Florence Nightingale, the founder of modern nursing, grew up in England and opened the Nightingale Training School at London’s St. Thomas Hospital to teach nursing and midwifery as a formal profession. With such a rich history in nursing, London has been an interesting location for Cleveland Clinic to open its third international hub, following Cleveland Clinic Canada in Toronto in 2006 and Cleveland Clinic Abu Dhabi in 2015.
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Leaders from Cleveland Clinic’s Zielony Nursing Institute are eager to work with nursing professionals at Cleveland Clinic London when its outpatient facility opens in 2020 and the inpatient hospital opens the following year. “What excites me most about the future of nursing at Cleveland Clinic London is the idea of marrying the best practices of nursing care Cleveland Clinic is known for with the best practices of the United Kingdom to deliver exceptional care,” says Deborah C. Small, DNP, RN, NE-BC, Chief Nursing Officer for Cleveland Clinic London.
Small, who served most recently as CNO and Vice President of Patient Care Services at Cleveland Clinic Fairview Hospital, relocated to London in summer 2018 to start shaping the direction of the new state-of-the-art outpatient facility and 185-bed hospital. She is collaborating with a team of healthcare professionals — some in the United States and others in the U.K. — to ensure nurses are ready to hit the ground running when the first patients arrive at Cleveland Clinic London.
A big part of that preparation is identifying similarities in nursing between the U.S. and the U.K., as well as sorting out the differences. “It’s about sitting down, taking what’s best from both places and amalgamating that in a way that will benefit us all,” says Frances Campion-Smith, RN, BSc, an experienced registered nurse and healthcare executive from the U.K., who joined Cleveland Clinic London as Director for Acute and Ambulatory Care. “Fundamentally, I believe all nurses want to provide the best care possible.”
Comparing scope of practice
Both the U.S. and the U.K. have organizations that oversee regulation of nursing practice — boards of nursing in the U.S. and the Nurse & Midwifery Council in the U.K. “Both exist to keep the public safe and ensure the workforce is competent to provide care,” says Small. “But how they interpret that responsibility and establish standards varies.”
The scope of practice in the U.K. is defined not only by training and competence, but also by “the Code” — professional standards of practice and behavior set by the Nurse & Midwifery Council. Nurses can perform nearly every task related to their specialties, from starting an IV to prescribing medication and providing respiratory therapy, as long as they are deemed competent in that task. “If a nurse has been trained to do a skill, has the ability to do it and can prove they have done it safely — then they may do that skill,” says Small.
Nurses prove competency, in part, through an observation that’s part of the registered nurse examination. “In the U.S., to become a registered nurse and prepare for entry-level nursing, candidates must graduate from an accredited nursing program and take a standardized exam called the National Council Licensure Examination (NCLEX),” says Patty Sypek, BSN, RN, Director of Nursing Operations for Cleveland Clinic, who is helping develop Cleveland Clinic London’s nursing operations model. In the U.K., nurses must graduate from accredited nursing programs and pass two exams — one comparable to the NCLEX, the second a videotaped observation called the Objective Structure Clinical Examination (OSCE).
“Licensing in London is based on nursing training, competence and practices that nurses have been safely signed off on to practice independently,” reiterates Small. For example, nurses can pass a nonmedical prescribers course and get prescriptive authority, but only within the specialty in which they practice, such as cardiology or oncology. Advanced nurse practitioners require a master’s degree and a separate license to practice in the U.S. In the U.K. these roles are known by various titles defined by different competencies and qualifications. In 2017, to avoid role confusion, a framework for advanced clinical practice was defined by Health Care England. Nurses can receive the title if they have a master’s or the equivalent degree qualification and are trained in clinical practice, leadership and management, education and research, and demonstrate the core capabilities and competence within a clinical specialty.
“In the U.S., we have acute care nurse practitioners with broadly developed skill sets to care for people with acute and critical conditions across the spectrum,” says Nicolas Houghton, DNP, MBA, RN, ACNP-BC, CFRN, the APN and PA Manager in hospital medicine at Cleveland Clinic. “In some ways, the U.K. is more advanced, having nurses with a depth of knowledge in a very specific area, such as nephrology, and prescribing privileges in just that area.”
Differing titles and uniforms
Many of the titles and responsibilities are the same on both sides of the Atlantic Ocean. For instance, both the U.S. and U.K. have chief nursing officers and clinical nurse specialists. Some titles are different, although the roles remain similar: A nurse manager in a private hospital in the U.K. is called a matron, and an assistant nurse manager is a senior sister.
One of the biggest differences is the banding system. “In the U.K., depending on your years of experience, education, and additional classes and certifications you take, you fall into a band,” says Sypek. “We don’t have these structured distinctions in the U.S.” The National Health Service (NHS) has delineated nine bands, with accompanying pay scales, for all healthcare workers. Within nursing, for instance, a clinical support worker is band 3, a new registered nurse is band 5 and a matron nurse is band 8.
A walk down the halls of a hospital in the U.K. points to another distinction — uniforms. “At Cleveland Clinic, we’ve chosen to put our nurses in white in most settings,” says Small. “In the U.K., the various nursing roles — staff nurse, charge nurse, clinical nurse specialist, matron — can be distinguished by the color of their uniform.” In addition, all healthcare workers in the U.K. are required to wear short sleeves as an infection prevention tactic, often described as “bare below the elbows.”
“The policies in the NHS, such as those related to infection control, are backed by research or evidence-based data that defines why nurses should practice a specific way,” says Small. This is one of many ideologies shared by nursing in the U.K. and the U.S.
Shared care planning and values
“The U.K. places a huge focus on patient safety,” says Kathryn Stuck Boyd, MSN, RN-BC, a Cleveland Clinic education manager. “As we think about onboarding our nurses in the U.K., it will be a little different because all nurses come with a variety of experiences, strengths and opportunities. But the focus on competency and patient safety is the same.”
Care planning for patients is also similar. “Nurses in the U.K. use assessment, problem identification, individualized care planning, implementation and evaluation — the nursing process, as we call it,” says Small. Just as Cleveland Clinic nurses rely on care path guides to treat patients for various conditions and diseases, U.K. nurses use guidelines from the National Institute for Health and Care Excellence (NICE). For example, Cleveland Clinic has a care path for preventing, assessing and treating pressure injuries, and NICE has guidelines for risk assessment, prevention and treatment of pressure ulcers.
In 2016, the NHS adopted the “6Cs”, stressing the importance of care, compassion, competence, communication, courage and commitment. These are ideals echoed by Cleveland Clinic’s emphasis on relationship-based care and putting patients first.
As Cleveland Clinic London ramps up its staffing, with the ultimate goal of employing 1,200 total caregivers, it will recruit nurses from the U.K., the U.S. and around the world who embody the 6Cs. The team will be among the most diverse workforces in the profession — about 52% of bedside nurses in London are international. “It’s a very culturally diverse city and has a very culturally diverse workforce,” says Small, adding that nurses from Cleveland will also have the opportunity to relocate to London.
There may be a few challenges as Cleveland Clinic London strives to recruit a cohesive group of nurses who are respected leaders in healthcare. But the organization is up to the challenge. “As nurses, we will continue to keep the patient at the center of everything we do,” says Campion-Smith. “If we’re all advocating for the patient, it is irrelevant which part of the globe we come from. We will be an integrated team and part of the global family of nursing.”