Rachel Munton had no intention of going into nursing. "I applied to study drama at university, but in my gap year I did some work experience as a healthcare assistant and that quickly led to a passion for mental health," she explains.
Today, Munton is executive director of nursing and allied health professionals at Nottingham Healthcare NHS Trust – a board level role which involves both strategically leading over 4,000 staff and meeting key corporate objectives. "Despite me never having had a master plan – in fact, in my early years as a nurse, I had no plans whatsoever to move up the ladder – I've found that nursing has a way of pushing your potential to the maximum," she says. "There's part of me that still can't believe I report directly to the chief executive of one of the largest mental health trusts in Europe."
Continuing Professional Development (CPD) is a growing focus within nursing, not least because there is a demonstrable link between its application to practice and enhanced service delivery and patient care. In addition, NHS initiatives such as Improving Working Lives have shown that staff who are given training and development opportunities are likely to be more motivated and satisfied at work, leading to increased staff retention.
Also helping today's nurses progress is the growing number of senior nursing roles available. Those interested in clinical management may become a modern matron, clinical manager, lead nurse, head nurse, assistant director of nursing or director of nursing, while others may prefer more hands-on senior roles such as ward sister. For those wishing to specialise – for example in incontinence, asthma or diabetes – there are opportunities to become a clinical nurse specialist, nurse practitioner, advanced nurse practitioner, consultant nurse or nurse adviser. Meanwhile, senior research and education roles include research manager, lead research nurse, practice educator or lecturer. Out in the community, you may wish to become a community matron or team leader or perhaps your dreams are to help head up a trust, in which case you can work towards roles such as head of commissioning or head of clinical governance.
Munton believes that in addition to taking advantage of training opportunities offered to you during annual appraisals – and in some cases actively seeking them out and persuading your trust to fund you – the nurses most likely to succeed are those who make themselves visible. "It's having the nerve to speak out when you don't feel care is patient-centred enough. Sometimes you pay for it, but if you're truly and uncompromisingly engaged in patient care and services, it won't be missed," she says.
She attributes her own progression to networking too. "If I've known someone and worked with them effectively, I've kept them on my contact list. I've also always ensured I've had a mentor or coach within the NHS – either informally or formally. Then there's the need to take risks. There's something about being able to work outside your comfort zone that goes far in nursing. I once took up an unfamiliar nursing role in Leicester with this in mind."
Mandie Sunderland, director of nursing at the Heart of England Foundation Trust, agrees. "I've always taken risks in my career, including going on a secondment to the Department of Health and going to work in Ireland. When these opportunities came along, it was very much a case of 'Shall I? Shan't I?' But you have to just go for it."
Alan Simmons, careers consultant for NHS Careers, explains why ambitious nurses may need to move around geographically. "If, for example, you wanted to work in paediatric cardiac surgery, there are only half a dozen places in the country you can gain that experience."
Simmons believes that as nursing becomes a graduate-only profession (diplomas are currently being phased out), senior roles will become even more accessible. "At the moment only some nurses are able to move into areas such as teaching and management, whereas in the future it will be open to all of them."
He is particularly excited by new roles such as prison nursing, and the new areas of emphasis such as community nursing, that are emerging within the NHS. "I'm also really pleased about the growth in nurse-led services. If you go to your local GP practice these days, you'll increasingly find your practice nurse is the first port of call. There are many nurse-led clinics too."
Consider, for instance, the new rapid response pain and symptom control clinic that has just been set up in Hull and East Yorkshire Hospitals NHS Trust to help palliative care patients remain at home for as long as they wish during their patient journey and at the end of life.
Many senior nursing roles now involve procedures that would previously have only been undertaken by surgeons or doctors – as Raymond Young has discovered. As advanced clinical practitioner working in the emergency department of Heart of England NHS Foundation Trust in Birmingham, he is one of a team of 10 advanced practitioners who work autonomously with undifferentiated and undiagnosed illness. A number of the tasks involved in his job – which requires a Masters level qualification – were previously exclusively the realm of doctors. "We might, in the context of managing, say a trauma patient, commence an infusion, prescribe medication to maintain their blood pressure, sedate and commence procedure to ventilate and insert a chest drain," he explains.
Young has found that nursing and the NHS have always rewarded ability. "I owe a huge burden of gratitude to the NHS for my continuing lifelong learning development and postgraduate training," he says. "I have had funding and support including protected study for my postgraduate studies." As nurses increasingly become the decision makers, he believes experiences like his will become even more common. Indeed, many nurses are now undertaking MBAs and PhDs.
