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Revalidation in the spotlight.

Community Practitioner hosts a discussion showcasing your experiences, concerns and opinions on revalidation

KO: Community Practitioner carried out a survey on revalidation that has been extremely well received with more than eleven hundred responses from members. More than half of our respondents felt that revalidation would not improve public protection, which is incredibly concerning. The Patients Association has said revalidation is a very important tool in ensuring public confidence in our healthcare professionals and the NMC itself puts public protection as the main purpose of this whole process so I think the first question we would like to ask is how do we bridge that gap between the NMC's idea that revalidation is the main focus to public confidence, patient value it and the perception of the process from nursing staff.

JB: There is definitely a mis-match between what we all want from revalidation, and what patients, providers and service users expect from revalidation and the view of practitioners on the ground. We were particularly interested in how you put the message across about revalidation and how the focus is on patient safety and how we can kind of change that perception and I don't know what the answer to that is really.

We've found as we go through the pilot that it does refocus you on your own professionalism and there are certain aspects of revalidation that do that more than others. The reflective discussion is a valuable part of revalidation, but equally the risk is that for those people who haven't been part of the pilot it could become part of the tick box thinking where its value is questioned.

KO: How do we get that message across to registrants that revalidation is not a test, exam, punitive thing, and that this is how we demonstrate to the public that we are safe practitioners?

KK: Those individuals who hear about revalidation for the first time tend to reply to it and respond to it in a very process driven approach. Once they go through it they experience a totally different thing and the majority of the 2,100 nurses that have taken part in the pilot have confirmed that once you go through and see that the process makes sense that the outcomes become clearer.

Revalidation will have added value in terms of reflection. So what is different from prep and any other system to-date in terms of the ability to practice, is that for the first time in nursing there will be a regulator putting in a regulatory process so we are saying "Jane, you are an individual senior nurse but we do believe you should be telling us what you are doing, we believe you should be doing that with another professional or your line manager and that adds value in that you're going to do that in line with peer pressure'.


KO: And in terms of patient safety reducing that professional isolation and sharing with colleagues is key to preventing something like Mid-Staffs.

KK: Exactly. We want revalidation encourages a different sort of behaviour. We want it to rigger more networking and more social relationships and professional relationships.

JB: So maybe we shouldn't be saying revalidation is going to improve public safety? I mean patient safety is the whole purpose of the regulation but maybe we should be saying revalidation is going to improve safety but it is not going to stop nurses or midwives who are bad people.

KK: No system is going to stop that and revalidation won't do it. It is very possible that x and y nursing/ midwives get revalidated today and go and do something horrible tomorrow, but that is not the purpose of revalidation.

KO: So maybe the message at least for CPHVA members is that revalidation is going to enable them to become better practitioners, is going to allow them to access to more tools of the trade, going to build their knowledge and make them experts because of networking, engagement and feedback?

KK: Reflection is a key word. Jane already alluded to the fact that the majority of the patients and their families are the most important aspect of revalidation and I hope we prove that when we publish the reports--but reflection highlights the culture within the organisation.

DB: I'm also part of South London Network and we meet up to talk about guidance about revalidation. What we found was of the eight CCGs, four of them felt revalidation was nothing to do with them. A lot of CCGs feel they have bought the licences in but the other four CCGS said "no, not interested'. Having spoken to colleagues across the country, quite a few CCGs are saying it's not their responsibility, it's down to the general practice and the nurses themselves to make sure they fulfil the requirements. I think it is a golden opportunity for the first time for many CCGs to know how many hours nurses are working especially if you have part time, agencies or bank nurses or it's a friend of the family coming in to help out a lot.

It is also about who do we as nurses talk with. Some of the nurses say: "well actually I have a really good friend that I have been discussing things with, but I am not sure about her qualifications and I have never worked with her.' Surely there is a responsibility to prove that they have fulfilled the requirements. The QNI carried out a questionnaire for 3,300 nurses and found that a third of practice nurses claim to have never had an appraisal.


