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Clinical Practice Keywords Workplace/Staff/Titles/ Professional identity/Harmonisation Innovation This article has been Job titles double-blind peer reviewed In this article... ● Information on the lack of consistency and clarity around the job titles of nurses and ● Why too many titles in and midwifery is bad for the profession ● How Imperial College Healthcare Trust reduced the number of nursing and midwifery titles it uses

Harmonising nursing and midwifery titles in an acute

Key points Authors Matthew Grundy-Bowers is consultant nurse (HIV and sexual health); A large number of Scott O’Brien is head of children’s services; Victoria Harmer is Macmillan consultant different job titles nurse (breast); all at Imperial College Healthcare Trust, London. are used for nurses and midwives Abstract When reading the job title on a nurse’s name badge, colleagues are often unclear about that nurse’s role, experience, seniority, education level and competence. The number of This article describes a project conducted at Imperial College Healthcare Trust, titles and lack of London, to narrow down and simplify the titles used for its nurses, midwives and consistency in their support staff. use confuse patients and staff Citation Grundy-Bowers M et al (2018) Harmonising nursing and midwifery titles in an acute hospital. Nursing Times [online]; 114: 1, 36-39. Many different titles results in ambiguous role ospital badges have several pur- what to expect regarding the nurse’s sen- expectations and poses but their key role is to iority, experience and competence. Two the scope of state the bearer’s name and pro- nurses who are employed by the same practice being Hfessional status. In nursing and organisation and perform similar roles – unclear midwifery there is a plethora of job titles or even the same role – may have different appearing on people’s badges (Leary et al, titles. Conversely, there could be two Confusion around 2017; Lowe et al, 2012; Donald et al, 2010; nurses who have the same job title but titles has a negative Grundy-Bowers, 2006). These titles are used completely different skill sets, who per- impact on the to communicate – and imply – many things form different roles or are employed on professional identity including education, seniority, role, spe- different pay bands. of nurses and cialty and skill set. However, their sheer This is not an uncommon issue in con- midwives number results in ambiguous role expecta- temporary healthcare and has been noted tions and an unclear scope of practice; it recently by Leary et al (2017). They reviewed contributes to “turf protection” (Donald et 17,960 specialist nurse posts and identified al, 2010) and, in conjunction with a lack of 595 different titles, which leads to “confu- consistency in the use of titles, confuses sion among the public, employers and both patients and colleagues (Leary et al, those commissioning services”. 2017; Ormond-Walshe and Newham, 2001). While research from the Royal College The job titles of nurses, midwives and of Nursing found almost 50 different job support staff at Imperial College Healthcare titles in use for specialist nurses working Trust (ICHT) have been narrowed down, in the field of urological cancers alone, it simplified and clarified after a year-long, also found that the inconsistency in titles trust-wide project consulting staff and was linked to an ambiguity regarding patients. This article describes the project. requirements and duties (Royal College of Nursing, 2015). Another group of staff in Lack of clarity which there are large variations in titles is When looking at a nurse’s job title, it is not support staff, such as healthcare assis- uncommon that colleagues – including tants, support workers and clinical techni- those within the profession – do not know cians (Cavendish, 2013).

