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What would the creation of a ‘Registered Older Person’s Nurse’ mean in practice?

March 4, 2013

Oh, Robert Francis – QC – remind me again what planet you’re on! Coz I’d quite like to move there myself. A planet with plenty of funds, plenty of nurses, plenty of funds for nurses to do courses and lots of smiling managers to wave them off on study leave. Just like the one I’m on. Not.

Recommendation 200 of the Francis Report states that ‘Consideration should be given to the creation of a status of Registered Older Person’s Nurse’. In paragraph 77 of chapter 23, Francis expands on this and gives his reasoning. ‘It is to be noted’ he says ‘that there is already a specialist register for nurses with expertise and training in paediatric care and mental health, as well as in midwifery. These categories of patients share with the elderly the characteristics of requiring specialist care and of being particularly vulnerable’. So Francis is suggesting that a Registered Older Person’s Nurse (ROPN) would parallel a Registered Sick Children’s Nurse, a Registered Mental Nurse or a Registered Midwife, right? Wrong.

A closer reading of the Francis Report reveals that unlike the three qualifications listed at the end of the last paragraph (or Registered Nurse, come to that) – which are all first-level, free-standing qualifications requiring full-time study and open to persons who have had no previous training in health care – the Registered Older Person’s Nurse will be a secondary qualification, obtainable only by those who are already registered (general) nurses. What is more, it will rely on on-the-job, day-release training. In Francis’s words it will be ‘largely obtainable in post’ (Ch 23, para 77).

To be fair to Francis, if we are serious about ROPNs, it’s difficult to envisage any alternative to what he is proposing. If ROPN were introduced as a first-level qualification, how would work be shared out from day to day on the average busy ward? Would the ROPNs care only for the older patients and leave the younger ones to standard RNs? What if a younger patient needed help and no one but an ROPN was around? And how do you define an ‘older person’ anyway? Over fifty? Over sixty? Past state-retirement age? Still-quite-young-but-diagnosed-with-dementia? Even more worrying, would ROPNs be viewed as second-class nurses, a bit like the old Enrolled Nurses? And remunerated accordingly?

It just wouldn’t work, would it, which is why we’re probably stuck with the Francis model. It’s hard to know, though, why he has limited its availability to Registered General Nurses. Why not include Registered Mental Nurses amongst potential beneficiaries? After all, the elderly mentally ill represent one of the most challenging patient groups in the entire health service. A better way forward might be an increased emphasis in all pre-registration training on understanding and helping people with dementia. Bigger questions are workforce planning and funding. How are we going to decide how many ROPNs are needed to make any quantifiable difference to care of elderly patients on general wards? And in the current financial climate, and with many services already chronically understaffed, where is the time and money to release sufficient numbers of staff for ‘in-post’ training going to come from? Will nurses be expected to pay for it themselves? Or give up their free time for study? And when they have finally got the certificate and the letters after their name, can they expect it to be reflected in their pay packet?

These questions become even more acute when one turns to the single patient-group who stand to benefit the most from the introduction of ROPNs: those who live in nursing homes. Unlike the publicly-funded NHS, most nursing homes are run by profit-making organisations and for that reason – and although I by no means wish to imply that many if not most nursing home proprietors are not good and considerate employers – money to fund extra training is likely to be even tighter. The worst-case scenario would be that nursing homes go in search of nurses who have already gained the ROPN qualification at public expense while working in the NHS, and then ‘cream them off’ – thereby depriving the public of of the investment it has made.

Amongst all these questions, however, one very large question has remained unasked: what do older people themselves think? Do they want to treated by nurses with special training to help them ‘understand’ the older age group? My guess is they do not. I would go even further, and suggest that many older people would see it as patronising and stigmatising to be singled out in this way because they see themselves, in essence, as just the same as everyone else. What they expect, therefore, is to be offered the same choices as everyone else – and to be treated with the same mixture of respect, courtesy, empathy and clinical expertise as everyone else. If nursing views the teaching of these most basic precepts as something which needs to be ‘bolted on’ to basic training at a later date, then we really have gone very badly wrong indeed.

Francis, R (2013): Report of the Mid Staffordshire Foundation Trust Public Enquiry; London; The Stationary Office.

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