Revalidation is not in the Oxford dictionary (at least not the 1995 version within reach) so it must be jargon. But it is one of the most important words associated with nursing at the moment – disregard it at your peril. Jargon or not, it is a big deal for nurses and the care sector.
Since valid means to substantiate, confirm, be legally acceptable or describe something that has not yet reached its expiry date, it is reasonable to assume that to revalidate must mean to declare valid again. And so it is the word that the Nursing and Midwifery Council (NMC) is using to describe the new process by which all nurses will declare and demonstrate that, on a three yearly cycle, they remain fit to practise throughout their careers.
Fit to practise overhaul
The NMC is having to overhaul the system it uses to make sure nurses are fit to practise and that nurses consistently exhibit high degrees of professionalism and good practice. However, nationally some poor practice has been exposed, for example by the report into Winterbourne View1 and the investigation conducted by Sir Robert Francis QC into the standards of care at Mid-Staffordshire. As a consequence of his investigation Sir Robert recommended:
‘… that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional protection to the public2’.
The NMC accepted this recommendation and recognised that it needed to do more to inspire greater public confidence in nurses. It is essential for public safety that nurses are competent and safe practitioners and the public should rightly expect nurses to show that they are up-to-date in their practice. This will apply to all nurses: not just NHS nurses, not just those in clinical practice giving hands-on care, but also those in managerial and leadership roles, in education, research, public health and policy jobs who need to be registered nurses. Revalidation applies to any sphere of nursing practice and to anyone who wishes to continue practising and remain registered as nurse with the NMC.
The NMC has 670,000 nurses on the UK register3 and with 310,000 nurses working within the NHS in England4 around 60% of its nursing registrants work outside the NHS. There is, therefore, a considerable number affected by this change in the independent sector, in care homes with nursing, in domiciliary care and elsewhere. They might be giving hands-on care and might also be Registered Managers or in other roles where nurse registration is legitimately required. Revalidation is approaching fast and is a process that needs to be widely understood to be implemented effectively.
Revalidation in practice
From December 2015, all nurses who are due to re-register (that is those who are at the end of the three yearly cycle where they have to renew their registration with the NMC) will start using revalidation. This means that by December 2018 everyone on the register will have undergone revalidation.
This process of renewal every three years is not new. Nurses have to pay an annual fee to remain registered and every third year have had to declare themselves to the NMC as being up-to-date and fit to practise. Until now this three yearly renewal has been based on the PREP (post-registration education and practice) standards. PREP required nurses to make a self-declaration to the NMC that they had undertaken 450 hours of practice and 35 hours of continuing professional development (CPD) in the preceding three years. Those nurses who took PREP seriously will find that revalidation presents only modest changes. But PREP has been much criticised and, although all nurses have had to declare compliance with these standards, it has never been audited and so fitness to practise assurances through PREP could not be substantiated. The new system has to address this with a view to increasing public confidence in nurses whilst helping to improve standards of care and generating a culture of continuous improvement.
The requirements for revalidation differ from PREP in that, although there is still a need to undertake 450 hours of practice in three years, the hours needed for CPD go up by 5 hours to 40 hours in three years. Also the nature of the CPD will be slightly different in that 20 of the 40 hours will need to be participatory. This is to ensure that there is interactive learning in participation with other nurses and to guard against all CPD being done in isolation in front of a computer as e-learning. Participatory learning can take many forms; it could be formal classroom, on the job training, structured courses or activities such as mentoring, coaching or shadowing. The important feature being that the learning is relevant to the scope of practice and that there is evidence of what has been done with supporting evidence of learning through reflection.
