Revalidation: the professional development discussion.
"Revalidation is the process by which a regulated professional periodically has to demonstrate that he or she remains fit to practise" (DH, 2006).
Nursing and midwifery revalidation will be launched in October 2015, with the first NMC registrants going through revalidation in April 2016. The aim of revalidation is to ensure there is public and professional confidence in the standard of competence and conduct of those on the NMC register. NMC revalidation, as described in the NMC's pilot materials (NMC, 2015) has several aspects that differentiate it from the current prep requirements of continuing professional development (CPD) and practice hours. While CPD and practice hours form part of revalidation, the NMC registrant must also now gather and reflect on feedback about their practice, write reflections in relation to the NMC Code, review their reflections with a fellow registrant as part of a professional development discussion (PDD) and have their portfolio of evidence verified by a third party. In this article we look at the PDD in detail.
The aims of this article are to:
* Review the role of the professional development discussion as a means of ensuring continuing fitness to practice as a nurse or midwife
* Reflect on the experience of a professional development discussion as part of a revalidation pilot
* Provide guidance on how to conduct an effective PDD.
The journey towards nursing revalidation has been a long one. Calls for rigorous approaches to ensuring that healthcare professionals have continuing fitness to stay on their professional registers can be traced back to health scandal investigations in the 1990s (DH, 1999), such as the inquiry into children's surgery at Bristol Royal Infirmary (Secretary of State for Health, 2001), the Beverley Allitt case (Clothier, 1994) with successive governments calling for the introduction of regulatory checks and controls via health professional registration (DH, 2007, 2011). Medical revalidation was introduced by the GMC in 2012, requiring doctors to undergo appraisal and review using six types of evidence according to a five-year cycle. The proposed NMC model is leaner than the GMC approach and follows a three-year cycle. It does contain similar elements, with its focus on peer review, reflection and feedback.
NMC REVALIDATION NOW
The current model of revalidation (www.nmc-uk.org/ revalidation) has been in development since 2012. The professional officer team at Unite/CPHVA has been involved with the Revalidation Strategic, Task and Finish and Pilot groups since that time, with a view to ensuring as far as possible that the proposed model is applicable to members' practice. However, the scope to develop the model has been limited because of the constraints of the NMC's legislative framework, as detailed in the Nursing and Midwifery Order (2001). A number of consultations were undertaken that Unite/ CPHVA members contributed to that have influenced the NMC's thinking and have led to refinements on the model (www.unitetheunion.org/). The NMC has recently completed the pilot phase, involving 19 organisations employing nurses, midwives and specialist community public health nurses (SCPHNs) in a range of scopes of practice and settings between January to June 2015. They have engaged external consultants to conduct evaluations of the process, registrants' experiences and the cost to and preparedness of organisations. The outcome of the pilots will inform the final guidance from the NMC, due for launch in October 2015. The professional officer team at Unite volunteered to take part in the pilot. The aim of our participation was to further influence the model, be able to learn from the experience and pass on this intelligence to our members to ensure they are fully prepared. In addition, we wanted to ensure that the experience of SCPHNs was properly reflected in the revalidation model. This means that we have all 'road- tested' the NMC's draft guidance documentation and submission process. As registered nurses in non-clinical roles, we also wanted to make sure that the NMC revalidation model enables nurses across the wide range of professional roles to demonstrate their fitness to practice as nursing professionals.
WHERE DOES THE PDD FIT IN THE REVALIDATION PROCESS?
The NMC draft standards for the PDD are as follows:
'You must record a minimum of five written reflections on the Code, your CPD, and practice-related feedback over the three years prior to the renewal of your registration.
'You must have a professional development discussion with another NMC registrant, covering your reflections on the Code, your CPD, and practice-related feedback.'
