional status and in partnership, preserve their dignity at all times formulate and effective plan of care • Engage with them or their family or carers within their cultural • Assess and monitor their fl uid status and in partnership with environments in an acceptant and anti-discriminatory manner them, formulate an effective plan of care free from harassment and exploitation • Assist them in creating an environment that is conducive to • Engage with them in a warm, sensitive and compassionate way eating and drinking • Engage therapeutically and actively listen to their needs and • Ensure that those unable to take food by mouth receive concerns, responding using skills that are helpful, providing adequate fl uid and nutrition to meet their needs information that is clear, accurate, meaningful and free from • Safely administer fl uids when fl uid cannot be taken jargon independently. • Protect and keep as confi dential all information relating to them Medicines management • Gain their consent based on sound understanding and informed People can trust a newly registered graduate nurse to: choice prior to any intervention and that their rights in decision making and consent will be respected and upheld. • Correctly and safely undertake medicines calculations • Work within legal and ethical frameworks that underpin safe Organisational aspects of care and effective medicines management People can trust a newly registered graduate nurse to: • Work as part of a team to offer holistic care and a range of • Treat them as partners and work with them to make a holistic treatment options of which medicines may form a part and systematic assessment of their needs; to develop a • Ensure safe and effective practice in medicines management personalised plan that is based on mutual understanding and through comprehensive knowledge of medicines, their actions, respect for their individual situation, promoting health and risks and benefi ts. well-being, minimising risk of harm and promoting their safety at all times • Deliver nursing interventions and evaluate their effectiveness against the agreed assessment and care plan • Safeguard children and adults from vunerable situations and support and protect them from harm • Respond to their feedback and a wide range of other sources Link To/Go To to learn, develop and improve services • Promote continuity when their care is to be transferred to The full document of the 2010 NMC Standards for Nurse another service or person Education can be accessed at: • Be an autonomous and confi dent member of the nmc-uk.org/PreRegNursing/statutory/background/Pages/ multidisciplinary or multiagency team and to inspire confi dence introduction.aspx in others 16 Chapter 1 Nursing: Past, Present and Future

Th e appropriateness of the four nursing fi elds has been exam- Current Nurse Education ined with a concern that future health services may require a more generic worker, who would be helpful when meeting general health From September 2013, all programmes of study in nursing became needs. Th e provision of degree-level programmes has the potential degree level only, and diploma entry study in the UK has been to enhance the status of nursing even further, providing nurses phased out nationally as a move towards this development. Th e with skills that go beyond diploma level, with the aim of ensuring NMC sees the future nurse as a leader, delegator, supervisor and that the care of the patient is improved and enhanced. Th e new person who can challenge other nurses and healthcare profession- standards have been aligned with European Union Directive als. In order to develop and sustain change in practice, graduate 2005/36/EC Recognition of Professional Qualifi cations . Th is sets out (degree level) nurses need to: the requirements for training nurses responsible for general care • Th ink analytically and provides the baseline for general nursing in the EU. Th e Direc- • Use problem-solving approaches tive includes detailed requirements on programme length, content • Utilise best evidence in decision-making and ratio of theory to practice, as well as the nature of practice • Keep up with technological advances. learning and range of experience. ( NMC 2010 ) In the UK, student nurses qualify in a specifi c fi eld of nursing, and The Francis Report enter the NMC register as a nurse in one or more of the four fi elds. Th e education programme is full time and consists of 4600 hours Between 2005 and 2008, there was growing concern over the unu- of combined theoretical and clinical instruction distributed equally. sually high mortality rate at the Mid Staff ordshire NHS Foundation Trust ; this prompted an initial investigation in 2010 . Chaired by Robert Francis QC, this fi rst inquiry considered individual cases of Nursing Fields patient care, in an eff ort to learn lessons and prevent mistakes in Child and family nursing the future, not just at the Mid Staff ordshire Trust but across the The fundamentals