DM: There have been supervisors of midwives who have felt uncomfortable with changes that the NMC have brought in around midwifery and health visitors, and they felt they had to put extra checks and balances in place because they didn't agree with what was the NMC had done it right. But actually for that midwife that needed their certification to practice signing off they needed that signature to prove that they had done what the NMC had tasked them to do not what the individual thought they should do. How many of the 48 per cent of people who felt revalidation would improve public protection knew a lot about the system and how many people of the 52 per cent knew nothing or very little about the system? How many people don't know about it and just assume that it is going to be bad?

It could just be people's normal nature, being worried about things that are being brought in that it is going to make things worse. The relationship the NMC has built up in the past few years hasn't exactly been exceptional so people are automatically thinking that anything the NMC is bringing in are automatically bad and it might be that people just need to get over that issue and see revalidation as being positive and making people believe in the confidence to just give it a go.

KK: The only two individuals that can remove someone from the register are the nurses and midwives themselves or the NMC registrar, so we just want to make that very clear and it is something you may want to use as part of your messages there is noone else that can remove from the website. That means that if a confirmer or a reflective partner in the discussion challenges or raises issues or doesn't sign the document, the individual nurse or midwife would raise this with us because the alarm system asks--if you don't have your confirmation then why? Is it because you don't have the appraisal or don't have the network system to pick that up and as a result of that in that particular case we would try and see where the issues are.

JB: So what would happen to their registration? Would it lapse?

KK: It is clear in the guidelines that there are routes we will take but what we're not going to do is to remove people from the register.


KO: Are you expecting revalidation processes to be up to scratch in individual organisations when it comes to individual registrants revalidating?

KK: There are two parts of the process. In 2014 as you know we held a very lengthy consultation. As a result of that consultation we were able to get a very clear picture about who the nurses were that would be easy to revalidate and what kind of context--we're talking about those who have appraisals, who have a line manager, who work in large organisations or in a networking capacity. Then there are those who are in that harder to revalidate group. In 2015, we ensured our selection was overrepresented with the harder to revalidate than the easy to revalidate. We deliberately did not select a large number of easy to validate NHS trusts or large organisations--we over-represented the others, practice nurses, health visitors, GPs, school nurses as professional advisors and army nurses.

ND: It will be crystal clear what the requirements are that Id like to approach. You will need to make it very clear what you are required to do to revalidate and what you need to do to prove that. There will also be guidance for confirmers. If confirmers are given a very clear checklist from the very start, then we will produce professional confirmers who take responsibility for introducing that process.

KO: On the issue of guidance, 68 per cent of CPHVA members felt they hadn't received enough information about the revalidation process and 58 per cent had no idea when it was that they were supposed to revalidate.

KK: All of that process is available on our website and we have already sent out a postcard, which actually generated so many responses that registrations online spiked. Those who are registered got the postcard by post and were told to go online to get the information and as a result of that we got a dramatic increase in our online applications and the last month was higher than the normal amount.

It's not about the information that is available to organisations but is about the individual taking control of their professional development, showing that they can work with us being able to talk to somebody else and to interact.

I have not seen a single nurse or midwife who is not able to do that. I haven't met a single one that has said to me "you're getting it wrong".

JB: We do have a core group of people who are very negative about anything to do with regulation anyway but actually they kind of mix up revalidation with regulation and they eventually realise that it's not about "they're making us do this"

DM: The problem is that if the employers don't get wise to the fact that actually you know I pay you to be registered, not to help you be registered therefore any training you need--and you need forty hours of training in order to be registered--you have to self-fund because I am paying you to be registered to have it. It's that danger of employers always trying to find ways around revalidation. Will that emphasis on guidance give more power to employers to say well actually the NMC say we don't have to do this for you, you have to do it yourselves?

