‘Nurses can’t wait for a place at the table, we need to take it’
In his director role at NHS England, Paul Vaughan is pushing boundaries that hold nurses back
In his director role at NHS England, Paul Vaughan is pushing boundaries that hold nurses back
Paul Vaughan found out ‘by accident’ that men could be nurses. Growing up in the Republic of Ireland, he never encountered a male nurse and had no idea that such a being was possible. He worked for the civil service, then in a building society, and spent four and a half years training to be a priest before nursing even entered his head. ‘When I decided not to go ahead with the priesthood I went back to the building society and thought, “really, this isn’t what I want to do”.
‘By chance, I went to visit a friend in England and met a friend of his who said he was a nurse. I thought, “oh my God, I didn’t know men could be nurses, what a great way to contribute to society”.’
A suitable job for a man
On his return to Ireland he successfully applied to train at Jervis Street Hospital in Dublin, where he was one of the first two men to train as a nurse there. After the hospital closed, he qualified in 1989 from the city’s Beaumont Hospital.
Mr Vaughan points out that, nearly 30 years later, nursing still isn’t widely thought of as a suitable job for a man. In his current role he has a chance to do something about that.
As NHS England director of nursing, transformation, he leads the implementation of two national policy areas, both of which were launched in 2017 by the chief nursing officer for England, Jane Cummings. The ten point action plan for general practice nursing, backed by £15 million in funding, aims to improve recruitment and retention, and support existing general practice nurses.
The perception of nursing and midwifery programme is designed to enhance and modernise the image of the professions, re-ignite pride in them, and convince young people – including young men – of the exciting range of career options available.
‘A third of the general practice nursing workforce can retire tomorrow – they can go at any point. That’s a big challenge’
A sceptic might suggest that this sort of transformation role is detached from front-line realities. Mr Vaughan is wryly amused by the idea that there is anything ‘ivory tower’ about his work with NHS England. The job keeps him on the move, travelling across the country, leading and managing the work that is going on at the four regional boards that are sharing best practice.
Finding a gap in his schedule to do this interview hasn’t been easy. We end up meeting at a branch of Pret a Manger on the concourse of Birmingham New Street Station. It is very loud and freezing. I am slightly concerned throughout that he must be cold, because he got caught in the rain on the way here and (unaware that a photographer would be present) is wearing a T-shirt. Nursing Standard colleagues who have crossed paths with him in his previous role as RCN west midlands regional director have told me, with great enthusiasm, that he is ‘lovely’. I can only agree. He is cheerfully indifferent to the less-than-ideal interview location, pays for the coffees, and apologises for his casual clothes without getting stressed about what the photos will be like.
Finding the balance
We begin with the general practice nursing ten point plan. Just how bad is the state of general practice nursing? ‘It depends what lens you look through,’ he says. ‘If you look through the workforce lens, the Queen’s Nursing Institute report of 2015 found that a third of the workforce can retire tomorrow – they can go at any point. That’s a big challenge.
‘If you look through the lens of the contribution practice nursing makes, it’s fantastic, how advanced practice has become.’
‘People think that when you register you have to work in hospital and then you come into primary care, and that’s not the case – you can come straight into primary care’
The work he is doing with the ten point plan is about ‘finding the balance’ between supporting existing general practice nurses, addressing the problems that can make primary care a tough place to work, such as its relative isolation, and promoting the real, often hidden, satisfactions of the field to potential recruits.
Mr Vaughan wants to make primary care ‘attractive to future generations of nurses so they see it as a first-destination career. At the moment the idea people have is that when you register you have to do work in hospital and then you come into primary care, and that’s not the case, you can come straight into primary care.’
General practice nursing: the action plan
- Recognise and celebrate the existing general practice nurse workforce and their contribution, raise the profile of general practice nursing and healthcare support workers, and promote general practice as a first-destination career
- Extend leadership and educator roles
- Increase the number of preregistration placements in general practice
- Establish inductions and preceptorships
- Improve access to ‘return-to-practice’ programmes
- Embed and deliver a radical upgrade in preventive services
- Support access to educational programmes to deliver national priorities as set out in the Five Year Forward View
- Increase access to clinical academic careers and advanced clinical practice programmes, including nurse working in advanced roles in general practice
- Develop healthcare support worker, apprenticeship and nursing associate career pathways
- Improve retention
Nursing students are unlikely to choose to specialise in a sector that they have never experienced, which is why one of the commitments in the ten point plan is increasing the number of preregistration placements in general practice. ‘We are working alongside colleagues at Health Education England to create more placements so students can get a proper experience of working in primary care, so they understand what it is about. We are getting lots of examples.
‘A practice here in Birmingham has been working with Birmingham City University, and now they have a talent pipeline coming through. They can talent-spot and take on students and develop them.’
Practices working together
According to Ipsos Mori research in 2016, nursing students' perception of general practice nursing is that it is a ‘risky’ choice for newly qualified nurses, requires experience, and is a role in which new nurses become ‘deskilled’.
‘That’s because they don’t understand what primary care is actually about,’ says Mr Vaughan. ‘We’re trying to change that so that people understand what an exciting career pathway it is.’
The isolation that can make retention difficult and put off new recruits is being tackled, he says. ‘We are starting to see practices coming together to work in primary care networks. They have a footprint of 30,000-50,000 patients.
