Nursing in the United Kingdom

Nursing in the United Kingdom has a long history, but in its current form probably dates back to the era of Florence Nightingale, who initiated schools of nursing in the latter part of the 19th and early 20th century. During the latter part of the 20th century, increases in autonomy and professional status changed the nursing role from "handmaiden" to the doctor to independent practitioners.

The profession has gone through many changes in role and regulation. Nurses now work in a variety of settings in hospitals, health centres, nursing homes and in the patients' own homes. Nearly 400,000 nurses in the United Kingdom work for the National Health Service (NHS), which is the vast majority of nurses registered with the Nursing and Midwifery Council (NMC).

Florence Nightingale
See Florence Nightingale for a detailed history.

Florence Nightingale is regarded as the founder of modern nursing. There was no real hospital training school for nurses until one was established in Kaiserwerth, Germany, in 1846. There, Florence Nightingale received the training that later enabled her to establish, at St Thomas' Hospital in London, the first school designed primarily to train nurses rather than to provide nursing service for the hospital.

In March 1854 Britain, France and Turkey declared war on Russia. Nightingale was appointed to oversee the introduction of female nurses into the military hospitals in Turkey due to criticisms in the British press. On 4 November 1854, Florence Nightingale arrived at the Barrack Hospital in Scutari, a suburb on the Asian side of Constantinople, with the party of thirty-eight nurses. Initially the doctors did not want the nurses there and did not ask for their help, but within ten days fresh casualties arrived from the Battle of Inkermann and the nurses were fully stretched.

When Florence Nightingale returned from the Crimean War in August 1856, four months after the peace treaty was signed, she hid herself away from the public's attention. For her contribution to Army statistics and comparative hospital statistics in 1860 Florence Nightingale became the first woman to be elected a fellow of the Statistical Society. In 1865 she settled at 10 South Street, Mayfair, in the West End of London and apart from occasional visits to Embley Park, Lea Hurst and to her sister at Claydon House she lived there until her death.

History
The history of nursing dates back to ancient times, where medical lore was associated with good or evil spirits, the sick were usually cared for in temples and houses of worship. In the early Christian era nursing duties were undertaken by certain women in the church, their services being extended to patients in their homes. These women had no real training by today's standards, but experience taught them valuable skills, especially in the use of herbs and drugs, and some gained fame as the physicians of their era. Remnants of the religious nature of nurses remains in Britain today, especially with the retention of the term "Sister" for a senior female nurse.

1858-1902
When state registration of the medical profession had begun in 1858, many observers pointed to the need for a similar system for nursing. That year, the Nursing Record (re-named the British Journal of Nursing in 1902), a nursing journal called for;

"... the whole question of the Registration of trained nurses to be set forth in a succinct form before the profession and the public".

Support for the regulation of nursing began to become more widespread following the establishment of organised nurse training in 1860.

By the 1880s, the Hospitals Association (an early version of the NHS Confederation) was committed to the principle of registration for nurses. The Matrons' Committee, comprising the matrons of the leading hospitals, agreed but differed in their views of the required length of training, arguing for three years as opposed to the one supported by the Hospitals Association. In 1887, the Hospitals Association over-ruled the matrons and established a non-statutory voluntary register. At this the Matrons' Committee split, between one group which supported the Hospitals Association and another faction, led by Ethel Bedford-Fenwick, which opposed the new register and sought to align themselves more closely with the medical profession. Florence Nightingale, incidentally, supported neither group and was opposed to any form of regulation for nursing, believing that the essential qualities of the nurse could neither be taught, examined nor regulated.

In 1887, the group of nurses associated with Ethel Bedford-Fenwick formed the British Nurses' Association (BNA), which sought

"... to unite all British nurses in membership of a recognised profession and to provide for their registration on terms, satisfactory to physicians and surgeons, as evidence of their having received systematic training".

Therefore two separate voluntary registers now existed. Whereas that maintained by the Hospitals Association was purely an administrative list, the register established by the BNA had a more explicit public protection remit.

