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Principles of Nursing Practice: development and implementation

Manley K et al (2011) Principles of Nursing Practice: development and implementation. Nursing Standard. 25, 27, 35-37. Date of acceptance: January 20 2011.

Summary
This article, the first in a nine-part series, describes the development of the recent Principles of Nursing Practice initiative. It provides an overview of the Principles, the objectives that informed them and the challenges experienced in their development.

Authors
Kim Manley, formerly lead, Quality, Standards and Innovation Unit; Chris Watts, project manager, Evidence into Practice Team; Geraldine Cunningham, head of the Learning and Development Institute; Janet Davies, director of nursing and service delivery; Royal College of Nursing, London. Email: chris.watts@rcn.org.uk

(RCN 2009b); a way of evaluating or measuring that standards have been achieved; and sufficient staffing and appropriate skill mix (RCN 2010a). The Principles of Nursing Practice provide an overarching framework for achieving quality nursing care and clarifying nursings contribution to improving healthcare outcomes and patient experiences. In addition to being a useful resource enabling nurses to demonstrate, measure and evaluate nursing practice, the Principles assist patients in evaluating whether or not the care and treatment delivered by nurses meets their expectations. They are: 4Principle A: nurses and nursing staff treat everyone in their care with dignity and humanity they understand their individual needs, show compassion and sensitivity, and provide care in a way that respects all people equally. 4Principle B: nurses and nursing staff take responsibility for the care they provide and answer for their own judgements and actions they carry out these actions in a way that is agreed with their patients, and the families and carers of their patients, and in a way that meets the requirements of their professional bodies and the law. 4Principle C: nurses and nursing staff manage risk, are vigilant about risk, and help to keep everyone safe in the places they receive health care. 4Principle D: nurses and nursing staff provide and promote care that puts people at the centre, involves patients, service users, their families and their carers in decisions and helps them make informed choices about their treatment and care. 4Principle E: nurses and nursing staff are at the heart of the communication process they assess, record and report on treatment and march 9 :: vol 25 no 27 :: 2011 35

Keywords
Health and quality of life, nursing care, Principles of Nursing Practice, quality assurance, Royal College of Nursing These keywords are based on subject headings from the British Nursing Index. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords. THIS ARTICLE IS the first of a nine-week series on the Principles of Nursing Practice developed by the Royal College of Nursing (RCN). The Principles were developed by the RCN in collaboration with patient and service user organisations, the Department of Health (DH) (England), the Nursing and Midwifery Council (NMC), nurses and other health professionals. It provides an overview of the development and implementation of the Principles. Subsequent articles discuss the rationale for each Principle and explore existing and potential means of implementation. Examples of quality measurements and good practice are provided. There are four prerequisites to quality nursing care: standards that clearly articulate expectations of quality nursing care (RCN 2009a); the supervisory role of team and clinical leaders NURSING STANDARD

art & science principles series: 1

care, handle information sensitively and confidentially, deal with complaints effectively, and are conscientious in reporting the things they are concerned about. 4Principle F: nurses and nursing staff have up-to-date knowledge and skills, and use these with intelligence, insight and understanding in line with the needs of each individual in their care. 4Principle G: nurses and nursing staff work closely with their own team and with other professionals, making sure patients care and treatment is co-ordinated, is of a high standard and has the best possible outcome. 4Principle H: nurses and nursing staff lead by example, develop themselves and other staff, and influence the way care is given in a manner that is open and responds to individual needs. Nursing has been examined from a range of different viewpoints and perspectives over the past 40 years. Studies have provided academic frameworks in which nursing as a discipline has sought to define, explain and research its purpose, its ways of working and its outcomes (RCN 2003), as well as prepare nurses to become an integral part of the multidisciplinary healthcare team. The contemporary focus for nurses, as for other members of the healthcare team, is increasingly on healthcare outcomes and their measurement, rather than the processes through which outcomes are achieved. In its definition of nursing, the RCN (2003) makes explicit the outcomes of nursing in relation to health, specifically health maintenance, improvement, recovery, coping and achievement of the best possible quality of life for each person. The RCN (2009a) suggests that the way nursing achieves outcomes is primarily threefold: 4By providing individualised patient care. Today, this is perceived not only as an outcome in its own right, but also as one bound up with the achievement of health outcomes. 4By providing safe and effective care, based on blending different types of evidence to support decision making aimed at achieving health-related outcomes and quality of life, as judged by the person. 4By developing the context and culture that enables person-centred, safe and effective care to be sustained by all members of the healthcare team. 36 march 9 :: vol 25 no 27 :: 2011

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In this environment, the Principles of Nursing Practice have been developed as a set of overarching statements that describe what can be expected of nursing. They cover quality nursing care in all settings, regardless of whether the immediate provider is a registered nurse, healthcare assistant, assistant practitioner or nursing student. An important attribute of the Principles is that they are clearly understandable to everyone, whether a professional, patient, carer or member of the public. The Principles have been awarded the Crystal Mark by the Plain English Campaign. Another important objective in developing the Principles was that they reflect best practice in partnership and multidisciplinary working and in representing genuine public and patient involvement and engagement. Throughout the development process, challenges have been raised regarding the efficacy and necessity of the Principles: first, that they are obvious expectations of nursing that should be an innate part of nursing practice and should not need to be spelt out; second, queries about the difference they will make; and third, that they duplicate other UK-wide standards.