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stakeholders as possible. Targeted groups included: Cardiothoracic ●  Addictions Case Manager Nursing and midwifery staff – two staff Psychiatry/Alcohol Specialist Senior surveys were sent out: the first one was Clinical Nurse Specialist sent to nurse/ specialists and Lung Cancer Gender Services Journey Nurse Sister Cardiac/Rehab Co-ordinator - the second was open to all nursing and Liaison Nurse midwifery staff; Vascular Access Lead Nurse ● Senior nurses and midwives – two Modern & ENT Nurse “back-to-the-floor” Friday sessions Safety Specialist Apheresis Nurse Thermometer Practitioner Co-ordinator were held so that senior nurses/ Falls & Osteoporosis midwives from across the organisation Nurse Arrhythmia and could meet to discuss pertinent issues; Syncope Clinical Nurse Specialist ● Patients – these could make use of the ICHT patient communication group; ● Senior human resources team; ● All trust staff – the partnership committee; ● Healthcare support workers at their annual conference; ● The team; ● Nurse specialists and nurse practitioners – a dedicated meeting was held; ● Department nurse and midwife leads – a professional practice committee Nurse workshop was conducted. At all of these events there was broad support for the harmonisation of titles. Reaching a consensus on the titles to This lack of clarity undoubtedly has a aim was to harmonise the titles used for feature in the final list, however, drew negative impact on our professional iden- nurses, midwives and support staff by: much debate. tity (Reveley, 1999) yet, despite calls for a ● Reducing their number; The patients present at the patient com- reduction and standardisation of titles in ● Simplifying them and making them munication group meeting unanimously nursing (Leary et al, 2017; Commission on clear and gender neutral; reported that this was an area well worth the Future of Nursing and Midwifery in ● Standardising their use. tackling. England, 2010), this thorny issue persists. ICHT has 4,333 individual posts for reg- Indeed, Professor Leary’s article led to a istered nurses and midwives, and 1,088 Outcomes of engagement circular (07201) on 7 September 2017 from individual posts for unregistered staff, so activities the Chief Nursing Officer for England sug- the scale of the problem was potentially Endorsement from staff survey gesting nurse directors should: huge. A search of the address book on the The divisional nurse directors sent the ● Ensure all staff titles recognised as trust’s email system identified 91 different second survey to their teams via email. delivering nursing or midwifery care nursing titles, but this was thought to be A total of 138 staff responded: 85% were clearly reflect their registered or an underestimation. A further examina- registered nurses or midwives, 5% were regulated status; tion of the email list, focusing on clinical unregistered support staff and the l Consider whether the word “nurse” is nurse specialists, identified 226 different remainder were from other staff groups. appropriate if used; titles in use for nurse specialists and The majority of respondents were in broad ● Ensure the correct processes are in practitioners. agreement that: place regarding how such roles are During the engagement process ● We should attempt to reduce the advertised in relation to identifying (detailed below), it was identified that number of nursing and midwifery titles their registered/regulated status, there were: in use (85%); aligned qualifications and the ● 11 different titles to describe 15 nurse or ● Titles should be gender neutral (80%); boundaries of their roles (Nursing midwife educators; ● Specialist titles should be simplified to Times News Desk, 2017). ● 46 different titles to describe 74 senior ‘nurse specialist’ or ‘’. nurses; Furthermore, 60% of respondents Tackling the issue locally ● 10 different titles to describe 65 support endorsed the suggested list of titles devel- In December 2015, Janice Sigsworth, nurse staff; oped from engagement events and various director at ICHT, commissioned a project ● Nine different titles to describe 11 searches, considering them “clear” and to assess and address the issue locally members of the senior midwifery team. “appropriate”. In total, 35% of respondents around nursing and midwifery titles. The had comments or suggestions but did not project was undertaken as part of a trust Engagement process specifically endorse or oppose the list, leadership programme and drew wide sup- From December 2015 to February 2016, a with some thinking the proposed titles port across senior teams, from nursing series of engagement events were held should be more nuanced. Only 5% of and midwifery to wider management. Its across the organisation to reach as many respondents disagreed with the list.

