Nursing in the United Kingdom

History and organisation of nursing in UK

Nursing in the United Kingdom is the largest health care profession in the country. It has evolved from assisting doctors to encompass a variety of professional roles. Over 700,000 nurses practice, working in settings such as hospitals, health centres, nursing homes, hospices, communities, military, prisons, and academia. Most are employed by the National Health Service (NHS). Nurses work across all demographics and care areas: adults, children, mental health, and learning disability. Nurses work in specialties across medicine, surgery, theatres, and investigative sciences such as imaging. Nurses also work in sub specialities such as respiratory, diabetes, cancer, neurology, infectious diseases, liver, research, cardiac, women's health, sexual health, emergency and acute care, gastrointestinal, infection prevention and control, neuroscience, ophthalmic, pain and palliative, and rheumatology. Nurses often work in multi disciplinary teams, but increasingly work independently. To practise, all nurses and nursing associates must be registered with the Nursing and Midwifery Council (NMC). Dental Nurses, Nursery nurses and Veterinary nurses are not regulated by the Nursing and Midwifery Council and follow different training, qualifications and career pathways.

Florence Nightingale is regarded as the founder of the modern nursing profession. There was no real hospital training school for nurses until one was established in Kaiserwerth, Germany, in 1846. There, Nightingale received the training that later enabled her to establish, at St Thomas' Hospital in London, the first school designed primarily to train nurses rather than to provide nursing service for the hospital. In the Crimean War against Russia, Nightingale was appointed to oversee the introduction of female nurses into military hospitals in Turkey. In November 1854, Nightingale arrived at the barrack hospital near Constantinople, with a party of 38 nurses. Initially the doctors did not want the nurses there and did not ask for their help, but within ten days fresh casualties arrived from the Battle of Inkermann and the nurses were fully stretched. When Nightingale returned from the Crimean War in August 1856, she hid herself away from the public's attention. For her contribution to Army statistics and comparative hospital statistics in 1860, Nightingale became the first woman to be elected a Fellow of the Statistical Society.

To practise lawfully as a registered nurse, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council. The title "registered nurse" can only be granted to those holding such registration; this protected title is laid down in the Nurses, Midwives and Health Visitors Act 1979.

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Revalidation is a requirement for all NMC registered members to revalidate every three years in order to ensure their registration can be renewed. Revalidation was introduced in April 2016. Revalidation replaces Prep.

A new NMC Code was introduced in March 2015, this replaced the 2008 NMC code. The NMC code presents the professional standards that nurses and midwives must uphold in order to be registered to practise in the UK.

As of 2024 over 200 organisations are related to nursing as regulated by the Nursing and Midwifery Council, not including nursing departments in universities or in the NHS. These include professional bodies, nursing specialties, charities, and migrant support networks. Four unions represent nurses, the Royal College of Nursing (RCN) Unite the Union, UNISON and GMB. The RCN has a dual role as both a Royal College and a trade union with over 500,000 members: nurses, midwives, students and healthcare assistants. They denote accepted values that are to center compassion within nursing practice.

More than a third of nurses in training fail to complete the training course, as has been the case for more than a century. In January 2016 the RCN stated that more than 10,000 nursing posts went unfilled in 2015. This represented a 3% increase year on year from 11% in 2013, 14% in 2014 and 17% in 2015 of all London nursing positions and 10% as an average nationwide. From 2016/17 registered nursing numbers fell 3% along with a 23% rise in de registrations. 17,000 nurse permanently unfilled vacancies were observed. In 2019 clinical pharmacology, spinal injuries, paediatric surgery, neurosurgery and neurology were the worst affected specialities. They had an average of less than 90% of their planned nurse staffing levels. School nurses were also in short supply. Hospitals in England are required to report the number of nurses employed on each ward each month. After this was established, ward nurses increased by 13,500, although the numbers of community nurses declined.

A 2015 Organisation for Economic Co operation and Development survey reported that 21.7% of NHS nurses were born abroad, compared with 26.9% in Ireland, 9.8% in Italy, 14% in Germany and 5.9% in France. The UK was also the highest exporter of nurses, with more than 50,000 working in other OECD nations. The Migration Advisory Committee criticised the Department of Health, Health Education England, and NHS trusts for not recognising obvious warning signs and "reluctantly" agreed to keep nursing on the list of shortage occupations. An English language test is compulsory for all foreign nurses, even if they are from English speaking countries. The process of registering as a nurse can take migrants up to a year and cost more than £3,000.

Nursing is subject to regular health campaigns. Scale ranges from nationwide to ward based. Sign up to Safety – National campaign to ensure staff coordinate their efforts and ideas around ensuring and enhancing safety. NHS Change Day – Annual 1 day campaign to get staff contributing ideas to improve the NHS. Antibiotic Guardian – Gathers pledges to slow antibiotic resistance. European Antibiotic Awareness Day (EAAD) is held on 18 November.