1905-1920
The pressure for state registration grew throughout the 1890s but was undermined by disagreements within the profession over the desired form and purpose of the regulatory system. In 1902, the Midwives Registration Act established the state regulation of midwives and, two years later, a House of Commons Select Committee was established to consider the registration of nurses.
 * National Council of Nurses formed.
 * The First World War results in large numbers of unmarried women, many of whom devote their lives to nursing.
 * College of Nursing founded in 1915.
 * 1919 sees the Nurses Registration Act and the establishment of the Ministry of Health.

The committee reported in 1904 and set out a detailed and persuasive case for registration. However, the government sat on the report and took no action. Over the next decade, a number of private member's bills to establish regulation were introduced but all failed to achieve significant support in Parliament.

The First World War provided the final impetus to the establishment of nursing regulation, partly because of the specific contribution made by nurses to the war effort and also as a reflection of the increased contribution of women more generally in society. The College of Nursing (later the Royal College of Nursing) was established in 1916 and three years later persuaded a backbench Member of Parliament (MP), Major Barnett, to introduce a private members bill to establish a regulatory system. The bill was finally passed in December 1919 and separate Nurses Registration Acts were passed for England/Wales, Scotland and Ireland, which was still part of the United Kingdom at the time. These acts established the General Nursing Council for England and Wales and the other bodies which survived intact until the legislative changes in 1979 which were to create the UKCC and the National Boards of Nursing. Ethel Bedford-Fenwick was the first nurse on the English register.

1920s

 * Role of sister tutor created.
 * Examinations introduced to join the nurse register; first diploma of nursing examination.
 * Alexander Fleming observes the antibacterial effects of penicillin in 1928. [[Image:Rcn-logo.gif|thumb|right|180px|[[Royal College of Nursing]] Logo. (c) Royal College of Nursing]]

1930s

 * Foundation of the National Society of Male Nurses.
 * The College of Nursing gains its royal charter.

1940s

 * Role of state enrolled nurse formally recognised, with two years' training instead of three.
 * Horder Committee recommends fewer nursing schools and the introduction of inspection.
 * Penicillin becomes available for civilian use.
 * Numbers of male nurses increase as demobilised service men with medical experience join the profession.
 * The National Health Service (NHS) is launched, offering free, comprehensive health care for all.

1950s

 * Large influx of Caribbean entrants into British nurse training.
 * Introduction of tranquillisers transforms mental health nursing.
 * Male nurses join the main nursing register in 1951.
 * University of Edinburgh runs the first course for clinical nurse teachers.
 * The Mental Health Act 1958 abolishes the legal separation of psychiatric hospitals, allowing those patients to be admitted to any hospital.[[Image:Cicelysaunders.jpg|thumb|right|180px|Dame Cicely Saunders]]

1960s

 * Availability of sterile supplies brings an end to washing and sterilization of equipment such as dressings and syringes
 * Edinburgh initiates the first degree in nursing.
 * The Nursing Homes Act 1963 brings registration and greater control by local authorities.
 * The Salmon report calls for reform to nurse grading, initiating the end of matrons.
 * Nurse Dame Cicely Saunders sets up the first hospice in 1967.
 * Termination of pregnancy becomes legal under the Abortion Act 1967.

1970s
The Briggs Committee was established in 1970 due to pressure from the RCN to consider issues around the quality and nature of nurse training and the place of nursing within the NHS, rather than regulation per se. It reported in 1972 and recommended a number of changes to professional education. Almost as an afterthought, Briggs also recommended the replacement of the existing regulatory structure (involving nine separate bodies across the United Kingdom) with a unified central council and separate boards in each of the four countries with specific responsibility for education. Six years of debate and delay followed before the modified Briggs proposals formed the basis of the Nurses, Midwives and Health Visitors Act 1979. This was due to the need to take account of devolution, Treasury misgivings, lack of consensus within the professions (especially from midwives), and a lack of government will to find the parliamentary time to enact the legislation.
 * Nurses march to Downing Street demanding better pay, and win increases of up to 58 per cent.
 * Manchester University appoints the first professor of nursing.
 * The Royal College of Nursing (RCN) becomes a trade union.
 * The Nursing Process establishes an ethos based on assessment, planning, implementation and evaluation.
 * Reform of shift patterns begins