of child and family nursing are addressed in NHS. His fi nal report, a public inquiry, was published in February Chapter 11 . Nurses working in this fi eld understand the 2013. Th is report builds on the work and conclusions of the fi rst developmental needs of children, in particular those who are acutely ill or suffering long-term debilitating conditions. inquiry. It tells of a culture of secrecy and defensiveness, which led Children’ s nurses are skilled in working alongside parents and to appalling suff ering by many patients and their families ( Mid families. Staff ordshire NHS Foundation Trust 2013 ). Learning disabilities nursing In his fi ndings, Francis highlights a culture of care that The fundamentals of learning disabilities nursing are failed in its primary concern of protecting patients and upholding addressed in Chapter 10 . the public ’ s confi dence in the system of care provided. In both In essence, these nurses care for people with a wide range reports, he sends a clear message that ‘it should be patients, not of physical and mental health conditions. The work is numbers, which count’. Although focussed on one organisation, demanding and the skills needed include: assertiveness to the report highlights a whole system failure, which has major advocate against discrimination; an awareness of legislation implications for all healthcare systems across the UK. Th e 1782 and support mechanisms to promote independence; the ability page report has 290 recommendations, calling for a re-emphasis to work in a specialist support team in a variety of settings on what is important in care and not, as some might have that might include schools, workplaces, residential care homes and community centres. expected, a total re-organisation of the system. What Francis wanted to do was to use the evidence to focus on the positive Mental health nursing The fundamentals of mental health nursing are addressed in values of care and to learn from this so that the failings identifi ed Chapter 12 . are not repeated. His recommendations focus on a series of Nurses in this fi eld are skilled in supporting patients and themes based around: families, forming therapeutic relationships and enabling • Openness, transparency and candour throughout the healthcare recovery from mental health breakdown where possible. system The range of mental health problems is vast, and mental • Fundamental standards for healthcare providers health nurses understand the many dimensions that can • Improved support for compassionate caring, committed nursing impact upon a person’ s mental well-being. and stronger healthcare leadership. The work is predominantly focussed in the community, with some aspects of acute care hospital-based. Th ere is recognition that the focus of compassion and caring in Adult nursing nursing should be emphasised right from recruitment into nursing, Specifi cally focussed on work with adults, but by its nature will through education and continuous professional development cover all areas of care, from the community to the hospital (CPD). Francis makes the point that training and CPD in nursing setting. This is working with adults who have long-term chronic should apply at all levels from student nurse to director of nursing. illness or acute illness and also with well adults as promoters Th e challenge will be in resourcing this development. of health. Th e message from the inquiry strongly promotes the culture of Nurses working with adults need to be skilled in putting patients fi rst and protecting them from avoidable harm. It communication, understanding of the sciences on which also strongly advocates an open and honest approach to patient nursing is based, knowledge of ethics and principles of health. care, where patients share in the decision-making of their care They also need technical and clinical competence. Adults will present with mental health problems and learning based on the best information available. In addition, the report diffi culties, and as such, awareness of these fi elds is essential. identifi es the need for a greater role for families and carers of older people. Chapter 1 Nursing: Past, Present and Future 17

In response to the Francis report, the NMC has highlighted the core theme of ‘the Code’ ( NMC 2008 ), which states ‘make the care The New Framework for Nursing of people your fi rst concern, treating them as individuals and and Midwifery respecting their dignity’. Th e chief executive of the NMC recom- mends that ‘this needs to be the core principle of the whole health- Launched by the NMC in July 2013, the new framework sets out a care system’. three-year strategy for assuring the quality of nursing and mid- Th e RCN has also responded to the report, supporting the wifery education, and the supervision of midwives. Th e Quality notion of transparency and the importance of speaking out in Assurance (QA) framework’ s principal aim is to ensure patient defence of patients in poor care. It