Obesity and smoking have long been an issue in nurse health. The effect of nursing on nurses' physical and mental health has been a subject of research papers where the effect of shift work and working with chemicals such as in chemotherapy has been explored. In 2016 the government announced £600 million was to be spent on "tackling obesity and improving the well being of its 1.3 million staff".

Non registered staff typically working in direct patient care (often on wards), performing tasks such as personal care (washing and dressing), social care (feeding, communicating to patients and generally spending time with them) and more specialised tasks such as recording observations or vital signs (such as temperature, pulse and respiratory rate, or TPR) or measuring and assessing blood pressure, urinalysis, blood glucose monitoring, pressure sores (see Waterlow score) and carrying out procedures such as catheterisation and cannulation). Some unregistered staff work as phlebotomists, ECG technicians, and smoking cessation therapists beyond the hospital. Others expand their ward based role to include such tasks. Few areas of nursing cannot be legally performed by suitably trained non registered staff. They legally must be supervised (either directly or indirectly) by a registered nurse. In 2019 it was reported that mental health support workers were increasingly covering shifts because of the shortage of mental health nurses. Non registered staff have various job titles such as "clinical support worker", "care assistant", "nursing assistant" and "healthcare assistant" (HCA). Typically they are on pay band 2 or 3, although senior healthcare assistants can be on band 4.

more informationTraditionally, on completion of training, nurses would be employed on a hospital ward, and work as staff nurses. The ward hierarchy consists of:
Nursing Associate – first grade of qualified nursing staff. Ben Gummer MP introduced the role of Nursing Associates, who would work alongside healthcare support workers and qualified nurses focusing on patient care. The Nursing and Midwifery Council announced in 2016 that it would professionally regulate the role (qualification code NAR). Nursing associates train in the four branches of nursing, following a FdSc apprenticeship programme. They deliver care in a wide range of settings; primary, secondary, community and social care. Their training will provide them with both clinical knowledge and skills. Nursing associates are able to administer some medicines without supervision. Under Agenda for Change they attract a Band 4 salary. Staff Nurses/General Nurse/Staffer of Nursing – the second grade of qualified nursing staff. These nurses are responsible for a set group of patients (e. g. administering medications, assessing, venepuncture, wound care and other clinical duties). Under Agenda for Change they attract a Band 5 salary but sometimes a Band 6 salary. Senior staff nurses/Staffer Manager – these nurses carry out many of the same tasks, but are more senior and more experienced than the staff nurses. Many NHS Trusts do not have Senior Staff Nurses as the role is seen to be superfluous. Junior/Deputy Ward Sister; Charge Nurse; Deputy Ward Manager – responsible for the day to day running of the ward, and may also carry specific responsibilities for the overall running of the ward (e. g. rostering) in accordance with the wishes of the ward manager. These nurses are assigned band 6. In some NHS Trusts, these will be known as Sisters/Charge Nurses. Ward Manager/Ward Sister/Charge Nurse/Nurse Manager/Clinical Ward Nurse Lead – responsible for running a ward or unit, and usually has budgetary control. They will employ staff, and be responsible for all the local management (e. g. rostering, approving pay claims, purchasing equipment, delegation duties or tasks). These nurses are band 7. They are generally Senior Staff Nurses or Charge Nurses as well. Senior Ward Sister; Senior Charge Nurse; Senior Ward Manager – if there is a need to employ several nurses at a ward manager level (e. g. in A&E), then one of them often acts as the senior ward manager. These nurses attract a banding anywhere between 7 and 8c. The status in the hierarchy of specialist nurses is variable, as each specialist nurse has a somewhat different role. They are generally experienced nurses and are employed at least on band 6.

Many nurses who have substantial experience in clinical settings join the ranks of NHS management. This used to be seen as a natural career progression for ward managers positions, however with the advent of specialist nursing roles, this has become a less attractive option. Modern Matrons/Nursing Director/Nurse Matron – developed in response to some patients' perception of the detachment of nursing from its vocational history, the modern matron is responsible for overseeing all nursing within a department or directorate. Modern matrons are employed on bands 8a c. Modern matrons were poorly received by nursing staff and their imposition was not called for by any professional group within the health service. Clinical Nurse Manager/Nurse Lead – A nurse who is responsible for an entire directorate/department (i. e. Surgical, Medical Diagnostic & Imaging etc.) or at least more than one ward, is often referred to as a clinical nurse manager. Depending on both the inclination of the NHS Trust and themselves, they may be more or less involved in actual clinical nursing or management on a clinical level. These nurses attract band 8a (or occasionally 8b/8c) under Agenda for Change.