1980s
In 1983, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) was set up. Its core functions were to maintain a register of UK nurses, midwives and health visitors, provide guidance to registrants, and handle professional misconduct complaints. At the same time, National Boards were created for each of the UK countries. Their main functions were to monitor the quality of nursing and midwifery education courses, and to maintain the training records of students on these courses.
 * Mass meetings are held over pay, the state of the NHS, clinical grading and the abolition of the enrolled nurse.
 * United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) becomes the profession's new regulatory body in 1983.

This structure survived with minor modifications until April 2002, when the UKCC ceased to exist and its functions were taken over by a new Nursing and Midwifery Council (NMC). The English National Board was also abolished and its quality assurance function was taken on board by the NMC. The other National Boards were also abolished, but new bodies were created in each country to take over their functions, for example, NES in Scotland.

1990s

 * Reforms to training under Project 2000 begin to be implemented.
 * Post-registration education is introduced.
 * Nurse-led helpline NHS Direct is founded. [[Image:Nursingmc logo.gif|thumb|right|Nursing and Midwifery logo.(c) NMC]]

2000-2005

 * Health care reforms set out in The NHS Plan.
 * The Nursing and Midwifery Council takes over from the UKCC in 2002.
 * Agenda for Change paves the way for a new pay structure for nurses.
 * Nurse employers inspected for staff-friendly policies under Improving Working Lives and Investors in People.
 * In 2005 nurse numbers hit 397,500 - an all-time high.

The Nursing and Midwifery Council
See Nursing and Midwifery Council for more information.

The core function of the NMC is to establish and improve standards of nursing and midwifery care in order to serve and protect the public. Its key tasks are to:

provide advice for registrants on professional standards; consider allegations of misconduct, lack of competence or unfitness to practise due to ill health.
 * maintain a register listing all nurses and midwives;
 * set standards and guidelines for nursing and midwifery conduct, performance and ethics;
 * quality assure nursing and midwifery education;
 * set standards and provide guidance for local supervising authorities for midwives;

The powers of the NMC are set out in the The Nursing and Midwifery Order 2001.

The council consists of twelve registrant members, twelve alternate registrant members and eleven lay members. The registrant members consist of equal numbers of nurses, midwives and specialist community public health nurses. The lay members include people from education, employment and consumer groups (who are appointed by the Privy Council. The former president and vice-president were Sir Jonathon Asbridge and Mary Hanratty respectively.

The NMC held its first elections of registrants for its governing council, with all members. The new council came into being being in July, 2006. The first elected President of the council is Sandra Arthur, with the vice-president position vacant.

Regulation
To practise lawfully as a registered nurse in the United Kingdom, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council. The title "registered nurse" can only be granted to those holding such registration, this protected title is laid down in the Nurses, Midwives and Health Visitors Act 1997.

The register
As of August 2005, the NMC register split into three parts: nurses, midwives and specialist public health nurses. Previously, it only contained 15 "sub-parts", a list of which can be viewed here

According to the Nursing and Midwifery Council, there are 672,897 registered nurses on the register, as of 2005. Of these:


 * Over 10% of registrants are male.
 * Over 53% are on part 1 of the register (Adult).
 * Over 60% are under the age of 40.
 * There are only two male school nurses registered with the NMC.

Employment of nurses
The National Health Service is the provider of almost all healthcare in the United Kingdom, and employs the vast majority of UK nurses and midwives which number 386,000 according to the Department of Health.

The nursing staff is split into two main groups:


 * Non-registered staff
 * - e.g. auxiliary nurses and healthcare assistants.


 * Registered staff (split into four further groups)
 * - First level nurses.
 * - Second level nurses.
 * - Specialist nurses.
 * - Managers.