'You must ensure that the NMC registrant with whom you had your professional development discussion signs a form recording their name, NMC Pin, email, professional address and postcode, as well as the date you had the discussion' (NMC, 2015)
There is flexibility within the draft guidance for nurses to choose their fellow registrant for the PDD, and to choose the reflections to be discussed at the PDD meeting. Evidence of the reflections and the discussions will not be routinely requested by the NMC but should be retained in case they are called for. The PDD should take place late in the revalidation cycle, with sufficient time allowed for third party verification to occur before submission, although the NMC suggests that confirmation is valid for twelve months. Following the PDD, the registrant must demonstrate to a 'third party con-firmer' that they meet all of the requirements of revalidation. The NMC recommends (but does not insist) that the 'third party confirmer' is the registrant's line manager and that the third party discussion takes place as part of an annual appraisal. It also suggests that the PPD and third party confirmation discussion may be combined into one appraisal discussion, if the registrant's line manager is also a registered nurse or midwife. The PDD should link to the registrant's understanding of the Code (NMC, 2015), which is our standard of professional conduct and practice.
THE REVALIDATING REGISTRANT'S PERSPECTIVE
Overall for me, going through the revalidation process was a positive experience. Yes it did take some time (around three days) to compile the documentation required for the submission but this in itself was a learning experience and provided time to reflect. I spent more time than anticipated on preparing my portfolio, in particular in reviewing my previous three years of evidence and also writing a blog! (www.commprac. com; 22 April). I appreciated the fact that work on revalidation was part of my role and that as a team we were fortunate to have an employer who was willing to support us in completing the process.
I had written my five reflections using different models in order to test whether there was one that better facilitated the PDD. However, Jenny and I found the NMC template to be the most appropriate. Without doubt I found that the most beneficial part of the revalidation process was the PDD. I felt it gave me permission to spend time to reflect on and discuss my own professionalism in the context of the many and varied elements of my role and how I undertook these in line with the Code (2015). It felt very different from an appraisal, which from previous experience tended to focus on the business needs of the organisation rather than on any professional needs. This perception may be because I have been working in less traditional nursing roles for some time (for advice on the appraisal process see: http://goo.gl/DvNkLK).
As I am not managed by an NMC registrant I was required to identify someone with whom I could have my PDD. I considered the options of asking one of the other NMC registrants within the organisation, but as a team we decided it would be more of a test of the model if we chose different scenarios, with mine being to go external to the organisation.. I chose Jenny because she had worked with me in my previous role and we have collaborated on a number of articles since that time so I felt she was familiar with my practice, but equally as she has considerable experience in regulation, she would challenge. I had not considered due regard, the concept of choosing someone on the same part of the register and in the same field of practice (NMC, 2008) before going into the PDD but this was an issue I reflected on in hindsight. The guidance from the NMC was focused on the role of the confirmer which meant there wasn't a blue print for the PDD. Jenny had asked to me to send my reflections to her prior to our discussion. Initially, I wasn't sure how I felt about this as I had been led to believe by the NMC that the intention was that reflections were discussed rather than read. Indeed, there may be issues with sending them outside organisations; for example, if a reflection was on a discussion with colleagues but related to a rare condition or an unusual situation/event that even if it contained no patient identifiable information the person reading it would know who it was about! This might be something for registrants in roles like mine to consider when choosing the person with whom you are going to have your PDD in terms of ensuring confidentiality and commercial sensitivity, as the conversation strayed into talking more broadly about the work of my organisation. However, the fact that Jenny had read and considered my reflections was extremely helpful to the discussion as she were able to consider them in more depth and she could ask for clarity where required.
The PDD took around two hours. In the main this was because we were both using it as a learning opportunity. However, I also found during the course of reviewing my reflections within the context of my scope of practice and the Code, I needed to talk through the principles of health visiting as referenced in the CPHVA 4,4,4 5,6,6 model (www.commprac.com/news/ new-health-visiting-model-graphic-launched) and had to be more explicit about how different elements of my role demonstrated I was practicing in line with the themes contained within the Code. This extended our discussion and may be a luxury unavailable to nurses and midwives in clinically demanding and time-pressured roles. However, having to provide this assurance gave me and my fellow registrant the added confidence that I could demonstrate adherence to the Code despite being in a non-conventional nursing role. While writing my reflections, particularly in relation to the professional development training I had delivered, I had felt unsure as to whether the feedback was sufficiently constructive to reflect in a meaningful way. Having discussed the importance of my role as a professional officer in supporting other NMC registrants to interpret and follow the Code, we came to the conclusion that my work is very much aligned to my nursing skills, values and experience and SCPHN scope of practice (www. unitetheunion.org/health/nmcrevalidation).
