Are the needs of children and young people being overlooked in major NHS policy initiatives?

Nursing associates, PJ paralysis and stranded patients, Annette Dearmun looks at the relevance for children’s nursing of some major policy drivers

Nursing associates, pyjama paralysis and stranded patients; Annette Dearmun looks at the relevance for children’s nursing of some major policy drivers

There is still time to have your say on how the new nursing associate workforce should be regulated. A consultation on the proposals by the Nursing and Midwifery Council is due to close on July 2.

One trust's response to the campaign is ‘sit up, get dressed, and keep moving’ but is this appropriate for children's services?
Picture: iStock

Nursing associates (NA) as a new role were created as a response to the Shape of Caring review of 2015. The aim of this was to improve healthcare following the Mid Staffordshire hospital care failures. The new role was announced earlier this year.

Heralded as a ‘new professional in the nursing team’ the nursing associate role is designed to provide a career path between the healthcare assistants and the registered nurse (RN). The move is supported by England’s Department of Health which sees it as the answer to the challenge of recruiting sufficient RNs. However, the challenge is to find the right place for this role in practice, especially in children’s services.  

This change to create a new role is moving quickly. There was an initial consultation at the end of 2017 and, despite the limited response rate (n=373), a decision was made. In April this year the government identified the next steps to implementation; an executive summary described the Order of Council and the resultant amendments gave the Nursing and Midwifery Council in England the legal powers to regulate nursing associates, therefore allowing them to safeguard the public, should any concerns be raised about their practice.

Registered NMC associates

From January 2019, individuals who can demonstrate the acquisition of knowledge and skills by the achievement of competencies will be regulated by the NMC. Essentially this means that there will be a register of those who hold this qualification and only those registered with the NMC will be able to use the title nursing associate.

The bespoke curriculum will be accredited and monitored and, in September 2018, the NMC will approve the final standards. It is anticipated that the first cohort will qualify in January 2019.

The NMC says it is an England-only role at the moment and there are no plans to use the role in Scotland, Wales and Northern Ireland.   

The NMC is seeking views from nurses in the consultation on the following areas:

The new standards and procedures for nursing associates. These are derived from the standards of proficiency for RNs, designed for all fields of practice and outline what they should ‘know’ and be able to ‘do’.  The structuring under six components allows a direct comparison between the performance expected by the NA and RN.   

The proposal is to apply the same approach to NA, as for nurses and midwives.

The intention for the NA to support, rather to be a substitute for a RN, has led to a lively debate about their scope of practice, not least the extent where they will be involved in the administration of medications – which is yet to be determined. As well as the inherent challenge of integrating a new role in practice, for example the interface with associate practitioners, there is no field-specific element to the educational programme in the plans. This lack of detail invites questions about the introduction of this role in a child health setting and whether the NAs will they have the aptitude, requisite knowledge and skills to care for the nuances of this patient group. 

The nursing associate role could mean profound change for children’s nursing.

You can make comments and determine the future here

Are children stranded in their pyjamas?

In the past year there have been two initiatives aimed at reducing the harm to patients and the organisation caused by delayed discharge. First an NHS Improvement resource, published in 2017, to assist practitioners caring for adults called Reviewing ‘Stranded’ Patients in Hospital – What Are Patients Waiting For’? and a campaign to end PJ Paralysis launched in March – which is due to end at the end of June and linked to the 70th anniversary celebrations of the NHS.

Stranded patients review

Each week patients in hospital for more than seven days are coded, and there is an analysis of the reasons for the delay to discharge and a multi-agency discussion to support the patient journey and inform system change. It is predicted that this will enable the escalation and challenge of the barriers to effective discharge and will provide opportunities to look at the management and care of patients in more creative ways, for example the elimination of unnecessary investigations, exploring further pre-operative preparation, identification of additional resources and interventions to aid rehabilitation, and securing support from other agencies for patients who could receive the appropriate interventions and care outside hospital.

There are 33 codes and some would be applicable for children for example: waiting for return to another acute hospital; waiting for a healthcare package or equipment adaptations; safeguarding concern; condition requiring interventions or immediate care in acute setting, but unfortunately the document expressly states that children are excluded. This could be and an oversight or a lack of recognition that children can also find themselves ‘stranded’ without a plan or the necessary resources to enable them to be looked after in the appropriate setting, usually their home.

It is possible to modify the codes for this patient group and it has been found that there are impediments to timely discharge and the transfer of children from one setting to another. For example, children in critical care because of lack of beds on the general ward, children in hospital on child protection plans, awaiting foster care, unavailability of inpatient child and adolescent mental health facilities. This means that children and young people stay in acute care without the appropriate mental health input as well as delays in the provision of the care and education packages to provide safe care at home for children requiring long-term ventilation, intravenous or nasogastric feeding

Ending pyjama paralysis

Associated with the NHS 70-year celebrations, pyjama paralysis has become a global challenge. It started on 17 April 2018 and will continue until 26 June 2018. Again, the focus is on older adults and the intention to get patients out of bed and dressed, as the evidence suggests that this will enhance well-being and recovery and assist in maintaining usual routines.  

There is a question however. Should something similar, aimed at swifter recovery and avoidance of complications, be developed for use with children and young people? The response of one NHS trust is ‘sit up, get dressed, and keep moving’ and this could certainly be adapted for children and young people.

What are the factors that would maximise mobilisation and well-being in children and young people? It is mused that the focus should be on appropriate recreational and group activities; maintenance of social interactions and normal routines, all key tenants of children’s nursing. 

With both these initiatives, the perspectives of children and young people seem to have been overlooked. I think this means that opportunities may have been missed to share good practice and introduce an initiative in parallel which would be of significance to children and their families.   


About the author

Annette Dearmun is associate lecturer, Oxford Brookes University, nursing consultant Fullflight Ltd, Oxford, and consultant editor Nursing Children and Young People

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