supports the notion that safety. poor leadership creates a culture of poor care and is critical of the lack of guidance into safe levels of staffi ng. Support for the Professional and Legal Issues recruitment of the right students who possess the values identifi ed in the review has been made; however, like the NMC, the RCN The Quality Assurance (QA) framework (2013) aims to: does not support the recommendation that student nurses should • Increase lay involvement through the increased use of have an extended period of direct patient care as a pre-requisite reviewers who are neither nurses nor midwives to training. Th e RCN believes that the current system of 2300 hours • Increase the proactive management of emerging risk by in practice for student nurses is suffi cient, but emphasises the ensuring that education institutions (HEIs) and local supervising need to support mentors in practice to ensure positive learning authorities (LSAs) have approved safeguards in place experiences. • Over the three-year cycle, reduce the burden of regulation on Th e Cavendish Review released in July 2013 looked at the com- well performing education institutions and LSAs plexity of caring roles within health care carried out by non- • Ensure that quality assurance focusses on outcomes of education and midwifery supervision as opposed to dictating regulated and trained individuals. It found over 1.3 million frontline how standards should be met. staff that are not registered nurses, but are responsible for the ( NMC 2013 ) delivery of the majority of hands-on care both in hospitals and in the community. It highlights the confusion that patients feel when approached by diff erent carers, the assumptions made by patients that all carers are nurses, the bureaucracy of employment, and the Th e target audience for the framework is primarily the public, lack of consistency of approach to training and development. It and the NMC sees this as a means to transparency, clarity, utility, proposes a ‘certifi cate of fundamental care’ linked to nurse training accountability and improvement. Th e term ‘public’ encompasses among its many recommendations (DH 2013 ). the population of nurses, service users and carers, and the specifi c community of educators and service providers. Changes to the framework have been informed by a number of factors, not isolated to the response to the Francis inquiry report into the Mid Staf- Link To/Go To fordshire Foundation Trust, but the use of data from nurses, service users and carers, educational institutions and service providers. Th e QA sets out its approach as follows: The Cavendish Review is an independent review into Healthcare assistants and Support Workers in the NHS and PUBLIC PROTECTION: care settings and can be accessed at: • Ensure new entrants to the register are capable of safe, eff ec- www.gov.uk/government/uploads/attachment_data/fi le/ tive practice 12732/Cavendish_Review_ACCESSIBLE_-_FINAL_VERSION • Ensure the profession knows how and when to raise a concern _16–7-13.pdf • Ensure swift and eff ective response to fi tness for practice concerns. ‘RIGHT TOUCH’ REGULATION: • Encourage stakeholder feedback, and comment on, for Th e Care Quality Commission (CQC) is an independent regula- example, the transparency and accountability of the tor of health and adult social care services in England. It ensures framework. that the care provided by hospitals, dentists, ambulances, care FOCUSSING ON OUTCOMES: homes and home-care agencies meets government standards of • Shift of emphasis from how standards are achieved towards quality and safety. In addition, it protects the interests of vulnerable focus on outcomes of education to better protect the people, including those whose rights are restricted under the public Mental Health Act. • More discretion for the interpretation and meeting of stand- By putting the views, experiences, health and well-being of ards in diverse settings. people who use services at the centre of its work, it has a range RISK-BASED: of powers to take action if people are getting poor care. Table 1.4 • More scrutiny and support for the practice-based element gives an overview of the standards and desired out comes, which of the course the CQC applies to measure care within health and social care set- • Proposed publication of guidance for educational audit of tings, and relates to the quality and safety of care. Providers must practice placements. have evidence that they meet the outcomes (CQC 2010 ). INVOLVING STAKEHOLDERS: In addition, public interest in the quality of nursing education • Build on the theme of engagement with service users and and practice has prompted the NMC to review its Quality Assur- carers to develop programmes of education ance and publish its latest framework ( NMC 2013 ). • Seek direct student feedback as a mechanism for quality 18 Chapter 1 Nursing: Past, Present and Future

