Specialist and advanced children’s and young people’s nursing practice in contemporary health care: guidance for nurses and commissioners
Specialist and advanced children’s and young people’s nursing practice in contemporary health care: guidance for nurses and commissioners
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SpecialiSt and advanced children’S and Young people’S nurSing practice in contemporarY healthcare: a guide for nurSeS and commiSSionerS
Acknowledgements
Working group members• JudithCampbell,AdvancedPractitioner
PaediatricDiabetes,RoyalManchesterChildren’sHospital
• DaveClarke,Lecturer,ProfessionalHeadCYPNursingandAssociateDirectorofUndergraduateStudies,SchoolofHealthcareSciences,CardiffUniversity
• IslaFairley,PaediatricDiabetesNurseSpecialist,RoyalAberdeenChildren’sHospital
• JulieFlaherty,ConsultantNurseChildren’sUnscheduledCare,SalfordRoyalFoundationTrust
• CaroleGelder,Children’sDiabetesNurseSpecialist/Lecturer,LeedsTeachingHospitalsNHSTrustandUniversityofYork
• RachelHollis,LeadNurseChildren’sCancer/Matron,LeedsTeachingHospitalsNHSTrust
• AngelaHoulston,Matron,TheChildren’sHospital,OxfordUniversityHospitals
• HelenJagger,AdvancedPaediatricNursePractitioner,CalderdaleandHuddersfield NHSFoundationTrust
• KathrynKrinks,LeadNurse,WorkforceandEducationCentralManchesterUniversityHospitalsNHSFoundationTrust
• FionaSmith,HonFRCPCH,AdviserinChildrenandYoungPeople’sNursing,RoyalCollegeofNursing
• RenateTulloh,AdvancedNursePractitioner,PaediatricOncology,GreatOrmondStreetHospitalNHSTrust
Reference group• DorisCorkin,SeniorLecturer(Education),
SchoolofNursing&Midwifery,Queen’sUniversityBelfast
• KarenSelwood,AdvancedNursePractitioner(PaediatricOncology)AlderHeyNHSTrust
• DrMarieMarshall,PaediatricDiabetesNurseSpecialist,RoyalManchesterChildren’sHospital
• DrCarolEwing,RoyalManchesterChildren’sHospital/RoyalCollegeofPaediatricsandChildHealth
• SueDryden,MaternityandChildrenNetworkManagerandLeadNurse,EastMidlandsStrategicClinicalNetwork&Senate
• JeanDavies,ClinicalNurseManagerPaediatrics,UniversityHospitalCrosshouse,Kilmarnock,Ayrshire
• JennyEdmonds,Sister/AdvancedPaediatricNursePractitioner,EmergencyDepartment,IpswichHospitalNHSTrust
• HazelGibson,PaediatricRenalNurseCoordinator,RenalUnit,RoyalBelfastHospitalforSickChildren
• TrudyWard,Chair,RCNChildrenandYoungPeople’sContinuingandCommunityCareForum
• RayMcMorrow,Chair,RCNChildrenandYoungPeople’sStayingHealthyForum
• DoreenCrawford,Chair,RCNChildrenandYoungPeople’sAcuteCareForum
• MargaretFletcher,Chair,RCNChildrenandYoungPeople’sProfessionalIssuesForum
• MervynTownley,ConsultantNurseforChildandAdolescentMentalHealthServices,GwentNHSHealthcareTrust
• LindseyRigby,CongenitalHyperinsulinismSpecialistPractitioner,RoyalManchesterChildren’sHospital
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RCN Legal DisclaimerThispublicationcontainsinformation,adviceandguidancetohelpmembersoftheRCN.ItisintendedforusewithintheUKbutreadersareadvisedthatpracticesmayvaryineachcountryandoutsidetheUK.Theinformationinthisbooklethasbeencompiledfromprofessionalsources,butitsaccuracyisnotguaranteed.WhilsteveryefforthasbeenmadetoensuretheRCNprovidesaccurateandexpertinformationandguidance,itisimpossibletopredictallthecircumstancesinwhichitmaybeused.Accordingly,theRCNshallnotbeliabletoanypersonorentitywithrespecttoanylossordamagecausedorallegedtobecauseddirectlyorindirectlybywhatiscontainedinorleftoutofthiswebsiteinformationandguidance.PublishedbytheRoyalCollegeofNursing,20CavendishSquare,London,W1G0RN©2014RoyalCollegeofNursing.Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,ortransmittedinanyformorbyanymeanselectronic,mechanical,photocopying,recordingorotherwise,withoutpriorpermissionofthePublishers.Thispublicationmaynotbelent,resold,hiredoutorotherwisedisposedofbywaysoftradeinanyformofbindingorcoverotherthanthatinwhichitispublished,withoutthepriorconsentofthePublishers.