KK: No--let's just be clear--training on average will be 12 to 13 hours a year so for somebody who is employed full-time and even for somebody who is employed part-time, I'm sure 10 hours, 12 hours a year can be met even with no employer input. For me, out of our 1,200 people going through the pilot, meeting the CPD requirements was the least contentious.

JB: I think in some ways that is a slight concern that actually it might be the other way then that employers will say, well actually because most people more than meet the requirements, we can pull back on the training so we do need to be really careful of messages around CPD.

DM: If you want revalidation to be a positive thing then what we want is for employers to say we want you to do forty hours of really good training every three years to mean that we have good staff--and I'm paraphrasing here--but saying that well anyone can do that takes it away from it.

KK: The NMC strategy has to be about the requirements and we ensure that the ownership is with the individual and they know what they need to have. Although we are saying in the guidance that employers should aim to help nurses get what they need and why this is important, I think there is a role for you here and for the other professional bodies to push the agenda.


DB: People regard reflection as what do I do? But really you do it every single day when choosing what to wear, what to buy when you go to the shops and throughout your nursing career, really you are doing it all the time but when it comes to revalidation its about when you've finished, just write a few lines--what have you got from here, what you'd do differently, have you shared that with your colleagues have you gone back and said? Just write two lines, we're not being asked for a whole assignment just to say what benefit it has been and if it hasn't been a benefit why hasn't it?

This should be arms open wide, this is fantastic as we've now got something that we can work with, so for the first time its not a negative thing having an appraisal, now its a positive because now if you don't fill those requirements you will now potentially lose your pin number, you will not be able to work and your GP will not be able to have their nurse. We've had to do it that way and when we've gone to GP federation meetings we've had to say to them that you've got to support your nurse or else she will not be able to work with you, you will not be able to get your QOF and payment accrued and it is as simple as that.

Instead of looking at it negatively--and we should all be doing some prep anyway--practice nurses for the first time could actually go to their employer and say "I would like my appraisal done and its my time to shine and highlight what I've been doing," because the GP might not actually have known all the courses they have been on. It gives us an opportunity to talk about pay rises and to use revalidation as a way into looking at supporting practice nurses to fulfil the criteria.

We've asked every nurse to stop panicking, take a deep breath and look at how this is going to benefit you because it is not against you.

JB: We've had people who are on more than one part of the register think that they have to do five reflections per each part or if they are in a management role they have to pull out the hours when they are working in the code and say "well does your job description require you to be a nurse and a registrant?" and they go yes and you just count the whole role then, you don't sit there thinking, well I've been doing something that is purely management then so I can't count this as part of that.

KK: It doesn't have to be written in your job description as a nurse because I think there is a risk that individuals who think that they are revalidating against their job description, but essentially they are actually revalidation against the code so what we're saying with this code of practice is that you are registered with the NMC and you are a registered nurse or midwife with any additional skills or qualifications that you may or may not have you are a skilled and within that you are doing that against the code.

JB: We would recommend that over the three years you should have at least one reflection per year rather than five reflections in the last year so are you saying you should have a reflection from each of your different roles?

KK: From the pilot we were talking about CPD and reflection in terms of saying there has to be a reflection on the practice as a whole so if you had something that happened in your practice that significantly influenced you then surely you would want to include that so revalidate as a result of the targets.

So an individual could have accounts on a combination of things. It could be CPD from a conference they went to, it could be that they received feedback from a colleague or a patient, but another individual on the other extreme could have five on CPD only and both would be OK obviously which one would you say was most valuable we can all make a judgement call on that but for us now at the NMC the important thing now is to not overdo it. It would be great if we could have a cross section of variety, and if you spoke to your members that would be nice but it's not mandatory. You can't say to people.


KO: Does this raise data protection issues and governance concerns if we're talking about patient feedback?

ND: We took a lot of legal advice about data protection issues and one thing that we found was that there were ways around patient feedback, how to store information and we provide a whole separate sheet of information at the back of the guidance including case studies in there so an example would be--we saw this patient, they had this treatment and this is what happened to give practical examples while getting around the data protection issue so that no-one who follows the instructions we give will be in breach of data protection rules.