Non-registered staff
These staff can be found carrying out a number of roles, attracting various titles such as auxiliary nurse, healthcare assistant (HCA), clinical support worker, care assistant and nursing assistant. These titles all describe workers who work in direct patient care (often on wards), performing tasks such as personal care (washing and dressing), social care (feeding, talking to patients & generally spending time with them) and recording observations (such as measuring blood pressure).

Some unregistered staff can work in more specialised roles, for example as phlebotomists (taking blood samples) and ECG technicians (recording ECGs). Others can expand their ward-based role to include these tasks (and others). Technically, there are few areas of nursing practice that cannot be legally performed by suitably trained non-registered staff, although they cannot fully replace them, as they legally must be supervised (either directly or indirectly) by a fully qualified registered nurse.

Registered staff
See Registered Nurse for more information.

First level nurses
First level nurses make up the bulk of the registered nurses in the UK. They were previously known by titles such as RGN (registered general nurse), RSCN (registered sick children's nurse), RMN (registered mental nurse) and SRN (state registered nurse) etc.

The majority of first level nurses are employed as staff nurses with the minority in management and specialised roles.

Second level nurses
See state enrolled nurse for more information.

Second level nurse training is no longer provided, however they are still legally able to practice in the United Kingdom as a nurse. Many have now either retired or undertaken conversion courses to become first level nurses.

Specialist nurses
The NHS employs a huge variety of specialist nurses. These nurses have many years of experience in their field, in addition to extra education and training (see below).

They split into several major groups:
 * Nurse practitioners - these nurses carry out care at an advanced practice level. They often perform roles similar to those of doctors. They commonly work in primary care (e.g., GP surgeries) or A&E departments, although they are increasingly being seen in other areas of practice.
 * Specialist community public health nurses - traditionally district nurses and health visitors, this group of practitioners now includes many school nurses and occupational health nurses.
 * Clinical nurse specialists - nurses undertaking these roles commonly provide clinical leadership and education for the staff nurses working in their department, and may also have special skills or knowledge which ward nurses can draw upon.
 * Nurse consultants - these nurses are similar in many ways to the clinical nurse specialist, but at a higher level. These practitioners are responsible for clinical education and training of those in their department, and many also have active research and publication activities.
 * Lecturer-practitioners - these nurses work both in the NHS, and in universities. They typically work for 2-3 days per week in each setting. In university, they train pre-registration student nurses (see below), and often teach on specialist courses for post-registration nurses (e.g. a Lecturer-practitioner in critical care may teach on a Masters degree in critical care nursing).
 * Lecturers - these nurses are not employed by the NHS. Instead they work full time in universities, both teaching and performing research.

Managers
Many nurses who have worked in clinical settings for a long time choose to leave clinical nursing and join the ranks of the NHS management. This used to be seen as a natural career progression for those who had reached ward management positions, however with the advent of specialist nursing roles (see above), this has become a less attractive option.

Nonetheless, many nurses fill positions in the senior management structure of NHS organisations, some even as board members. Others choose to stay a little closer to their clinical routes by becoming clinical nurse managers or modern matrons

Non-registered staff
There is no mandatory training for persons undertaking these roles. The majority of NHS employers, however, have created "in-house" training for these members of staff, both in the form of induction programmes and ongoing education. Some work collaboratively with local further education colleges to provide theoretical input, and may award an award, for example, and S/NVQ in healthcare.

Many trusts and health boards create opportunities for these staff members to become qualified nurses, this is known as secondment (whereby the trust/health board continues to pay them for the duration of their training, and often guarantees employment as qualified nurses following the completion of their training).

Pre-registration
In order to become a registered nurse, and work as such in the NHS, one must complete a programme recognised by the Nursing and Midwifery Council. Currently, this involves completing a degree or diploma, available from a range of universities offering these courses, in the chosen branch speciality (see below), leading to both an academic award and professional registration as a 1st level registered nurse. Such a course is a 50/50 split of learning in university (i.e. through lectures, essays and examinations) and in practice (i.e., supervised patient care within a hospital or community setting).

