Today is international nurses' day. It always makes me re-examine my own profession and reflect on where nursing is today. In 2000 the Labour Government issued the NHS Plan (DoH 2000). Maximising the potential of the nursing profession to care for patients was the role of the Chief Nursing Officer and she articulated ten key roles for nurses in this plan. These included making direct referrals to therapists (i.e not via a Dr); ordering blood tests and x-rays; admitting and discharging patients (within protocols) and triage. Nothing remarkable here you might think- but it was hugely ambitious. I was a new Director of Nursing at the time, and viewed it as my responsibility to lead the national nursing strategy in my PCT, and so took the opportunity to use my time studying at HSMC to undertake my dissertation on this topic. I was keen to identify enabling and prohibitive factors to help me take this agenda forward- I knew from bitter experience that any advancement was likely to be resisted in all camps (including nursing), so I felt some thinking time, literature reviews and empirical data would help me.

I unearthed a rich seam of wisdom- from nurses describing the constant change in management as disruptive to this agenda, to those hiding their technical ability to protect scarce nursing resources (if you had a certificate to say you could cite a venflon, it was hard to persuade a busy Dr to come to do this medical task to leave you to comfort a bereaved family.) Through the literature review I charted the movement of nursing away from one in which individuals needed to have a certificate signed by a Dr to demonstrate they were competent to cannulate, or catheterise male patients (often these certificates were hospital - sometimes ward specific only, so had to be retaken when the nurse moved,) to the establishment of approved courses for non-medical prescribing, meaning District Nurses no longer had to stand outside the GP’s door to ask them to sign the prescription for the wound dressing they knew would be effective for their patient. Progress indeed.

However implementation was fraught with difficulty - as I suspected - and many urban myths existed then - and I fear do now. For example, referring to a Community Psychiatric Nurse (CPN) was channelled through GPs in times of GP Fundholding in the 1990's - to ensure GPs kept control of referrals and budgetary consequences. GP Fundholding no longer exists but I still meet nurses who say they are "not allowed" to refer direct to CPN's.  Whilst certifying death can only be undertaken legally by Drs, nurses can verify death - which may mean the undertaker would attend the house after a home death prior to a Dr attending, and minimise a distressing wait for some families. However a resistance to accepting this was ever present.

Recently I have been interviewing return to practice nurses who are surprised to find the level of proof needed to demonstrate competencies for tasks they used to undertake ten years ago-male catheterisations were mentioned here. Does this smack of a return to 1970’s "Extended Roles" requirements?

What would patients want? I would want a caring knowledgeable nurse who could sit and comfort me if I was vomiting or nauseous, prescribe and administer the anti-emetic drug AND clear up the vomit at the same time? Intellect and compassion are not mutually exclusive attributes after all.

My reluctant conclusion to all this reflection therefore is that nursing as an autonomous, accountable profession, still has a journey ahead. This negatively impacts on patient care. As one of my community nurse interviewees said in 2003, when she had been energised to fight for the right to catheterise male patients: "When you get to learn the process that a patient has to go through, to get a male catheter in , you know, they are in clinic and it’s a conveyer belt..and you think something must be better. Something could be done somewhere along the line that could be better for them." Who can argue with that?

Department of Health (2000). The NHS Plan. The Stationery Office. London.