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Howling at at the moon: why we need more answers about NMC revalidation proposals

February 4, 2014

“So how do I know” asked Stacie “whether I’m a good nurse?”
“Course you’re a good nurse!” said Liz. “I signed your piece of paper to say so, didn’t I?”
Stacie frowned. “Oh yeah” she said. “But then…how do I know whether you’re a good nurse?”
“Well obviously I’m a good nurse” said Liz. “because you signed my piece of paper. And you’re a good nurse.”
From Pianosa Ward by Grumbling Appendix (Unpublished draft)

Wine gives me headaches, so I don’t drink it. Ask me if I’d rather have a full-bodied Merlot or a cheeky little Chablis, and I’ll tell you you’re missing the bigger picture. Part One of the Nursing and Midwifery Council’s consultation on its practitioner revalidation proposals (‘focusing…on how the proposed model of revalidation can be implemented in a variety of employment settings and scopes of practice’ makes me feel the same way. I’ve got so many questions, but I’m not getting the chance to ask any of them. Will I be able to ask them in Part Two? Who knows. The exact focus of Part Two seems as yet…unfocussed; you’ll trawl the NMC’s website in vain if you want an answer to that one.

The NMC says the overarching aim of revalidation is to ‘improve public protection’ and to ‘increase public confidence in nurses’. It will achieve this not by abolishing the current system, (whereby nurses self-certify as fit to practice), but by essentially adding to it. So under the new dispensation, practitioners would continue to certify themselves, but at three yearly intervals they would also have to confirm that they have ‘sought and received third party feedback which has informed their reflection on their practice. This…could be from patients, carers, students (for educators) or peers’; and have ‘sought and received third party confirmation that they are fit to practise’. The NMC will not routinely scrutinise the evidence individuals collect; instead, it will select a yearly sample for audit.

To be clear then: the NMC does not want your views on whether its ideas represent the best way of inspiring confidence and protecting the public – it has already decided (without consultation) to go with this model; the point of the online questionnaire it has launched as part of the current process is simply to ascertain how things might pan out in the many and varied nursing environments, including those where registered practitioners rarely come into contact with other nurses.

To cater for these individuals, the NMC has come up with the controversial suggestion that the ‘third party confirmation’ of practitioner’s fitness to continue on the register could come from a colleague or manager who is not themselves a nurse. Wow…how to make friends and influence people – not. Big hitters like Professor Peter Griffiths of Southampton University have gone public with warnings that ‘the potential for a nurse to be revalidated without any professional involvement undermine[s] the principle of professional regulation’.

For a group as professionally insecure as nurses, such anxieties are very pertinent. For the general public however (and let’s not forget, these proposals are first and foremost about protecting the public) they look a tad navel-gazing. Service-users are going to be more concerned, and rightly so, about how the proposals will work for them. This, unfortunately, is an area that the NMC seems distinctly reluctant to discuss and, rather than arguments about exactly who will sign what, it is this that diminishes the plans as a whole.

My questions about third party confirmation are almost too numerous to list in an article of this length – but I suppose that isn’t a reason not to ask them anyway. So…the NMC says that third party confirmation is likely to come from ‘a manager, another registrant or a supervisor’. OK – so can you grab anyone who happens to be passing, or will organisations be expected to prepare an approved list? Assuming the latter, what training will they get, and who will provide and pay for it – the NMC or employers? Will individuals be told who to use as their third party or will they be allowed to choose someone (from the putative list) who they think will give them an easy ride?
And there’s more. What happens if a third party who has confirmed others cannot themselves obtain third party confirmation or even becomes the subject of a fitness to practice hearing? Are their ‘confirmations’ thereby invalidated? What happens if the third party and the registrant can’t agree? Are lengthy appeals procedures going to join lengthy Fitness to Practice hearings as a defining feature of the NMC? What does the registrant do in the meantime? Suspended on full pay? If so, isn’t there a danger that third parties will come under pressure to confirm everyone, even if they don’t merit it? I could go on…

Without answers to these questions, the whole enterprise just looks like another scandal waiting to happen; one is tempted to conclude that a non-nurse manager of independent views might indeed make a more reliable third party than a mate from the ward who goes clubbing with you. The question then becomes one of how easy it will be for anyone, nurse or otherwise, to make an objective, standardised judgement.

The NMC says that revalidation should be closely tied to reflection on, and compliance with the Code of Conduct; in tandem with the revalidation proposals, it is working on a revised Code which it wants to see ‘position[ed] at the heart of everyday nursing and midwifery practice…provid[ing] the opportunity to confirm practice and celebrate professionalism’. The trouble is that apart from a few vague platitudes about how ‘our Code sets standards of conduct and competence for registered nurses and midwives’, the NMC has so far published few concrete proposals on how it will achieve this fine aspiration. Because we don’t know what will be in the revised code, we don’t know how easy or difficult it will to measure performance against it.

And to be honest, the NMC in some ways seems to have failed to put the Code at the heart of its own proposals. Take Question 16 on ‘practice related feedback’. It asks ‘who should contribute to…feedback on practice?’ and gives a list of possible sources, including ‘Nursing or Midwifery students (in the case of educators)’. Who are ‘educators’? Is it a term that is solely applicable to University Lecturers, or – given that Article 23 of the Code states: ‘You must facilitate students and others to develop their competence’ – does it mean everybody who comes into contact with students? Let’s pray it’s the latter, because placement and mentorship are long overdue for overhaul. If the NMC fails to use this process as a lever for improvement, then I have got only three words to say: Massive – Missed – Opportunity.

While linking revalidation to appraisal gives some reassurance of a safety lock, the current appraisal system is notoriously patchy and poorly-observed; a lot of beefing-up will be required to make it robust enough to support the revalidation project. And of course, it raises more questions. If a nurse who is up for revalidation next year is found at this year’s appraisal to have problems, who is going to be responsible for helping him or her to resolve them in time for revalidation? A proper process would have to be put in place and adhered to or any failure to revalidate would simply be challenged on a technicality.

I’m all for protecting the public. Believe me, I want this process to work. I would encourage everyone to go ahead and respond to the NMC’s consultation questionnaire. But without more information on how the plans will work in practice, it all just seems like so much howling at the moon.

For Professor Peter Griffiths’ views, see:

For NMC information on revalidation see: (and related content).

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