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Gender-neutral titles Table 1. The 12 core titles From the outset it was felt that it was important to have gender-neutral titles to Core title Prefixes Possible titles clearly show that nurse and midwife roles Nurse director ● Deputy ● Nurse director are open to all. Most staff supported the ● Divisional ● Deputy nurse director use of gender-neutral titles but continued ● Divisional nurse director to feel attached to historical titles such as ● Deputy divisional nurse director “sister” and “matron”. Lead nurse/midwife ● Trust ● Lead nurse/midwife Support staff titles ● Divisional ● Trust lead nurse/midwife Most support staff preferred the titles ● Directorate ● Directorate lead nurse/midwife “nursing assistant” and “midwifery assis- Consultant nurse/ ● Trainee ● Consultant nurse/midwife tant”, while the midwifery team preferred midwife ● Trainee consultant nurse/midwife “midwifery support worker” (which was Nurse practitioner ● Lead ● Nurse practitioner already in use). However, it was felt that ● Senior ● Lead nurse practitioner “nursing assistant” was too similar to the ● Advanced ● Senior nurse practitioner title for the new nursing associate role, so ● Trainee ● Advanced nurse practitioner the senior nursing team thought it more ● Trainee nurse practitioner appropriate to use “healthcare assistant” to avoid confusion. Nurse/midwife ● Lead ● Nurse/midwife specialist specialist ● Senior ● Lead nurse/midwife specialist Specialist and practitioner titles ● Trainee ● Senior nurse/midwife specialist There was a desire to have a single unifying ● Trainee nurse/midwife specialist title for nurse specialists and nurse practi- Clinical educator ● Senior ● Clinical educator tioners; “specialist nurse in advanced prac- ● Senior clinical educator tice” – as outlined by Read (2015) – was sug- Research nurse/ ● Lead ● Research nurse/midwife gested but deemed inappropriate because midwife ● Senior ● Lead research nurse/midwife it was too wordy. Furthermore, the nurse ● Senior research nurse/midwife specialists and practitioners at the trust thought that, due to their professional Charge nurse/ ● Deputy ● Charge nurse/midwife identities within their teams, they were midwife ● Deputy charge nurse/midwife not currently in a position to unify titles; Staff nurse/midwife ● Senior ● Staff nurse/midwife however, they were keen to revisit this at a ● Senior staff nurse/midwife later date. Nursery nurse ● Senior ● Nursery nurse There were tensions around how best to ● Senior nursery nurse describe band 6 nurse specialist or practi- tioner posts. Many felt there should be a Nursing associate ● Nursing associate distinction between band 6 and higher Healthcare assistant ● Senior ● Senior healthcare assistant bands, but there was little consensus on ● Healthcare assistant how to achieve this. Some felt that the term “trainee” would be appropriate, as Table 2. Agreed list of prefixes these posts are often developmental ones for those progressing to become specialist Prefix Use or practitioner. However, some posts, are Trust, divisional, For roles that have a broad remit over the trust, division or not developmental and some postholders directorate directorate do not desire progression; as such, “junior” Lead For posts in which leadership is a core component – for was suggested instead – although many example, a nurse specialist who manages a team of nurse felt this was also inappropriate. The con- specialists sensus of the senior nursing and mid- wifery team was that band 6 posts could be Senior For posts with seniority over other similar posts but no core nurse specialist or nurse practitioner, and leadership or management component – for example, a band that for some “trainee” would be appro- 8a nurse specialist without management responsibilities in a priate. team that also has band 7 nurse specialists One of the largest areas of contention Advanced For those posts that meet the requirements for advanced was the use of the words “clinical” or practice across the four pillars (clinical practice, leadership and “advanced” for nurse specialists and nurse management, education, and research) as stipulated by Health practitioners. Many felt passionately about Education England (2017) these being included in their titles. For Deputy For managerial posts – for example, a band 6 deputy charge some, this was because “advanced” was nurse in a ward or department that has a band 7 charge nurse associated with education at Master’s level; for others, it was about “clinical” featuring Trainee For trainee posts – for example, a band 6 trainee nurse in national guidelines. practitioner

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Box 1. Principles governing the new titles l Fewer titles l Clear, unambiguous and easy to understand l Gender neutral l Approved list of prefixes l Titles to include details of division, department or specialty at the end in brackets if needed l Titles to include the word “nurse”, “midwife”, “nursing” or “midwifery” when possible l Extra details incorporated in job description when possible l How an individual presents themselves within the trust may differ from how they present themselves outside of it l Title configuration to be: prefix (if needed)/core title/(division, department or specialty) (if needed)