Table 1.4 Outcomes applied by the CQC in relation to the quality and safety of care. TITLE AND SUMMARY OF OUTCOME Care and welfare of people who use healthcare services People experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. Assessing and monitoring the quality of service provision People benefi t from safe, quality care because effective decisions are made and because of the management of risks to people’s health, welfare and safety. Safeguarding people who use services from abuse People are safeguarded from abuse, or the risk of abuse, and their human rights are respected and upheld. Cleanliness and infection control People experience care in a clean environment, and are protected from acquiring infections. Management of medicines People have their medicines when they need them, and in a safe way. People are given information about their medicines. Meeting nutritional needs People are encouraged and supported to have suffi cient food and drink that is nutritional and balanced, and a choice of food and drink to meet their different needs. Safety and suitability of premises People receive care in, work in or visit safe surroundings that promote their well-being. Safety, availability and suitability of equipment Where equipment is used, it is safe, available, comfortable and suitable for people’ s needs. Respecting and involving people who use services People understand the care and treatment choices available to them. They can express their views and are involved in making decisions about their care. They have their privacy, dignity and independence respected, and have their views and experiences taken into account in the way in which the service is delivered. Consent to care and treatment People give consent to their care and treatment, and understand and know how to change decisions about things that have been agreed previously. Complaints People and those acting on their behalf have their comments and complaints listened to and acted on effectively, and know that they will not be discriminated against for making a complaint. Records People ’s personal records are accurate, fi t for purpose, held securely and remain confi dential. The same applies to other records that are needed to protect their safety and well-being. Requirements relating to workers People are kept safe, and their health and welfare needs are met, by staff who are fi t for the job and have the right qualifi tions,ca skills and experience. Staffi ng People are kept safe, and their health and welfare needs are met, because there are suffi cient numbers of the right staff. Supporting workers People are kept safe, and their health and welfare needs are met, because staff are competent to carry out their work and are properly trained, supervised and appraised. Cooperating with other providers People receive safe and coordinated care when they move between providers or receive care from more than one provider.

• Educators feedback on the application of standards in healthcare professionals, with the aim of developing their full practice. potential. Roles are described as both generic and specialist. All of the criteria set out as shown are focussed on responding Registered nurses working in clinical settings can carry out roles to the strength of public interest in the quality of nursing and such as: midwifery education and practice, and an acknowledgment from • Managing caseloads our professional body that high profi le failures in care undermine • Administering and prescribing medications (if qualifi ed as a the public ’ s trust in nursing. Th e process of raising concerns is non-medical prescriber) addressed in Chapter 3 of this book. • Delivering care which is evidence-based and which follows an agreed pathway or model of care Role of the Nurse • Managing teams Th e role and function of the nurse has evolved and developed over • Discharge planning the years and were explored in the fi rst part of this chapter. In order • Documentation and communication of care. to meet the healthcare needs of the nation, political and profes- As society changes, coupled with rapid and important advances in sional pressures have transformed the role of the nurse and other science and technology, so too does the role and function of the Chapter 1 Nursing: Past, Present and Future 19 nurse and other health and social care practitioners. A reduction Benner ( 1982 ) discusses the subject of intuition as a form of in doctors’ hours saw the rise of the and the expertise. Intuition can be described as ‘just knowing’ and the ‘just specialist nurse ( McGee & Castledine 2004 ). Nurses are advancing knowing’ comes from the individual. It is internal and can occur their skills and their practice, underpinned by an evidence base and independently of experience or reason. It can become validated by further education. It is not unusual for nurses to undertake roles experience and interaction with other nurses. traditionally seen as medical, for example the nurse endoscopist, specialist ophthalmic nurses performing cataract surgery