KK: It doesn't have to be you naming people as part of revalidation.

KO: So using anonymised case studies means nurses don't have to gain consent?

KK: No

KO: So what would be the situation where you would obtain consent?

ND: According to the processes we have in place you shouldn't have to take consent because you won't be recording the details in any way that can identify the patient.

The emphasis isn't on the feedback itself, it's what you took from that which is the template that we have given people to use. They can come up with their own way of doing it which will follow straight from that concept of what did you learn from this, how will you improve your practice, how did you learn from the code and that's what we are trying to get at and I really hope that someone would see this as a chance.

KK: I see the regulator as sitting at a distance. There is the employer, the organisation and governance policy making --so many layers of management between us and the nursing and midwives. We regulate that and we must not undermine those and use them in a positive way. The CCG, NHS England, the chief nurse, there are so many people and structures between us and the register, so I see us as sitting here almost pushing buttons and then the butterfly effect means things happen as a result of the decisions we make here. Its not about us going through every single layer of that process--we could have a process and I think it is similar to the regulatory process where you say I implement the policy and set the code but manage every single layer of that until I get down to the registrar that I regulate and I am confident that it works or I set the tone, evaluate and see the change in behaviour because I trust the individual person at the end of it and I do whatever I can to engage with the layers between me and them.

It comes back to the original point that we have to let it go and see, let it show us how revalidation is working. We at the NMC are committed to not making this process misleading to those midwives on the registers so we will do anything we can in terms of our processes and support that we are offering through our online system, our call centre that we are adding resources to.

Nobody should be using revalidation as a way of raising problems because by then it is too late.

JB: If they haven't met their requirements in three year, they've lapsed and it doesn't become a fitness to practice but would have to be a return to practice.

ND: There are reasons why people cannot meet these requirements for revalidation. If there are particular reasons why people can not meet the additional criteria then between the employer and the individual there will be measures but into place so that the individual does not lapse on a technicality. We don't want our process to get in the way of nurses and midwives practising professionally. If there is a perfectly good reason for this, they can get in touch with us.

JB: Going back to the subject of feedback, I don't see the point in saying that you have to have five pieces of feedback if you don't have to keep a record of it or that you don't have to show to your confirmer evidence that you've got five pieces of feedback. So either you say you want all of the reflections to be based on feedback or your reflections of CPD feedback because it is part of the process that the confirmer had to tick that we had five pieces of feedback so he hadn't had our reflective discussion with us so he wanted to see where is the five pieces of feedback.

I supposed we could have just discussed those, but if you are gathering those over three years, you aren't going to remember what they are unless you store them as they come up.

DB: I've got some GPs that when you look at the documentation, and you dig round a bit further, you find that all their confirmers are family members.

If every single registrant actually had their template looked at and going back to then that may be the only way that it is ever going to be a real safeguard that every single registrant is actually working and going through this process.

KK: To do this within the cost of the registration fee is not possible and we don't want to have to increase the fee as a result of this process. You know there is something around how much do you want the NMC to check and how much financial burden you want to add.


The roundtable participants

Katie Osborne (KO) deputy editor of Community Practitioner

Jane Beach (JB) Unite/CPHVA professional officer and lead for regulation

Debbie Brown (DB) nursing consultant in primary care, Queen's Nursing Institute

Katerina Kolyva (KK) director of continued practice at the Nursing and Midwifery Council

Natasha Dare (ND) policy manager at the Nursing and Midwifery Council

Dave Munday (DM) Unite/CPHVA professional officer

Angela Lewis (AL) health visitor and CPHVA member

Obi Amadi (OA) Unite/CPHVA lead professional officer
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Publication:Community Practitioner
Article Type:Discussion
Geographic Code:4EUUK
Date:Oct 1, 2015
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