Sharon McDonald, who lectures in nursing at the faculty of health and social care at Angela Ruskin University, has seen a direct link between nurses taking courses – which range from stand alone modules in burns care to Masters degrees – and being promoted. "There's no doubt it gives them a step up," she says, although other nurses point out that practical experience can count for as much – if not more – than training.
Cathy Taylor, careers adviser for the Royal College of Nursing, adds that being in the right place at the right time can also count for a lot. "The process of moving up the ranks is still admittedly a bit too ad hoc, depending on which trust you work for. It is still the case that nurses find themselves in a position of not being quite sure how they got where they did, but more is being done to ensure definitive career roles," she says.
Around 25 per cent of nurses are employed outside the NHS, including the voluntary sector, private hospitals and clinics, occupational health services, the pharmaceutical industry and the military. Senior roles range from heading up helplines to specialist jobs such as fertility or palliative care specialists. "There is also the opportunity to manage and develop services," says Taylor. "Many nurses manage care homes, for instance, which can vary in size and those working for large companies which own several homes can progress to regional management/training and lead nursing positions. In addition, there are opportunities for nurses with entrepreneurial skills to branch out on their own – perhaps setting up a nurse recruitment agency or working as an independent trainer."
Liz Bardolph, who has been a senior nurse and ward sister, now runs her own company as an aesthetic dermatology nurse. "Medical nursing was my real love and I progressed up the nursing structure in that area," she says. "Years later, I was asked to set up a laser clinic, doing things such as tattoo removal and laser for acne and fine lines and wrinkles. I became increasingly involved in the cosmetic side and decided to go off and do some training and set up my own company 10 years ago. The business is going well and I still get the benefit of having contact with patients."
There is still a perception, according to the RCN, that to progress in nursing, you have to move into management. But today, says Taylor, that could not be further from the truth.
'Working with children in A&E is the best job in the world'
Billy Drysdale is a paediatric lead in the Accident and Emergency unit of Cumberland Infirmary.
"When I was younger, I helped care for my grandmother. It was a role I enjoyed and it was that need to continue helping people that eventually drew me into nursing – albeit after a spell as a nightclub bouncer!
In 1992, I made my career switch. At first, I wanted to work in mental health, but there weren't enough places so I wound up working with children. I'm glad that happened now. The job I currently have – working with children in A&E – is the best job in the world. The results are so tangible. You get these children coming in who are distressed and whose families are upset and often, within half-an-hour you've got them laughing and joking and on their way home.
When I first started working in a children's ward, a little girl came in who had a hole in her heart. I'll always remember it because I didn't know anything about her condition. It prompted me to do more training – and I've done a lot more since. At most of my appraisals, we've discussed what training would help me in my role and it's all been funded. I've had to do a lot of studying in my own time, but I don't mind because the training ultimately means I can go to work and not be frightened that I don't know what's going on.
I've worked in various hospitals and various types of children's wards – and I think it's this experience, coupled with my training – that has helped me move up the ranks. I'm now in a band 7 role which includes a mixture of hands-on nursing and managing. It's a great mixture."
'My employers have supported me so well in my training'
Cecilia Anim is a clinical nurse specialist in contraception and sexual health at a nurse-led clinic in London.
"Our clinic is led by 30 nurses. We run four sessions a day, seeing around 30-40 patients in each one – all of whom have appointments. Alongside that, we have a walk-in facility.
My role involves talking to each patient that I see about contraception. I advise them on the methods available and I do a full assessment to make sure that whatever method they want to use is appropriate for their needs. At the end of the day, the choice lies with them, but it's my job to give them the information they need to make an informed decision. I really enjoy seeing a good outcome – for example, if a person can't get on with the oral contraceptive pill but they find the implant really suits them. I'm also involved in health promotion, which includes giving advice on things such as smoking cessation and the screening aspects of women's health.
I trained as a midwife in Ghana and came over here in the Seventies. After doing paediatric work, I moved into family planning in 1979. My background in midwifery had led to my growing interest in women's health – and because family planning is a Monday to Friday 9-5 job, it's an area of nursing that fits in well with having children – I have three. I found it pretty easy to get the training that I needed to make the move.
In fact, throughout my career, it's become increasingly apparent that nurses can do more than they used to and I think it's with this in mind that my employers have supported me so well in my training.
At each annual appraisal, my training needs have been identified and I've always felt encouraged and supported. It doesn't just suit me, of course, but my employers too because nurse-led clinics mean other medics' time is freed up.
All the courses I've done have been funded by my employers and even though I've had to give up some of my time to study, I've also been given time off, which has really helped."