Training is not mandatory for most people undertaking non registered staff roles such as Healthcare Assistant. But the majority of NHS employers use "in house" training for such staff, including induction programmes and ongoing education to achieve a recognised qualification. Some collaborate with local education colleges for theoretical input, and may award a recognised qualification. Some NHS employers ask for some type of health or social care qualification for recruits: for example, an SVQ/NVQ or HNC/HND under qualification names including health care, social care, and health & social care. Many trusts and health boards create opportunities for these staff members to become qualified nurses. This is termed secondment (whereby the trust/health board continues to pay them for the duration of their training, and often guarantees employment following successful completion).

Registered nurses must complete a nursing degree programme recognised by the Nursing and Midwifery Council from an approved provider (universities offer these courses).

Earlier, State Enrolled Nurses (SENs) were trained in hospitals. Nursing education was closely linked to the hospital where nurses were placed and often lived. This has been replaced by degree requirements, although nurses who hold a nursing diploma or a certificate are able to continue to practice.

All new qualifying nurses must hold a degree.

Midwifery training is similar in length and structure, but is sufficiently different that it is not considered a branch of nursing. 18 month programmes allow nurses already qualified in the adult branch to register as both a nurse and a midwife. Two year courses allow graduates of other disciplines to train as nurses. This is achieved by more intense study and a shortening of the common foundation programme.

Student nurses in England and Wales receive no bursary from the government to support them during their nurse training. Diploma students in England receive a universal bursary of £6,000 – £8,000 per year (with additional allowances for students with dependent children), while degree students may qualify for a means tested bursary (often a considerably smaller amount). Degree students are, however, eligible for a student loan, unlike diploma students. In Scotland and Wales, all student nurses (regardless of which course they are undertaking) receive a bursary in line with the English diploma course. All student nurses in Wales study, initially, for a degree, but may choose to remain at Level 2, thereby achieving a diploma rather than a degree. It was announced in the Chancellor's Spending Review of November 2015 that from 2017 the NHS bursary would be removed for future nursing, midwifery and allied health professionals in England. Welsh and Scottish students remain unaffected.

Graduate courses require two years. They often require prior learning and relevant experience, often termed Accreditation of Prior and Experiential Learning (APEL). Registered nurses must update their skills and knowledge at the rate of at least 35 hours every three years, as part of its post registration education and practice (PREP) requirements. Nurses can add certifications in areas such as cannulation, venepuncture, intravenous drug therapy, and male catheterisation are common among many others, such as Advanced Life Support. Many nurses who qualified with a diploma choose to upgrade their qualification to a degree via additional study. Many nurses prefer this to completing a degree initially, as nurses can study in a specialist field as a part of the degree. Financially, in England, it was more lucrative, as diploma students get the full bursary during their initial training, and employers often pay for the degree course as well as the nurse's salary. To become specialist nurses (such as nurse consultants, nurse practitioners, etc.) or nurse educators, some nurses undertake further training above bachelor's degree level. Master's degrees exist in various healthcare related topics, and some nurses choose to study for PhDs or other higher academic awards. District nurses and health visitors are also considered specialist nurses, and to become such they must undertake specialist training (often in the form of a top up degree (see above) or post graduate diploma). All newly qualifying district nurses and health visitors prescribe from the Nurse Prescribers' Formulary, a list of medications and dressings. Many of these (and other) nurses undertake training in independent and supplementary prescribing, which allows them to prescribe almost any drug in the British National Formulary. This has been the subject of debate in medical and nursing circles. As of 2012 over 25,000 Nurse Prescribers had been qualified. They may now prescribe exactly the same medicines as Doctors.

The Nursing and Midwifery Council has a specific process for inducting Registered Nurses trained outside UK / EU. Prior to October 2016 an outside UK RN would have to undergo an Overseas Nursing Program known in short as the ONP. The ONP had to be undertaken by the candidate after NMC makes necessary checks and issue the candidate with a decision letter stating that the person may join a university to undertake the ONP. However, due to shortage of nurses and NMC striving for gold standards in nursing they have now updated their new process to a two part test of competence. The first part is called CBT and Part 2 (objective structured clinical examination (OSCE). The process includes an English language test which has been criticised as discriminatory because it demands an academic standard of reading and writing that many native English speakers could not meet. This means at least 3,000 qualified nurses from India who are already in the UK are not on the register, and so are paid less for similar work. For International Students Who want to be a nurse at free, there are some universities and online learning platform which helps to learn nursing absolutely free. OpenLearn by The Open University: The Open University offers free online courses related to nursing and healthcare. While these won't lead to a nursing degree or diploma, they can provide valuable knowledge and skills. NHS Learning Hub: The National Health Service (NHS) in the UK offers various free online courses and resources for healthcare professionals. These can help you enhance your skills and knowledge in the field. Apprenticeships: The UK government offers nursing apprenticeships, which allow you to earn while you learn. You'll work as a healthcare assistant while studying for a nursing degree. Apprenticeships are typically paid, and the cost of your education is covered by your employer. Bursaries and Scholarships: While not entirely free, you can explore nursing bursaries and scholarships to help cover the costs of your nursing education. These are often offered by universities and healthcare institutions. Volunteer Work: Consider volunteering in healthcare settings to gain practical experience. While this doesn't provide a formal qualification, it can be a valuable stepping stone towards a nursing career. Online Learning Platforms: Websites like Coursera, edX, and FutureLearn offer a wide range of healthcare related courses. While most of these courses are not entirely free, they often provide financial aid or scholarships to eligible learners.