THE FELLOW REGISTRANT PERSPECTIVE
I was honoured to be asked to take part in Jane's PDD.
We had worked in parallel roles some years ago (full disclosure: in policy and standards at the NMC) and since then had collaborated on work for Unite on record keeping and documentation. I, like Jane, have a longstanding interest in regulation and in health policy and have recently been involved in revalidation preparation for an NHS foundation trust. I think that one of the reasons Jane asked me to work with her on the PDD was so that it gave us an opportunity to collaborate on a piece of work of real interest to us, always with an eye on the benefit of our critical reflections to Unite health sector members. I think that I was able to offer Jane the opportunity to think critically about her work as a professional officer and about herself as a nurse and health visitor, informed by our shared history and shared interests.
As Jane describes, I requested to see Jane's reflective accounts in advance. I also read as much as I could find on the NMC revalidation policy and process, but found there was little on PDDs beyond the draft guidance. My reason for wanting the reflective accounts prior to our meeting was to enable me to have time to prepare some questions for Jane and to consider how we might best use these reflections to consider two aspects: how Jane's work, feedback and CPD link to the Code and to her professional officer role, and how Jane might develop her nursing and health visiting practice further, in the next few years. I saw the PDD as an opportunity to look both back and forward. It was not just about her proving she was fit to be on the NMC register, but also about how she might use the learning from her CPD, feedback and reflections to inform her future practice. For me that is the essence of a 'professional development' meeting. There has to be some growth and development that occurs in or stems from the PDD. Whilst the 'third party confirmation' may be about reviewing proof that the registrant meets requirements, consolidating and confirming registration, the PDD is about 'being a professional'. The PDD, if it is to be a meaningful learning and professional development activity, should not just be about maintaining competence, but also should 'develop your competence and improve your performance' (NMC, the Code, 2015, 22.3).
Like Jane, I found the NMC reflection prompts (as found in their templates) to be simple and helpful. The reflections that she had written based on those four questions stimulated our discussion. There was no template for our meeting, however, so we referred to the NMC draft guidance for third party confirmers to ensure that due process was followed. Jane, like many nurses in the trust in which I've been working, is not line managed by a nurse. In this circumstance I wonder if PDD fellow registrants will end up taking a stronger role in supporting individual registrants. Where more senior nurses rather than peers undertake PDDs for less senior staff, the senior nurse is bound to be seen as a guide and expert on the revalidation process and regulated practice as well as the sphere of professional practice in which both nurses work. Those fellow registrants who are asked to undertake PDDs must ensure that they are very familiar with both the NMC Code and the revalidation model, in order to offer revalidates a meaningful and truly developmental PDD.
MORE GUIDANCE PLEASE!
The NMC published draft guidelines to be used in the pilot for those asked to provide confirmation.
These state that the confirmer has to discuss and verify that the revalidating registrant has fully met the requirements. Where the PDD is undertaken with an NMC registrant who is also the revalidating registrant's line manager this can take place within the PDD discussion. However, it is less clear who takes responsibility for discussing the revalidation requirements when the manager is not an NMC registrant. Certainly our experience of the PDD was that CPD, reflections and practice in the context of the Code were discussed. This meant that the confirmation meeting with the line manager was more about checking that each requirement had been achieved. It could therefore be viewed as a 'tick box' exercise, although the manager did read a reflection to provide assurance to himself that he was following the process. Was this sufficient? If not it would potentially involve two in-depth discussions and a more prolonged process. More guidance is needed therefore on what the PDD should include and on the roles of confirmer and PDD fellow registrant, to account for circumstances in which they are distinct or combined.
