OPEN BOARD OF DIRECTORS 2 nd December 2015 Open BoD: 02.12.15 Item: 13 TITLE OF PAPER TO BE PRESENTED BY ACTION REQUIRED Nurse Revalidation Progress Report Clive Clarke, Deputy Chief Executive, on behalf of Liz Lightbown, Executive Director: Chief Nurse/Chief Operating Officer To receive and note the progress on Nurse Revalidation OUTCOME TIMETABLE FOR DECISION LINKS TO OTHER KEY REPORTS/DECISIONS LINKS TO THE NHS CONSTITUTION & OTHER RELEVANT FRAMEWORKS BAF, RISK, OUTCOMES IMPLICATIONS FOR SERVICE DELIVERY & FINANCIAL IMPACT CONSIDERATION OF LEGAL ISSUES Executive Directors Group and Board of Directors continue to support the Trust s current position in progress for Nurse Revalidation December 2015 Board Meeting The NMC s Revalidation Evidence Report 2014 The Code (professional standards of practice and behaviour for nurses and midwives) Jane Cummings, CNO Letter dated 30 October 15 (See Appendix 1) HSE MH Act Equality NHS Constitution: Patients Public Staff Requires an increase in the numbers of trained registered nurse appraisers Requires an increase in the release of nurses from direct clinical / patient care to appraise and be appraised Inability to implement an effective system of revalidation means nurses may not be in a position to practice, affecting both direct patient care and services. Some individual nurses may not meet the new requirements for revalidation thus affecting clinical care and service delivery Paper to Board in April 2015 outlining the Requirements for Nurse revalidation Business case submitted to Business Planning Group (BPG) and Executive Directors Group (EDG) July 2015 Inability to meet requirements of nurse revalidation thus affecting ability to deliver safe nurse staffing levels and care standards (as required by the regulator) resulting in legal claims Authors of Report Liz Lightbown; Giz Sangha Designation Executive Director: Chief Nurse/Chief Operating Officer; Deputy Chief Nurse Date of Report 23 rd November 2015 13 Open BoD Dec 15-Nurse Revalidation Progress Report Page 1 of 6
SUMMARY REPORT Report to: Open Board of Directors Date: 2 nd December 2015 Subject: From: Nurse Revalidation Progress Report Clive Clarke, Deputy Chief Executive, on behalf of Liz Lightbown, Executive Director: Chief Nurse/Chief Operating Officer Authors: Liz Lightbown, Executive Director: Chief Nurse/Chief Operating Officer Giz Sangha, Deputy Chief Nurse 1. Purpose For Approval For a collective decision To report progress To seek input from For information Other (please state below) The Trust has purchased 600 re-validation licences from a third party provider named HeART. This is an online Healthcare e-portfolio based system built & specifically designed by IT Premier to manage Appraisal, Revalidation and Training for Nurses, Midwives and Healthcare Professionals. The HeART system is currently being populated with information related to Directorates / Teams nurses are based in. This includes Primary Care, Mental Health, Substance Misuse and Learning Disability nurses. A nurse has commenced employment as lead to support revalidation. It is anticipated that the system will go live fully on the 1 st February 2016. The first cohort of nurses will need to be ready for revalidation by the end of February 2016. It is recommended that all nurses employed by the Trust should use the HeART system for revalidation purposes to ensure effective monitoring / auditing of compliance rates. Those nurses who do not meet the requirements of revalidation will be unable to practice. 2. Summary The Nursing and Midwifery Council has changed the requirements of revalidation by which nurses and midwives renew their registration every three years. To support and evidence the declarations referenced in the April / August 2015 Board papers all registrants will need to keep records of their participation in a portfolio. Each year the NMC will audit a sample of portfolios to enhance their understanding of risk and inform future phases of revalidation. The Nurse Revalidation Steering Group, chaired by the Deputy Chief Nurse agreed to deliver a new electronic solution for Nurse Revalidation Requirements. It has been agreed this would be undertaken by introducing a central mechanism for effective Continuing Professional Development, Appraisal, Data Capture and reporting across Trust services by December 2015. To this effect the Trust purchased the HeART System in August / September 2015 to be used to ensure all nurses complete their revalidation requirements. 13 Open BoD Dec 15-Nurse Revalidation Progress Report Page 2 of 6
