the francis report: to inifinity and beyond

The Francis Report

Roger Watson FRCN FAAN

Professor of Nursing

November 2015

Making nursing a degree-entry profession was

a disaster. It was like decreeing that

motherhood should be for graduates only.

You automatically excluded many of the best

and gentlest candidates.

Lord Willis (RCN Congress 2013)

“Unsurprisingly, we found no evidence that there is

somehow a conflict between intellect and

compassion. What neither Francis nor our

Commission recommended was that potential

students should spend a year working as unqualified

and unregulated health care support workers and,

that by a process of osmosis, they would somehow

be fit to become nursing students.”

3

422 730 patients aged 50 years or older

who underwent common surgeries in

300 hospitals in nine European

countries.

Findings

An increase in a nurses' workload by one patient

increased the likelihood of an inpatient dying within 30

days of admission by 7% (odds ratio 1·068, 95% CI

1·031–1·106), and every 10% increase in

bachelor's degree nurses was associated with a

decrease in this likelihood by 7% (0·929, 0·886–

0·973). These associations imply that patients in

hospitals in which 60% of nurses had bachelor's

degrees and nurses cared for an average of six

patients would have almost 30% lower mortality than

patients in hospitals in which only 30% of nurses had

bachelor's degrees and nurses cared for an average

of eight patients.

Findings

An increase in a nurses' workload by one patient

increased the likelihood of an inpatient dying within 30

days of admission by 7% (odds ratio 1·068, 95% CI

1·031–1·106), and every 10% increase in bachelor's

degree nurses was associated with a decrease in this

likelihood by 7% (0·929, 0·886–0·973). These

associations imply that patients in hospitals in which

60% of nurses had bachelor's degrees and nurses

cared for an average of six patients would have

almost 30% lower mortality than patients in hospitals

in which only 30% of nurses had bachelor's degrees

and nurses cared for an average of eight patients.

Mid Staffs

Francis report (2013)

‘Knee-jerk’ reaction

Francis recommendations

1. In nurse training, education and professional development there should be an increased focus on the practical as well as the theoretical requirements of delivering compassionate care.

Francis recommendations

2. Training should be reviewed to ensure sufficient practical elements are incorporated for a consistent national standard to be achieved by all trainees.

Francis recommendations

3. There should be a national entry-level requirement that students spend at least three months working in the direct care of patients under the supervision of a registered nurse. Such experience would ideally include older people and involve hands-on physical care. Satisfactory completion of this direct care experience should be a condition of continuing nurse training.

Francis recommendations

4. The Nursing and Midwifery Council (NMC), working with universities, should consider introducing an aptitude test to be undertaken by aspiring nurses. The test should explore attitudes to caring, compassion and other professional values.

Francis recommendations

5. The NMC and other professional and academic bodies should work towards a common qualification assessment or examination.

Francis recommendations

6. There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard in the fundamental aspects of compassionate care.

Francis recommendations

7. Employers recruiting nursing staff should assess candidates’ values, attitudes and behaviours in relation to the wellbeing of patients and their basic needs.

Francis recommendations

8. The Department of health (DH) and the NMC should introduce the concept of a ‘responsible officer for nursing’, appointed by and accountable to, the NMC.

Francis recommendations

9. The NMC should introduce common minimum standards for appraisal with which responsible officers would be obliged to comply. The officers could be required to report regularly to the NMC.

Francis recommendations

10. Every nurse should be required to demonstrate in an annual learning portfolio up-to-date knowledge of nursing practice. The portfolio should provide evidence of commitment, compassion and caring for patients, with feedback from patients and families on the care provided by the nurse. This portfolio and each annual appraisal should be made available to the NMC, if requested, as part of a nurse’s revalidation process.

Francis recommendations

11. Ward managers should operate in a supervisory capacity, and not be office-bound or expected to ‘double up’ – except in emergencies – as part of the nursing provision on the ward. They should know about the care plans relating to every patient on his or her ward. They should make themselves visible to patients and staff alike, and be available to discuss concerns with all, including relatives. Critically, they should work alongside staff as role models and mentors, developing clinical competencies and leadership skill in their team.

Francis recommendations

12. The NHS knowledge and skills framework should be reviewed with the intention of recognising explicitly nurses’ demonstrations of commitment to patient care and, in particular, to dignity and respect.

Francis recommendations

13. Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all NHS healthcare provider organisations.

Francis recommendations

14. Healthcare providers should be encouraged by incentives to develop and deploy transparent measures that define the ‘cultural health’ of frontline nursing workplaces and teams. The measure will build on the experience and feedback of nursing staff using a robust methodology, such as the ‘cultural barometer’.

Francis recommendations

15. Each patient should be allocated a named key nurse for each shift who would be responsible for co-ordinating the provision of the care needs of the patient.

Francis recommendations

16. The creation of the status of registered older person’s nurse should be considered.

Francis recommendations

17. The RCN should consider whether it should divide formally its ‘royal college’ functions and its employee representative/trade union functions between two bodies.

Francis recommendations

18. Recognition of the importance of nurse representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role.

Francis recommendations

19. A forum for all directors of nursing should be formed to provide a means of co-ordinating the leadership of the nursing profession.

Francis recommendations

20. All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and encouraged to consider recruiting nurses as non-executive directors.

Francis recommendations

21. Commissioning arrangements should require the boards of provider organisations to seek and record the advice of their nursing director about the impact on the quality of care and patent safety of any proposed major change to nurse staffing. Boards should record whether they accepted or rejected that advice; and if rejecting the advice, recording their reasons for doing so.

Francis recommendations

22. The effectiveness of the chief nursing officer should be kept under review following the role’s move from the Department of Health to the NHS Commissioning Board. The review should ensure the role provides a leading representative of the whole nursing profession, and that the post holder is able and empowered to give independent professional advice to the government on nursing issues; and that he or she is accorded equal authority to that of the chief medical officer.

Francis recommendations

23. There should be a uniform description of the role of healthcare support workers (HCSWs).

Francis recommendations

24. Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that an HCSW is easily distinguishable from a registered nurse.

Francis recommendations

25. A registration system should be created under which no unregistered person can provide for reward direct physical care to patients currently under the care and treatment of a nurse or a doctor in a hospital or care home.

Francis recommendations

26. There should be a national code of conduct for HCSWs.

Francis recommendations

27. There should be a common set of national standards for the education and training of HCSWs.

Peter Carter: “In what other walk of life would you employ people, put them in a uniform and expect them to learn by watching what is going on?”

Francis recommendations

28. The code of conduct, education and training standards and requirements for HCSW registration should be prepared and maintained by the NMC.

Francis recommendations

29. Until such time as the NMC is given the recommended regulatory responsibilities, the DH should institute a nationwide system to protect patients from harm. This system should allow employees who have been dismissed on the grounds of being unfit for such a post a fair opportunity to respond.

Raising the bar

Shape of caring: a review of the future education and training of registered nurses and care assistants

Lord Willis, Independent Chair – Shape of Caring review

Health Education England (2015)

r.watson@hull.ac.uk

@rwatson1955