and sur- gical practitioners skilled in vascular surgery and hernia repair. What the Experts Say Many of the new nursing roles identifi ed here exist today Within this Trust we have initiated hourly patient because, over time, the nursing profession has sought to advance communication from senior nursing staff. An adult its professional practice and status. Th e key issues of clinical com- male had been admitted early one morning with a petence, clinical decision-making and the awareness of boundaries severe asthma attack, he was wheezing and and limitations are central to the safety of the patient and the exhausted and we commenced medications and regular success of such roles. monitoring of his saturation levels. Later that day whilst on my Other key roles that are part of the scope of practice and can hourly rounds, the staff nurse communicated that the patient infl uence the career pathway of the nurse include: had suddenly improved; she knew this because he had stopped wheezing and was dropping off to sleep. As soon as I • Mentoring and teaching in practice caught sight of him my intuition told me that something was • Taking on leadership roles: ward sister/charge nurse wrong: the patient had stopped wheezing from sheer • Specialist public health nurse exhaustion and his saturation levels were low, he was • Nurse consultant unresponsive and I immediately called the emergency team. • Nurse prescriber (Clinical Matron, Medical Unit) • • Nursing researcher. Nurses use their body of knowledge in order to provide care The Evidence The Intellectual Properties of the Nurse that has undergone critical scrutiny, or a systematic approach has been used to provide that care. Care becomes creative and innova- • A body of knowledge on which professional practice is based • A specialised education to transmit this body of knowledge tive and provides nurses with new ways of thinking and addressing to others the problems that people may have. Advancing nursing practice • The ability to use the knowledge in critical and creative ensures that nurses have the knowledge base and practical skills to thinking. provide specialist nursing care. Critical thinking allows nurses to ( Hood 2010 ) see diff erent approaches to clinical situations, and can occur when nurses are faced, for example, with people who have complex needs. Specialist nursing roles and professional development are In order to develop and sustain the caring perspective of considered in Chapter 2 . nursing, there has to be a theoretical basis from which they prac- tice. Nurses draw upon the scientifi c and theoretical perspectives The NHS and Healthcare Reform of other disciplines to enhance the nature and safety of the care that On 1 April 2013, the NHS saw its biggest reform in its 65-year they provide. history. Hundreds of NHS organisations were abolished and hun- dreds of others were created, transforming the provision, commis- Jot This Down sioning and regulation of health care. Th e Health and Social Care Act 2012 has abolished 153 primary In order to provide evidence-based safe and effective care, nursing draws information from a number of care trusts responsible, up until the new Act, for commissioning disciplines. health care, and the nine strategic health authorities responsible • Make a list of the disciplines that you think support for performance managing the NHS. In their place are 211 Clinical the theoretical and practice base of nursing. Commissioning Groups (CCGs) led by GPs. Under the plans, GPs and other clinicians have much more responsibility for spending the budget in England, while greater competition with the private I n t h e ‘ J o t Th is Down’ exercise above, you may have considered sector will be encouraged. Th e CCGs are held to account by NHS disciplines such as the life sciences: sociology, psychology and England, who will commission specialist services and Primary biology. Other disciplines include pharmacology, physiology and Care operating regionally through 27 local area teams. Originally, microbiology. Th emes such as economics and budget management, the commissioning groups were to be led by GPs, but other profes- leadership skills and teaching are infl uential theoretical principles sionals, including hospital doctors and nurses, will also now be for the registered nurse. Th e combination of knowledge related involved. to science and experience has the potential to enable the nurse to Th e reforms are designed to help ensure the long-term sustain- make reliable clinical decisions. Professional nursing practice is ability of the NHS, by achieving value for money and shift ing also based on a body of knowledge that is derived from experience care out of hospital and into the community. Th e CCGs are expected – expertise. Th e use of expertise should never be undervalued to use their expertise and clinical knowledge to purchase the however; having experience may not always be enough to help most effi cient services and the hope is that tendering for these provide safe care. Nurses derive knowledge through intuition, tra- services will drive up competition and so improve quality and dition and experience. standards. 20 Chapter 1 Nursing: Past, Present and Future