Educator titles Implementation responsibilities of the nursing and mid- Concerns were raised by clinical educators The project team worked with human wifery workforce. NT that some members of their team were resources and other departments – such as allied health professionals and so could security, which issues name badges – to References Cavendish C (2013) The Cavendish Review: An not have “nurse” or “midwife” in their title. ensure a smooth implementation and Independent Review into Healthcare Assistants It was agreed that “clinical” would be used embedding of the initiative. The security and Support Workers in the NHS and Social Care for these education posts instead. department and the external company Settings. Bit.ly/DHCavendish printing the name badges knew they were Commission on the Future of Nursing and The new titles to limit people’s options to the agreed list. Midwifery in England (2010) Front Line Care: Report by the Prime Minister’s Commission on the The existing myriad titles was reduced to a The project and communication teams Future of Nursing and Midwifery in England – 2010. core list of 12 titles (Table 1), supplemented developed initiatives to ensure that Bit.ly/FrontLineCare with prefixes, along with suffixes in patients, staff and colleagues are aware of Donald F et al (2010) Clinical nurse specialists and brackets indicating division, department the changes, including: nurse practitioners: title confusion and lack of role clarity. Nursing Leadership; 23: 189-201. or area of specialty if needed. There was l Leaflets and posters for patients and Grundy-Bowers M (2006) Defining advanced broad agreement to restrict the prefixes clinical areas to explain what to expect practice. In: Grundy-Bowers M, Davies J (eds) used to a defined list (Table 2). The princi- from each staff group; Advanced Clinical Skills for GU Nurses. Chichester: ples that were followed when determining l An update on the project at the John Wiley and Sons. the new titles are listed in Box 1. monthly chief executive briefings; Health Education England (2017) Multi-Professional Framework for Advanced Clinical Practice in l  Communication and a mapping exercise A screensaver for staff computers to England. Bit.ly/HEEAdvancedClinPractice took place with senior nurses and midwives inform them about the project. Leary A et al (2017) Variation in job titles within in each of the trust’s divisions, so they could The project team had received a grant the nursing workforce. Journal of Clinical Nursing; identify and report issues they expected to from Imperial Health Charity to support 26: 23-24, 4945-4950. Lowe G et al (2012) Time to clarify – the value of encounter when adjusting the titles of implementation across the organisation. advanced practice nursing roles in . nurses and midwives within their care. This The money covered the cost of replacing Journal of Advanced Nursing; 68: 3, 677-685. exercise did not highlight any major issues. security and identification badges, and Nursing Times News Desk (2017) Nursing producing the information leaflets and directors encouraged to check unqualified staff awareness campaign targeted at trust staff are not working under ‘nurse’ titles. Nursing Times; Nursing Times 19 September. Bit.ly/NTNDNursetitles and patients. Journal Club Ormond-Walshe SE, Newham RA (2001) It was decided that the document of Comparing and contrasting the clinical nurse To use this article for a work should be turned into a trust policy specialist and the advanced nurse practitioner roles. journal club discussion to embed it into clinical practice and the Journal of ; 9: 4, 205-207. (2015) Foreword. In: HSJ Workforce: Time with colleagues, go to nursingtimes. Read C trust’s wider environment. Work is for Some Advanced Thinking: The Benefits of net/NTJCJobTitles and download the ongoing to finalise this trust policy – final- Specialist nurses. Health Service Journal Spp; 1-11. article along with a discussion handout isation of it was postponed so the national Reveley S (1999) The professional and legal to give to members of your group announcement from Health Education framework for the nurse practitioner. In: Walsh M et before the meeting. England (2017) regarding advanced prac- al (eds) Nurse Practitioners: Clinical Skills and Professional Issues. Oxford: Butterworth-Heinemann. Your journal club activity counts as tice could be incorporated. Royal College of Nursing (2010) Guidance on participatory CPD hours or can be used Safe Nurse Staffing Levels in the UK. Bit.ly/ as the basis for reflective accounts in Conclusion RCNSafeStaffing your revalidation activities. This work has allowed us to narrow down For more Nursing Times Journal the number of nursing and midwifery For more on this topic go online... Club articles and tips on how to set up titles across ICHT to reduce confusion l The development of advanced and run your own group, go to: among patients and health professionals. nursing roles nursingtimes.net/NTJournalClub We hope it sets a precedent for others and Bit.ly/NTAdvancedRoles

ALAMY will result in more clarity in the roles and

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