In the October 2015 Nurse Revalidation Steering Group, members discussed the need to send a communication to all nurses in the Trust regarding revalidation as there were individual staff emailing with similar questions, anxieties and concerns. In November 2015 a leaflet was issued / intranet site setup and communicated to all nurses in the Trust by email/including contact details for the Lead Nurse in revalidation. Assistant Clinical Directors / Lead Nurses have been asked via the Nurse Leadership Group to ensure that revalidation is a regular item on their team discussion agendas. Numbers of Nurses per Cohort Requiring Revalidation The numbers of nurses requiring revalidation is calculated monthly using the Electronic Staff Record (ESR) database. ESR is continually being updated as each nurse s information held on the system related to their role / function in the Trust is proactively being checked with individual nurses. The first cohort of nurses requiring revalidation is by the end of April 2016 in line with Nursing Midwifery Council (NMC) Guidance. It is anticipated that 16-20 nurses are in this cohort, though some 1 clarity is being sought from nurses before exact confirmation of numbers. In December 2015, the required support will be identified for the first cohort of nurses by the lead in revalidation. This will involve preparation of the documents required to be scanned / types of evidence to be gathered / identifying who will be their confirmer to be uploaded into the HeART system. From the Electronic Staff Record (ESR) data (November 2015), it is anticipated that less than 50 people will require revalidation between April end June 2016, again subject to clarity from nurses regarding their roles. Confirmer Arrangements The revalidation steering group members will be discussing confirmer arrangements in the November 2015 meeting. The initial recommendation from the group was that the confirmer should be the line manager if they are a Nurse or an Assistant Clinical Director. However the NMC have shared that: 2 Nurses and midwives will need to use their judgment to choose who should provide confirmation. We strongly recommend that it is provided by their line manager wherever possible. They do not need to be an NMC registered nurse or midwife. In most cases, the line manager will be an NMC-registered nurse or midwife. However, if you are not an NMCregistered nurse or midwife, the nurse or midwife will need to have had their reflective discussion with another NMC-registered nurse or midwife before seeking confirmation from you. Training Requirements Included in the HeART package is a training option, to train 2 super user administrative staff, 4 super users and 80 additional staff. An implementation plan is being developed by the revalidation steering group members / lead nurse and this will include Trust / Primary Care sites nurses. Staff offered training will be selected from each directorate to become familiar with the Heart System / create a cascade of training and support networks in their teams supported by the lead nurse in revalidation. This process will be overseen by a designated operational manager. It is anticipated that Super Users of the system will be trained on the 15 th January 2016 and additional staff members on the 29th January 2015. This will ensure trainers are in place before system goes live on the anticipated date of 1 st February 2016. 1 Clarity is being sought as some nurses are not practising as nurses due to being in management / Cognitive Behavioural psychotherapy / other roles. Therefore they have an option to retain their nursing registration / allow it to lapse if not required for their current role. At a later date they may wish to undertake a refresher course to return to nursing practice and then reregister with the NMC. For those who wish to retain their registration in the above roles, further discussion is required for clarification on a Trust level. 2 Revalidation, Information for confirmers, NMC 13 Open BoD Dec 15-Nurse Revalidation Progress Report Page 3 of 6