position that in the main, health care will remain free at the point Link To/Go To of delivery, funded from taxation and based on need and not an ability to pay. http://healthandcare.dh.gov.uk/system/ Conclusion

Figure 1.7 gives an overview of the health and care system from Being a competent registered nurse with the core values at the April 2013. It illustrates the statutory bodies that make up the centre of care brings with it many privileges, not least is the privi- system, oriented around people and communities and where they lege of working with the public and providing them with a service will receive their local health and care services. Clicking on any of that is safe and of a high quality. From a historical perspective, the organisations will provide you with more information about nurses have come a long way and are now seen as being profession- their specifi c role. als working comfortably and confi dently alongside other health- In addition to the changes at NHS Trust level, local authorities care professionals, with levels of education that match many of the have a much larger role in the responsibility for budgeting public allied professions in health care. health activities. Health, social care, public health and children ’ s With regards to the demand for health care, there are many services are integrated. Local authorities are charged with the role drivers, including the kind of and main causes of disease. Many of of working closely with health and care providers and to use their these will change over time, for example obesity levels and health local knowledge to take on challenges such as alcohol and drug inequalities are important factors that must be taken into account misuse, obesity and smoking. at present. Th ere will be a continued need to support the self-care None of the changes in this latest reform changes the way that of the growing numbers of people who experience long-term patients access services, nor do they alter the long-established health conditions. Th e continuing demand from the public to meet

Department Care DH of Health Quality Commission

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Medicines & Empowering patients and S Healthcare Products ON local communities ATI Regulatory Agency N NIS ATIONAL ORGA Supporting providers of care ING R RD EG GUA Safeguarding patients’ ULATION & SAFE interests ATE SECRETARY OF ST

Figure 1.7 An overview of the health and care system from April 2013. Source: Department of Health, used under the Open Government Licence v2.0. Chapter 1 Nursing: Past, Present and Future 21

health needs will remain high, as well as patient demand for choice, GNC: General Nursing Council (no longer in existence) including care packages and treatment options, and access to care NHS: National Health Service provision. All of these factors play a part in the modernisation of Paleopathology: the study of diseases in past populations nursing and the key areas to address within nurse education. Project 2000: a framework for pre-registration nurse Government reform of health care will continue to concentrate programmes, which was to radically change the experience on measuring eff ectiveness, ensuring value for money, reducing of student nurses in practice and in education disparity in performance (locally and nationally, individually and RCN: Royal College of Nursing corporately), improving safety and quality, enhancing productivity Standards for competence: identify the specifi c knowledge, and engaging clinicians and recipients of care in all of this. NHS skills and attitudes the student must acquire by the end of managerial structures are changing and this will continue, along the programme within the context of their particular fi eld of nursing with the provision closer to home for the more generalist services Standards of profi ciency: identify what students must and consideration being given to specialist services. Regulation of demonstrate at the point of registration with the NMC and the professions is continuing to come under scrutiny and this is guide the Approved Education Institutions (AEIs) and focussing on quality and safety. partners in the delivery of nurse education programmes Th ere is an increase in specialist and advanced roles and with Telecare: the use of electronic equipment, sensors and aids this comes a blurring of professional and sector boundaries (i.e. used in a person’ s home to support independent living health and social care sectors). Care provision will increasingly UKCC: United Kingdom Central Council for nursing, midwifery follow the patient pathway, with an emphasis on community care and health visiting (no longer in existence). closer to home and multidisciplinary teamworking.