In the November 2015 spending review, George Osborne stated that he would remove the NHS Student Bursary from 2017. This prompted several Nursing students to organise a political demonstration with other healthcare students at King's College London outside the Department of Health in December 2015 which was attended by several hundred supporters. Kat Webb also decided to start a petition on the government's e petition site, which received over 150,000 signatures

The student bursary debate has been raised in parliament at Prime Minister's Questions, and is the subject of the 'Early Day Motion (EDM) 1081 – THE NHS BURSARY', which was sponsored by Wes Streeting MP.

In December 2015, several hundred people protested the recent removal of the NHS student bursary as announced in the November 2015 spending review. The protest was attended by Shadow Health Minister Heidi Alexander MP, Wes Streeting MP, Natalie Bennett, Sian Berry, representatives of UNISON, Unite the Union and Royal College of Midwives. The hashtag #bursaryorbust was the top trending Twitter.

In February, NHS students walked out of placement in solidarity with the Junior Doctors strike.

Whilst nurses are not known for striking or taking industrial action, there have been many occasions when nurses have gone on strike, often over pay and conditions. The Royal College of Nursing had a no strike policy for 79 years until 1995, when the policy was dropped due to pay disputes at the time. In 1939 rallied together as it was reported in the Daily Mirror that many nurses were leaving the role and were enduring financial hardship. In 1948, following the establishment of the NHS, nurses realised that their pay had decreased, which led to strike action. In 1962 many nurses marched to Trafalgar Square as part of pay disputes under the banner of "Empty Purses Mean Less Nurses". In 1970 many nurses protested at pay and conditions. In 1973 it was reported that over 7,000 nurses marched in Sheffield. In 1974 several protests took place by nurses over pay and conditions. In 1976 many nurses took part in a low pay strike. In 1982 there was a National Health Service day of action with 120,000 workers marching at various locations around the country including many nurses. In 1988 Nurses went on strike in 1988 over pay and proposed changes to the NHS. In 2011 Unison nurses protested and marched over pay. In 2014 Midwives and some nurses went on strike over pay. In 2015 nursing students protested outside the Department of Health over the removal of the NHS student bursary. In 2016 nursing students marched to Downing Street to protest over the removal of the NHS student bursary. The protest was attended by Shadow Health Minister Heidi Alexander MP, Wes Streeting MP, Representatives of UNISON, Unite the Union and Royal College of Midwives. as of 2015 Northern Ireland have yet to announce their pay rates for 2015–16. In 2016 the government announced that nurses would receive a 1% pay rise which would take effect from 1 April 2016. The RCN Chief Executive Janet Davies stated that "The fact remains that pay awards for NHS staff have been severely constrained since 2010".

There have recently been complaints of Agenda for Change being a sexist system, as nurses, who are mostly female, claim that, as a profession, they are under valued using this system. In 2015 the RCN stated that Nurses had suffered a drop in pay equivalent to 9.8% in real terms since 2008.

In 2015 the government announced that there would be a gradual introduction of pay caps for agency nurses working under NHS England. Starting in November 2015, further caps came in February 2016 with the final cuts introduced in April 2016. The aim of the cap was to save £1bn over three years. The implications of the pay cap means that trusts will not be able to pay staff who work for an agency including doctors and nurses, more than 55% more for a shift than a permanent member of staff. Jeremy Hunt in his capacity as the Health Secretary said it would stop agencies "ripping off the NHS". In October 2016, Western Circle published research, claiming that the sector of NHS Nurses are heavily dependent on payday loan. According to the research, the number of nurses using payday loans has doubled in 3 years, since 2013. This research brought the matter of the low wages nurses received in the UK to the attention of media outlets. The claims were that nurses' salaries were frozen for more than 6 years and in some cases, resulted in financial distress, clearly as wages have not kept pace with the cost of living increases in this time. The lack of pay increases for, particularly nurses within the NHS continues to be an important topic of public discussion in the UK.

The NHS pension is the main pension offered to NHS staff. There have been three distinct changes made to the NHS pension. The type of pension someone is enrolled onto is referred to by the year that it was introduced or changed 1995, 2008 & 2015.