Impetus for change

It is necessary to examine the factors that led to the development of the Principles to address these challenges. They arise in a political context that emphasises quality improvement, with a specific emphasis on health outcomes, effective use of resources and improving productivity through prevention and innovation (DH 2009, Scottish Government 2010, Welsh Assembly Government 2010, Belfast Health and Social Care Trust et al 2011). There has also been an independent inquiry into the care provided by one NHS foundation trust (The Mid Staffordshire NHS Foundation Trust Inquiry 2010), as well as two potentially damning reports from the Patients Association (2009, 2010). The planned reform of the NHS in England includes an objective for shared decision making to become the norm (DH 2010). The RCN (2010b) continues to consult and respond to emerging healthcare reforms, and the implications are that the contribution and role of nursing will continue to be scrutinised. Further development work being undertaken by the RCN on the Principles aims to support nurses in proactively measuring and demonstrating the quality of nursing practice in response to patient expectations and patient choice. Achievable and sustainable quality practice requires effective workplace cultures in which everyone can flourish and where every member of the healthcare team is enabled to provide care that is person centred, safe and effective. Factors NURSING STANDARD

that enable such cultures include ensuring clarity of professional roles, with clearly defined expectations, and transformational clinical leadership (Manley et al 2007). Principles and standards are required to make explicit the behaviours expected of each member of the healthcare team, thereby reducing any misunderstandings based on unchallenged or unspoken assumptions. One challenge faced in the development of the Principles was the question: What difference will they make? A number of factors have been identified as vital in the effective implementation of best practice. These are the context in which implementation takes place, which includes effectiveness of leadership; the requirement for skilled facilitators to support implementation; and the quality of evidence (Kitson et al 2008). Practitioners should be supported to become aware of best practice through a process of critical review and self-reflection, rather than continued reliance on practice that is ritualised, accepted uncritically, taken for granted or viewed as common sense. Once there is an awareness of what constitutes best practice, it is the mechanisms of support, feedback, evaluation and clinical supervision that enable the nursing team to become aware of, and motivated to, change attitudes and behaviours. The RCN has produced an online resource to accompany the Principles (www.rcn.org.uk/ nursingprinciples). It includes a detailed

illustration of how the Principles, in focusing on the entire nursing team regardless of setting or who provides care, are aligned between the standards expected of registered nurses and standards expected of the multidisciplinary team. The online resource includes stories illustrating how the Principles are applied in real situations, together with a comprehensive explanation of how they relate to other publications and initiatives addressing the quality of nursing care, including The Code (NMC 2008). The resource also provides a set of example measures that might be used to determine how effective each Principle is in a given context. Work on developing outcome measures for nursing is in its early stages (Griffiths et al 2008), but the online resource explains how nurses are encouraged to contribute by submitting measurements to the RCN for endorsement.

Conclusion
This article has explored the development of the Principles of Nursing Practice, and makes clear the contemporary quality improvement context that makes them necessary and relevant. While the Principles articulate what can be expected from quality nursing care, key to their realisation is the implementation and measurement of each one. This series that will examine each of the \eight Principles in more detail and discuss their rationale and use NS

References
Belfast Health and Social Care Trust, University of Ulster, South Eastern Health and Social Care Trust (2011) Key Performance Indicators for Nursing and Midwifery Care. In press. Department of Health (2009) NHS 2010-2015: From Good to Great. Preventative, People-Centred, Productive. http://tiny.cc/ DH_109876 (Last accessed: February 17 2011.) Department of Health (2010) Equity and Excellence: Liberating the NHS. www.dh.gov.uk/en/ Publicationsandstatistics/ Publications/PublicationsPolicyAnd Guidance/DH_117353 (Last accessed: February 17 2011.) Griffiths P, Jones S, Maben J, Murrrells T (2008) State of The Art Metrics for Nursing: A Rapid Appraisal. http://tiny.cc/metricsfinal (Last accessed: February 17 2011.) Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A (2008) Evaluating the successful implementation of evidence into practice using the PARIHS framework: theoretical and practical challenges. Implementation Science. 3, 1. Manley K, Sanders K, Cardiff S, Garbarino L, Davren M (2007) Effective Workplace Culture: Concept Analysis. RCN, London. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Patients Association (2009) Patients Not Numbers, People Not Statistics. http://tiny.cc/ patientsnotnumbers (Last accessed: February 17 2011.) Patients Association (2010) Listen to Patients, Speak Up for Change. http://tiny.cc/listento patients (Last accessed: February 17 2011.) Royal College of Nursing (2003) Defining Nursing. RCN, London. Royal College of Nursing (2009a) Measuring for Quality in Health and Social Care. RCN position statement. RCN, London. Royal College of Nursing (2009b) Breaking Down Barriers: Driving Up Standards. RCN, London. Royal College of Nursing (2010a) Guidance on Safe Nurse Staffing Levels in the UK. RCN, London. Royal College of Nursing (2010b) Response to the NHS White Paper Equity and Excellence: Liberating the NHS. www.rcn.org.uk/__data/ assets/pdf_file/0016/341404/ RCN_response_to_NHS_white_ paper41.pdf (Last accessed: February 17 2011.) Scottish Government (2010) NHS Scotland Quality Strategy: Putting People At The Heart Of Our NHS. www.scotland. gov.uk/Publications/2010/05/ 10102307/0 (Last accessed: February 17 2011.) The Mid Staffordshire NHS Foundation Trust Inquiry (2010) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005 March 2009. http://tiny.cc/Midstaffs (Last accessed: February 3 2011.) Welsh Assembly Government (2010) Doing Well, Doing Better: Standards for Health Services in Wales. http://tiny.cc/doingwell (Last accessed: February 17 2011.)

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