Key Points References • The fundamental basis of nursing is associated with caring and helping, and nursing can be described as both an art Adams , C. ( 2012 ) Th e history of health visiting. Nursing in Practice , 68 . and a science. Anionwu , E.N. ( 2005 ) A Short History of Mary Seacole: a resource for nurses • Caring defi nes nurses and their work, and as such, there are and students. Royal College of Nursing, London. many facets associated with the role and function of the Baly M.E. ( 1995 ) Nursing and Social Change, 3rd edn. Routledge , London . nurse. The role is constantly evolving and is diffi cult to Benner , P. ( 1982 ) From novice to expert . American Journal of Nursing , classify. 82 ( 3 ), 402 – 407 . • Care has been claimed to be an essential human need for Carvalho , S. , Reeves , M. , Orford , J. (2011 ) Fundamental Aspects of Legal, the full development, health maintenance and survival of Ethical and Professional Issues in Nursing, 2nd edn. Quay Books, human beings in all world cultures. London . • Many of the theories developed through the 20th century Collin , R. (2012 ) Sarah Gamp: My favourite Charles Dickens character. that relate to nursing have a philosophical foundation, and Daily Telegraph , 14 February 2012. http://www.telegraph.co.uk/culture/ include ideas about the nature of nursing, the nature of the charles-dickens/9044813/Sarah-Gamp-My-favourite-Charles-Dickens person, the nature of society and the environment and the -character.html nature of health. Cottrell , E. , Chambers , R. & O ’ Connell , P. ( 2012 ) Using simple telehealth • With regards to the demand for health care, there are many in primary care to reduce blood pressure: a service evaluation . British drivers, including the kind and main causes of disease. Medical Journal , 2 , 6 . • Project 2000 introduced a framework for pre-registration CQC ( 2010 ) Essential Standards of Quality and Safety . Care Quality Com- nurse programmes, which was to radically change the mission , London . experience of student nurses in practice and in education. Davies , R. ( 2010 ) Marking the 50th anniversary of the Platt Report: from New developments have seen the revision of nursing exclusion to toleration and parental participation in the care of the curriculums from 2013 onwards. hospitalised child. Journal of Child Health Care , 14 ( 1 ), 6 – 23 . • On 1 April 2013, the NHS saw its biggest reform in its DH ( 2006 ) Modernising Nursing Careers: setting the direction. TSO, London. 65-year history. Hundreds of NHS organisations were DH ( 2010 ) Front Line Care. Report by the Prime Minster’ s Commission on abolished and hundreds of others created, transforming the the Future of Nursing and Midwifery in England 2010 . COI. TSO, provision, commissioning and regulation of health care. London. DH ( 2012 ) Compassion in Practice. Nursing, Midwifery and Care Staff , Our Vision Our strategy. TSO, London. DH ( 2013 ) Th e Cavendish Review: an Independent Review into Healthcare and Support Workers in the NHS and Social Care Settings. TSO, London. Glossary Doona M.E. (1996 ) Linda Richards and Nursing in Japan, 1885–1890. Essential skills clusters: are incorporated into the programme Nursing History Review , 4 , 99 – 128 . of study throughout the three years. These are common to Hallett C.E. (2010 ) Celebrating Nurses. A Visual History. Fil Rouge Press, all fi elds and include: care, compassion and communication; London . organisational aspects of care; infection prevention and Hamill , C. ( 1995 ) Th e phenomenon of stress as perceived by Project control; nutrition and fl uid management and medicines 2000 student nurses: a case study . Journal of Advanced Nursing , 29 ( 5 ), management 1256 – 1264 . Fields of nursing: identifi es which area of expertise the nurse Henderson , V. ( 1966 ) Th e Nature of Nursing: a defi nition and its implica- possesses at the point of entry onto the professional tions for practice, research, and education. McMillan Publishing, New register, i.e. Child, Mental health, Learning disabilities and York . Adult fi elds of nursing Hood ( 2010 ) Conceptual Bases of Professional Nursing , 7th edn . Lippincott , Philadelphia . 22 Chapter 1 Nursing: Past, Present and Future