There must also be clarity about how PDD fellow registrants and third party confirmers raise concerns and communicate with each other if they do not consider that the registrant is meeting the revalidation requirements. Revalidatees and PDD fellow registrants would benefit from more detailed guidance on how to prepare for and conduct a PDD. We have given our 10 steps here, but may need to revise them if they do not map onto the final NMC guidance. Whatever guidance is given by the NMC or by ourselves, it has to take account of the diversity of the nursing, health visiting and midwifery professions. It has to allow revalidatees to undertake a PDD that has value and meaning to them, as well as meeting regulatory requirements.
We would like to see more guidance on reflection. Should the reflective accounts be shared in advance? Should they reflect practice development over the three-year period, or could they all be written about very recent CPD and feedback? In addition, guidance is required on how the PDD should be conducted when it forms part of an appraisal process to ensure it receives the focus it deserves. In addition as there will undoubtedly be a preference for combining revalidation with existing processes particularly among employers, it needs to address how revalidatees can manage a situation whereby they do not consider their line manager who may be conducting their appraisal as the most appropriate person to conduct their PDD.
It is suggested that the PDD and confirmer elements of the revalidation process will in most cases be conducted by the registrant's line manager within the context of an appraisal. Our experience demonstrates that where the two elements have to be undertaken independently of each other, the process need not be onerous. Rather, as has been highlighted, there were positive benefits of the PDD for both participants. Unfortunately, experience with the Knowledge and Skills Framework (KSF) has shown that some managers are not keen of systems that don't help them to discipline their staff and if it is to have positive effects, revalidation should not be used in this way. The introduction of PDDs as part of regulation does feel like a move towards the profession regulating itself, something that the NMC has in recent years moved away from. The fact that you have to give details of the person you have had the PDD discussion with and that they have some accountability with the NMC means that there should be some formality and professionalism to the discussion. Furthermore, it has the potential to promote professionalism and reduce professional isolation. The draft NMC guidance is open to interpretation. While this does give us the scope to undertake PDDs that are meaningful to us and our development, this purpose of this part of the revalidation model could be better articulated and evidenced by the regulator. We hope that the final guidance and the pilot feedback will help all registrants to have a positive experience of revalidation.
10 steps to a great professional development discussion 1. Undertake your PDD with a fellow registrant who can support and value your professional development. 2. Be prepared--write and share your reflections in good time so the discussion can be prepared for by both parties. 3. Keep a detailed record of the discussion--agree which one of you will write it up and how the record will be shared. 4. Ensure that you have allowed plenty of time for the discussion to enable 'due regard'. 5. Take your reflections from across the range of your practice. This is your opportunity to consider your professional practice in the round. The broader the scope of your reflections, the more wide ranging your discussion can be. 6. Keep the Code in mind. Keep a copy of the Code to hand so that you can refer to it during your discussion. [I found referencing the section/sub section of Code to each reflection was powerful and helped bring the Code into sharper focus]. 7. Agree the bounds of confidentiality and what action will be taken where concerns about patient safety, risk or confidentiality are identified. 8. Be prepared to challenge and be challenged about the content and style of your reflections, as well as about your interpretation of the Code. 9. Seek constructive feedback about your reflections. Does your fellow registrant have an alternative perspective to the one you have presented? 10. Be clear about and articulate your own professional developmental needs versus organisational needs
Jane Beach, Unite/CPHVA professional officer
Jennifer Oates RMN, regulatory and policy research consultant
Clothier Report: Independent inquiry relating to deaths and injuries on the children's ward at Gran-tham and Kesteven General Hospital London: HMSO, 1994
DH 2001 Learning from Bristol: The Department of Health's response to the Report of the Public Inquiry into Children's heat surgeiy at the Bristol Royal Infirmary 1984-1995 London: TSO
Trust, Assurance and Safety--The Regulation of Health Professionals in the 21st Century Department of Health (2007)
Department of Health (2011) Enabling Excellence: Autonomy and Accountability for Health and Social Care Staff
NMC (2008) Standards to support learning and assessment in practice
The Code Professional standards of practice and behavior for nurses and midwives Nursing and Midwifery Council (NMC) 2015
Nursing and Midwifery Order 2001 SI 2002 No. 253
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|Title Annotation:||SPECIAL REPORT: CASE STUDY|
|Author:||Beach, Jane; Oates, Jennifer|
|Date:||Sep 1, 2015|
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