‘Where you have small or single-handed practices, it’s much harder for a nurse to experience working with others and sharing best practice, but that’s changing. And some of the things we are doing are making a difference.
‘We are working with NHS Digital to enable practice nurses to have face-to-face supervision over the internet and peer support. That will be helpful – we are just developing it now.’
An achievable target
The ten point plan is rooted in the General Practice Forward View, published in 2016, which pledged to expand the primary care workforce. Mr Vaughan has a target to increase the number of general practice nurses in England by 1,000 by the end of 2020 – up from 15,398 whole time equivalents in September 2015.
‘Some people might think that is a low target, but the challenge is that a third of the workforce can retire at any time. I would say it’s a target that is achievable, that will help to make a difference. And to be honest, it is not just about targets, the other part is how do we develop the nurse leaders of the future.’
‘The opportunities are there – nurses have to see this and grasp it’
He emphasises that he intends the work he is doing with the ten point plan to be sustainable, to carry on beyond 2020. Rather than reinventing the wheel, he is drawing on existing organisations to help deliver the plan’s aims; for example, he will be working with the NHS Leadership Academy to develop a leadership course for practice nurses.
There is innovation at local level that should have a lasting benefit, he points out, giving the example of a group of general practices that have come together in Nottingham and now have a ‘clear career framework’ for their nurses.
I ask him how he would sell practice nursing to an ambitious, recently qualified nurse who doesn’t think it is for them. ‘[I would say] they can end up an advanced clinical practitioner with their own caseload. And if you really wanted to push it, there’s a practice in London, called Cuckoo Lane, that is run by nurses who employ GPs. The opportunities are there – nurses have to see this and grasp it.’
Holding the profession back
The workforce pressures that make primary care a demanding place to work are also opening up opportunities to expand roles, work in different ways and ‘challenge the status quo’, he suggests.
But he adds that a ‘cultural change’ is required to give more nurses the confidence and skills to take these opportunities. To assist with this aim, he is working with the RCN and the Queen’s Nursing Institute to develop a three-day course to help nurses develop political leadership skills and the ability to build a business case.
‘There’s a horrible expression – “nurses eat their own”. We are very hard on our own profession’
Inaccurate and outdated perceptions of nursing as female, caring and unskilled are holding the profession back, along with a tendency to silence or overlook nurse leaders, he says. ‘And some of it is internalised. There’s a horrible expression “nurses eat their own” – we are very hard on our own profession.’
I wonder, though, how much the image of nursing is really to blame for recruitment and retention problems. Isn’t it the reality of nursing – the excessive workloads and the inadequate pay – that puts people off?
‘Of course it could be paid better,’ says Mr Vaughan. ‘Some nurses have really struggled and had to go to food banks.’ But the idea that nursing is low-paid drudgery is not the reality for most nurses, he says: ‘Let’s have a balanced view.’
Invest in women as leaders
He also hopes for ‘balance’ in the efforts to encourage more men into the professions – an area that is a particular focus in the perceptions of nursing and midwifery programme. Mr Vaughan points out that only 10% of nurses are men – a statistic that has barely budged in decades. An important part of nurse ambassadors’ work in schools (5,000 should be recruited by the end of next year) is promoting nursing’s diversity and presenting it as a rewarding career option for young men and women equally.
But it concerns him that, though few men enter the profession, they appear to be disproportionately represented in more senior positions. He mentions research by Alison Leary that showed male nurses’ career progress is quicker than their female peers’. ‘I would hate to see more men coming in and almost taking over the profession.’
He works closely with the global Nursing Now campaign, which shares many of the aims of the perceptions programme, and agrees wholeheartedly with its leader Barbara Stilwell that raising the status of nursing goes hand in hand with ‘investing in women as leaders’.
Mr Vaughan also shares Dr Stilwell’s impatience with the exclusion of nurses leaders from policy-shaping and decision-making. ‘Nurses have struggled against voices that are louder than ours,’ he says. ‘We need to find our place at the table. Actually, we don’t need to find it – just take it.’
‘Don’t be anxious about expanded roles for HCAs’
In his role as director of nursing, transformation, Paul Vaughan is working to support and raise the profile of healthcare support workers, as well as nurses. As a former HCA advisor at the RCN, it is something he is well-equipped to do.
Workforce pressures, and the rising numbers of people with complex conditions being managed in the community, mean that support workers are an increasingly important part of healthcare teams, driving the trend for HCAs to take on more responsibilities and the development of new roles such as nursing associates.
Mr Vaughan says he ‘absolutely gets’ why some nurses are concerned by these developments but he suggests that the risks are exaggerated. Nurses do not need to be anxious about being held accountable for HCAs’ practice: ‘HCAs are accountable for their own practice.’
The ‘context’ in which someone is working – their education, training and support – is what matters most.
Historically, he points out, there has always been resistance when one healthcare profession expands its range of responsibilities. ‘In the 1950s GPs were arguing should nurses be taking blood pressure.’
However, he would like to see more research into the impact different healthcare staff roles have on care. ‘We get into pitting one role against the other. We need to stop and think what is best for patient outcomes.’
Thelma Agnew is commissioning editor, Nursing Standard
Find out more