Leininger M ( 2002 ) : concepts, theories and practices , RCN ( 2007 ) Pre-registration Nurse Education. Th e NMC review and the 3rd edn . John Wiley and Sons , New York . issues . Policy Briefi ng 14/2007. Royal College of Nursing Policy Unit, Longley , M. , Shaw & C. Dolan , G. (2007 ) Nursing: Towards 2015: alternative London. scenarios for healthcare, nursing and nurse education in the UK in 2015 . RCN ( 2010 ) Th e Principles of Nursing Practice . Royal College of Nursing, University of Glamorgan , Pontypridd . London. www.rcn.org.uk/nursingprinciples (accessed July 2013). McGee , P. & Castledine , G. (2004 ) Advanced Nursing Practice , 2nd edn . Th e Mid Staff ordshire NHS Foundation Trust (2010 ) Independent Inquiry Blackwell Publishing, Oxford . into care provided by Mid Staff ordshire NHS Foundation Trust January Newman , M.A. ( 1979 ) Th eory Development in Nursing . Davis , 2005 – March 2009. TSO, London. Philadelphia . Th e Mid Staff ordshire NHS Foundation Trust ( 2013 ) Report of the Mid Nightingale , F. ( 1859 ) Notes on Nursing: what it is and what it is not. Blackie Staff ordshire NHS Foundation Trust Public Inquiry. TSO, London. & Son Ltd. , Glasgow . Th e Health and Social Care Information Centre ( 2012 ) Statistics on NMC ( 2008 ) Th e Code: Standards of Conduct, Performance and Ethics for Smoking: England, 2012. TSO, London. Nurses and Midwives. Nursing and Midwifery Council, London. UKCC ( 1986 ) Project 2000 – A New Preparation for Practice. United NMC ( 2010 ) Standards for Pre-Registration Nursing Education . Nursing Kingdom Central Council, London. and Midwifery Council, London. UKCC ( 1999 ) Fitness for Practice: Th e UKCC Commission for Nursing and NMC ( 2013 ) Th e Quality Assurance Framework for Nursing and Midwifery Midwifery Education . United Kingdom Central Council, London. Education and Local Supervising Authorities for Midwifery . Nursing and Watterson , L. ( 2013 ) 6Cs + principles = care . Nursing Standard 27 ( 46 ), Midwifery Council, London. 24 – 25 . Orem , D. ( 1991 ) Self-care Defi cit Th eory . Sage , California . White R. ( 1978 ) Social Change and the Development of the Nursing Profes- Peplau , H.E. ( 1952 ) Interpersonal Relations in Nursing: a conceptual frame- sion. A Study of the Poor Law Nursing Service 1848–1948 . Henry work of reference for psychodynamic nursing . Putnam , New York . Kimpton, London . RCN ( 2004 ) Th e Future Nurse: Th e RCN Vision Explained. Royal College Wills , M.E. & McEwen M. (2002 ) Th eoretical Basis for Nursing. Lippincott of Nursing, London. Williams & Wilkins, Philadelphia . Chapter 1 Nursing: Past, Present and Future 23

7. What percentage of all deaths of adults over the age of 35 years Test Yourself are attributed to cigarette smoking? (a) 18% 1. Nursing forms the largest body of registered professionals (b) 32% employed within the NHS (c) 43% (a) True (d) 20% (b) False 8 . Th e Cavendish Review is: 2. Paleopathology is: (a) An independent review into the quality of care homes (a) a way of carbon dating skeletal remains (b) An independent review into Healthcare Assistants and (b) the study of diseases in past populations Support Workers in the NHS and care settings (c) what historians rely on to interpret longevity (c) A review into the way overseas visitors access UK health (d) the study of food and diet in ancient civilisations care 3 . Th e fi rst health visitor was: (d) An inquiry into Government leadership within the NHS (a) Virginia Henderson 9. In the new NHS Reforms, Clinical Commissioning Groups are (b) Linda Richards made up of: (c) Employed in Salford in 1862 (a) Primary care trusts (d) Ethel Bedford-Fenwick (b) GPs only 4 . Th e Register of Nurses was fi rst published in: (c) GPs and other health professionals such as nurses (a) 1922 (d) Charitable organisations allied to health (b) 1902 10. NHS England’ s main aim is to: (c) 1942 (a) Purchase services such as dental and family planning for (d) 1890 the people of England 5. Hildegard Peplau was the fi rst published nurse theorist since (b) Regulate the way that hospitals run Florence Nightingale (c) Ensure that all nurses are registered (a) True (d) Improve health outcomes for people in England (b) False 6 . Th e Nurses, Midwives and Health Visitors Act was established in: (a) 1948 (b) 1952 (c) 1990 (d) 1979 24 Chapter 1 Nursing: Past, Present and Future

5. a Answers 6. d 7. a 1. a 8. b 2. b 9. c 3. c 10. d 4. a