Another new component part of revalidation is feedback. Not just feedback for its own sake, but being responsive to it and using it to change personal practice as a consequence. This feedback is, however, causing some anxiety about who might provide it, how it might be collected and how to deal with negative feedback. In reality, nurses are likely to use a range of sources. Feedback could come from patients, their families and carers, colleagues, mentors or through the appraisal system – but it must never be acquired by coercion. Indeed, using complaints could be very valuable. They might feel like a negative source of information, but they are important stimuli for learning. That highlights an important feature of revalidation: it is about a nurse’s continuing fitness to practise and not about managing performance. The NMC will not be interested in seeing the original feedback, which will remain confidential to the nurse, but it will be interested in a reflective account on the feedback which demonstrates what has been learnt and how it has changed practice for the better or that it has reinforced good practice.
Revalidation will also require five reflective accounts over the three year period on how CPD or feedback has changed or improved practice and how it is relevant to the Code. Nurses will then have a discussion with another nurse about their reflections on the Code, CPD and feedback.
In meeting these new requirements nurses will not just declare that they have met the standards, they will also have to seek third party confirmation that this is the case. This will need a professional development discussion with another NMC registrant covering reflections on the Code, CPD and practice-related feedback. The NMC provisional policy5 on this point says that confirmation will be provided by the nurse’s line manager. The preferred, and indeed ideal, confirmer is a line manager who is also an NMC registrant. There will be instances where the confirmer may not be a registrant and so the confirmation discussions will need to be held with a registrant who is not the line manager. For self-employed nurses, the NMC will provide guidance on how to access confirmation at a later date.
More details will emerge over the course of the year because the NMC is currently piloting and testing the new system. It is anticipated that the final standards and guidance on revalidation will be approved in October 2015. As part of the pilots the NMC will also decide how best to audit nurses’ portfolios of evidence and how many it will audit in any one year to satisfy itself that the process is effectively protecting the public. The pilots will be evaluated and revalidation itself will start in December 2015 for those renewing their registration at that time. There will also be an evaluation of the effectiveness of revalidation starting 2016.
There is a reasonable emphasis on the role of employers to support the system of revalidation. No good employer would want to employ a nurse who cannot revalidate and many will have sufficient CPD opportunities on offer to meet the NMC’s criteria and have effective appraisal systems to contribute to the process. However, some nurses might not have one employer consistently. They might be self-employed or work on a casual basis through a bank or agency, so they will have to think carefully about how to construct their revalidation. After all, it is ultimately the responsibility of the nurse to maintain their fitness to practise, keep up-to-date and have evidence to revalidate. It is a profoundly important aspect of professional practice to take this responsibility seriously as an individual.
There is one other new and crucial element to revalidation and that is the revised NMC Code6. The Code, published in January comes into effect on 31st March. It contains the professional standards that registered nurses must uphold whether they are providing direct care to individuals, groups or communities or bringing their professional knowledge to bear on nursing practice in other roles, such as leadership, education or research. It also aims to promote a culture of professionalism and accountability and states that employers should support their staff in upholding its standards as part of providing the quality and safety expected by service users and regulators. The Code is absolutely central to the revalidation process as a focus for professional reflection – and it’s a really important feature of this process to recognise that nurses will revalidate against the standards in the Code and not their job description.
Revalidation might still sound like jargon, but it is vitally important to every single nurse who wants to continue practising. It is also crucial that providers of care understand what revalidation means as a process and as a good employer. The NMC, quite rightly, wants all nurses to practise with a high degree of professionalism, ability and accountability in whatever setting they work. In the care sector especially, nurses give hands on care to some of the most vulnerable people in society: they need to trust their nurses and know that they are in safe hands. Revalidation might not mean anything much to them but they need to be confident that every nurse deserves his or her place on the register and that revalidation is an effective process to ensure that.
Acknowledgement: Thanks go to Dr Katerina Kolyva, Director of Continued Practice at the NMC for reviewing the contents of this article on behalf of the NMC.
Dr David Foster is Head of the Nursing, Midwifery and Allied Health Professions Policy Unit at the Department of Health. Professor John Clark is Director of Education and Quality at Health Education England – South.