These courses are three (occasionally four) years' long. The first year is known as the common foundation programme (CFP), and teaches the basic knowledge and skills required of all nurses. The remainder of the programme consists of training specific to the student's chosen branch of nursing. These are:


 * Adult nursing.
 * Child nursing.
 * Mental health nursing.
 * Learning disabilities nursing.

Midwifery training is similar in length and structure, but is sufficiently different that it is not considered a branch of nursing. There are shortened (18 month) programmes to allow nurses already qualified in the adult branch to hold dual registration as a nurse and a midwife. Shortened courses lasting two years also exist for graduates of other disciplines to train as nurses. This is achieved by more intense study and a shortening of the common foundation programme.

Student nurses currently receive a bursary from the government to support them during their nurse training. Diploma students in England receive a non-means-tested bursary of around £6000 per year (with additional allowances for mature students or those with dependant children), whereas degree students have their bursary means tested (and so often receive less). Degree students are, however, eligible for a proportion of the government's student loan, unlike diploma students. In Scotland, however, all student nurses regardless of which course they are undertaking, receive the same bursary in line with the English diploma course.

Before Project 2000, nurse education was the responsibility of hospitals and was not based in universities; hence many nurses who qualified prior to these reforms do not hold an academic award.

Post-registration
After the point of initial registration, there is an expectation that all qualified nurses will continue to update their skills and knowledge. The Nursing and Midwifery Council insists on a minimum of 35 hours of education every three years, as part of its post registration education and practice (PREP) requirements.

There are also opportunities for many nurses to gain additional clinical skills after qualification. Cannulation, venepuncture, intravenous drug therapy and male catheterisation are the most common, although there are many others (such as advanced life support) which some nurses will undertake.

Many nurses who qualified with a diploma choose to upgrade their qualification to a degree by studying part time. Many nurses prefer this option to gaining a degree initially, as there is often an opportunity to study in a specialist field as a part of this upgrading. Financially, in England, it is also much more lucrative, as diploma students get the full bursary during their initial training, and employers often pay for the degree course as well as the nurse's salary.

In order to become specialist nurses (such as nurse consultants, nurse practitioners, etc.) or nurse educators, some nurses undertake further training above bachelors degree level. Masters degrees exist in various healthcare related topics, and some nurses choose to study for PhDs or other higher academic awards. District nurses and health visitors are also considered specialist nurses, and in order to become such they must undertake specialist training (often in the form of a top up degree (see above) or post graduate diploma).

All newly qualifying district nurses and health visitors are trained to prescribe from the Nurse Prescribers' Formulary, a list of medications and dressings typically useful to those carrying out these roles. Many of these (and other) nurses will also undertake training in independent and supplementary prescribing, which allows them (as of May 1 2006) to prescribe almost any drug in the British National Formulary. This has been the cause of a great deal of debate in both medical and nursing circles.

Hierarchy & roles
Traditionally, on completion of training, nurses would be employed on a hospital ward, and work as staff nurses. The ward hierarchy consists of:


 * Healthcare assistants etc. (see above for other titles) - Unregistered staff responsible for providing direct patient care, under the supervision of qualified nurses (often staff nurses). Under clinical grading (see below), these staff usually attracted A or B grades, and are now employed in Bands 2-3 under agenda for change (see below)
 * Staff nurses - the basic grade of qualified nursing staff. These nurses are responsible for a set group of patients (e.g. one bay of a ward) or tasks (e.g. administering medications). In clinical grading, these nurses were usually employed at D grade, under agenda for change they are most likely to attract a band 5 salary. Level two nurses often hold positions anywhere between C and E grades, but are now banded exactly the same as first level staff nurses.
 * Senior staff nurses - these nurses carry out many of the same tasks, but are more senior to the staff nurses. This difference is usually academic, although it is evident occasionally when a senior staff nurse is in charge of the ward or department area during a shift. Employed at E or F grade under clinical grading, and may be assigned band 5 or 6 under agenda for change.
 * Junior/deputy sister; charge nurse; ward manager - responsible for the day-to-day running of the ward, and may also carry specific responsibilities for the overall running of the ward (e.g., rostering) in accordance with the wishes of the ward manager. These nurses were usually employed at F grade under clinical grading, and now are most likely to be assigned band 6, although some have attracted a band 7 salary.
 * Sister; charge nurse; ward manager - this nurse is responsible for running a ward or unit, and usually has budgetary control. He/she will employ staff, and be responsible for all the local management (e.g., rostering, approving pay claims, purchasing equipment, assigning tasks). These nurses were previously employed at G grade, and now usually attract a band 7 salary (occasionally band 6, e.g. in the case of a small ward, or if responsibility is shared).
 * Senior sister; charge nurse; senior ward manager - if there is a need to employ several nurses at a ward manager level (e.g. in A&E), then one of them often acts as the senior ward manager. These nurses were previously graded G or H, and now attract a banding anywhere between 6 and 8c.

There are also positions which exist above the ward level:
 * Clinical nurse manager - A nurse who is responsible for an entire department, or at least more than one ward, is often referred to as a clinical nurse manager. Depending on both the inclination of the trust and themselves, they may be more or less involved in actual clinical nursing or management on a clinical level. Often employed at H grade, these nurses now attract band 7 (or occasionally 8a/8b) under Agenda for Change.
 * Modern matrons - brought in in response to a perceived lack of skill and competence in nursing, the modern matron is responsible for overseeing all nursing within a department or directorate. Modern matrons used to be employed at H or I grades, and are now most commonly employed on bands 8a/8b/8c, occasionally on band 7. See Matron for more details of this role and its historical roots.

The status in the hierarchy of specialist nurses is variable, as each specialist nurse has a slightly different role within their respective NHS organisation. They are generally experienced nurses, however, and are employed at least on band 6 (previously F grade).

Pay scales
Until very recently, all nurses in the NHS were employed on a scale known as clinical grading (see below). Agenda for Change was developed by the NHS in response to criticisms that the old scale reflected length of service more than knowledge, responsibility and skills.

Whilst developed by the NHS for its own use, both of these systems are in widespread use throughout the private sector.

Clinical grading
Also known as the Whitley system. This placed nurses (and some other hospital staff) on "grades" between A and I (with A being the most junior, and I the most senior).

Unregistered staff were employed on grades A&B (and occasionally C). second level nurses were employed on various grades (usually between C and E), with first level nurses taking up grades D-I.

This system is still very popular amongst nurses, who will often refer to themselves by their old clinical grade than their agenda for change band (see below).

Agenda for Change
This system puts nurses (and most other non-medical/dental staff) on "bands" between 2 and 9. Unregistered staff take up bands 2-4, with qualified staff taking bands 5-8. Band 9 posts are for the most senior members of NHS management, currently there are no such positions in existence for nurses.

The idea of this system is "equal pay for work of equal value". There was a perceived discrepancy, under clinical grading, between ones grade (and therefore pay) and the work which one actually did, which Agenda for Change aimed to fix.

As of spring 2006, pay for nurses on each of the bands is as follows:


 * Band 2: £12,177-£15,107
 * Band 3: £14,037-£16,799
 * Band 4: £16,405-£19,730
 * Band 5: £19,166*-£24,803
 * Band 6: £22,886-£31,004
 * Band 7: £27,622-£36,416
 * Band 8a: £35,232-£42,278
 * Band 8b: £41,038-£50,733
 * Band 8c: £49,381-£60,880
 * Band 8d: £59,189-£73,281

Most nurses in England and Wales are now employed under agenda for change terms, however there are some still employed on clinical grades, especially in Scotland where only 9% of the workforce has been assimilated. The government has set numerous targets for the transition to be complete (all now passed), but a full transition is yet to take effect.