The lead nurse in revalidation is visiting Trust / Primary Care sites already and demonstrated the HeART system to Ward Managers / Revalidation Steering Group Members / Nurse Leadership Group. Policy / Guidance Development The current policy relating to clinical / professional verification will be reviewed to include revalidation requirements. This policy will be updated collaboratively with Human Resource (H/R), Clinical Commissioning Colleagues, and Union Representatives. A tentative meeting date is being sought to commence discussions to agree Trust guidance. Organisational State of Readiness for Nurse Revalidation The Nursing and Midwifery Revalidation Programme Board for England sent a tool to all organisations to enable self-assessment of organisational readiness for nursing and midwifery revalidation. This tool was completed for SHSC in July 2015 and submitted to NHS England. For the Trust it highlighted a number of areas that required attention: A robust effective CPD data collection system is required. Update: This issue is now resolved, the HeART system will be used. Work is being progressed regarding interface with other organisational systems i.e. ESR There is no one Trust system which can inform the Chief /Deputy Chief Nurses where all nurses are located by practice areas. Update: This information will be available and the 8 super users once trained will be able to extrapolate the required information to report progress to EDG / BoD There are delays in the current tracking system due to several systems being used currently and they require updating (ESR). Update: Work progressed with colleagues in H/R in July 2015 to refine data recording and for extrapolation purposes. This work will be completed by end January 2016. The outstanding issue is obtaining clarity for some nursing roles as identified in the section above headed: Numbers of Nurses per Cohort Requiring Revalidation Consequently, there is no one communication list specific to nurses to enable the Chief / Deputy Chief Nurse to send information in a timely and prompt manner to all nurses, given the timescales to implement revalidation are short (1 st January 2016). Update: supported by information technology colleagues, this list is now available and has been used to share the revalidation leaflet. The first cohort of Nurses who will go through the nurse revalidation process need to be identified via the ESR system. Update: this is highlighted in the report under the section of Numbers of nurses per cohort requiring Revalidation All nurses must be confirmed as fit to practice by another registered nurse, where a nurses line manager is not a nurse (and is another professional, i.e. a social worker / doctor / allied professional or general manager) they will require a registered nurse confirmer to be identified to enable them to revalidate (for their evidence checking). Update: confirmer arrangements will be discussed in the November 2015 meeting. Numbers of confirmers to be identified and a consistent approach to identifying registered nurse confirmers / training implications is required. Update: confirmer arrangements will be discussed in the November 2015 meeting / training plan arrangements commencing in January 2016. Dates for training confirmed by IT premier and revalidation lead. The Dashboard /portfolio HeART system will provide a central point for reviewing Revalidation against national, local, strategic and operational indicators and targets. The Trust will have the ability to display and drill down into data at Trust-wide, Directorate, Team and Individual level for monitoring purposes & to ensure the Trust remains on track for revalidation. 13 Open BoD Dec 15-Nurse Revalidation Progress Report Page 4 of 6
3. Next Steps Inform the relevant Directors of their nurse members in the first cohort January 2016. Revalidation Steering Group & Nurse Leadership Group work together to identify nurse confirmers in the Trust and put into place a training plan to ensure consistency of confirming. Communication list specific to nurses to be used by the Chief/Deputy chief nurses/ lead nurse in revalidation and the operational manager overseeing this project Relevant Directors to agree staff training for identified staff with access rights to ensure confidentiality to commence January 2016. Share learning from cohorts on a monthly basis / build up a log of issues / problems resolved Chief Nurse / Deputy Chief Nurse report progress to EDG / Board in February 2016. 4. Required Actions Board Member are asked to note the requirements for Nurse Revalidation and the work being undertaken/ progressed to date 5. Monitoring Arrangements Via Monthly Nurse Revalidation Steering Group Chair, Deputy Chief Nurse. Via Chief Nurse to EDG. Via Chief Nurse to Board. 6. Contact Details For further information, please contact: Liz Lightbown, Executive Director: Chief Nurse/Chief Operating Officer liz.lightbown@shsc.nhs.uk Giz Sangha, Deputy Chief Nurse giz.sangha@shsc.nhs.uk Tel: 0114 271 6713 13 Open BoD Dec 15-Nurse Revalidation Progress Report Page 5 of 6
Appendix 1 13 Open BoD Dec 15-Nurse Revalidation Progress Report Page 6 of 6