Children,youngpeopleandtheirfamiliesexpectnurses,doctorsandotherprofessionalswhohaveresponsibilityforchildrenandyoungpeople’shealthcaretobeappropriatelyqualifiedandexperienced.TheRCNChildrenandYoungPeople’sFieldofPracticehasrepeatedlyreinforcedtheneedfornursescaringforchildrenandyoungpeopletohavecompletedaspecificeducationandtrainingprogrammetomeettheneedsofthisgroup(RCN,2003;RCNCYPFoP,2007).
ThispublicationisdueforreviewinJune2017.Toprovidefeedbackonitscontentoronyourexperienceofusingthepublication,[email protected]
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SpecialiSt and advanced children’S and Young people’S nurSing practice in contemporarY healthcare: a guide for nurSeS and commiSSionerS
Contents:Executivesummary 5
Introduction 6
Background 6
Healthservicesforchildrenandyoungpeople 7
Thechildhealthworkforce 9
Reviewingnursingroles 9
Afocusonhealthoutcomes 10
Adefinitionofadvancedpractice 11
Advancedpracticevalues 13
Domainsofpractice 13
Advancedpracticeandspecialistnurses:rolesandtitles 14
Governanceandadvancepractice 17
Educationtrainingandprofessionaldevelopment
Careerframeworks 18
Conclusion 22
Appendices:
1:Workforceplanningtool 23
2:Keyelementsofthecareerframework 24
3:Keycharacteristicsofadvancedpracticeacrossthefourdomains 25
4:Exemplarnursingroles 26
5:Thecareerpyramid 27
6:AUKUHclinicalacademiccareerpathway 28
References 29
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ExecutivesummaryThisRoyalCollegeofNursing(RCN)publicationlooksatchildren’snurses’rolesandtheirpractice.Ittakesintoaccountachangingchildhealthservice,whereinterdisciplinarycollaborationandnewwaysofworkingareessentialwhenprovidingservicesthatimprovehealthoutcomes.
Thehealthoutcomesofchildrenandyoungpeople(CYP)intheUnitedKingdom(UK)areinferiortothoseincomparableEuropeancountries.ThereisacommitmentfromtheGovernmenttoimprovethequalityandefficiencyofCYPhealthservicestoimprovethoseoutcomes.Alongsidethiscommitmentisagrowingrealisationthatcurrentwaysofprovidingservicesareincreasinglyunsustainable.
Children’snursesworkingataspecialist,advancedandconsultantlevelcanmakeasignificantcontributiontotheredesign,developmentanddeliveryofservicestoCYP.Thispublicationoffersreallifeexemplarsofinnovativerolesandservices.
Whenplanningorevaluatingnursingroledevelopmentitiscriticalthatcommissionersandserviceprovidershaveasharedunderstandingofwhatismeantbybothadvancedandspecialistnursingpractice;thisisdefinedinthisdocument,alongwithanattempttoidentifythedifferentrolesandtitlesusedbynursesandemployers.
Itisalsoessentialthatpractitioners,employersandcommissionersofnursingservicesshareacommitmentto,andunderstandingof,arobustclinicalgovernanceframeworkrequiredtoensuresafeandeffectivecarewhendevelopingspecialistrolesandadvancedlevelsofpractice.Thisshouldincorporateaccountabilityandcompetenceframeworks,andagreededucationalpreparation.
Specialistpractitionersshouldbeeducatedtodegreelevel,withadditionalclinically-basededucationalpreparationwithinthespecialty;advancedpractitionersshouldbeeducatedtomaster’slevelandconsultantnursesshouldbepreparedatmaster’sordoctorallevel.Employersneedtosupportthecontinuingprofessionaldevelopmentofnursesintheseadvancedrolestomaintaintheirlevelofpractice.
Commissionersandemployersneedtoensurethatcareerframeworksforchildren’snursesincludespecialist,advancedandnurseconsultantrolessothatservicescontinuetodevelopandmeettheneedsofchildren,youngpeopleandtheirfamilies.Attentionshouldbepaidtonationalguidanceconcerningspecialtycareerframeworks,clinicalacademictrainingandclinicalresearchroles.
Definition of children and young people (CYP)Thetermchildrenandyoungpeople(CYP)isusedthroughoutthispublicationtomeanbabies,childrenandyoungpeoplefrom0to18yearsofage(upto19thbirthday).
ThechildhealthservicestheyrequireencompassallCYPservices:fromneonatalcaretoyoungpeopleintransitiontoadultcare;primarycarethroughtosecondaryandtertiaryspecialistcare;servicesfocussedonphysicalhealthtochildandadolescentmentalhealthservices,andthoseservicesforCYPwithlearningdisabilities.
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IntroductionThisRCNpublicationprovidesguidanceforthosedevelopingservicesforchildrenandyoungpeople(CYP),forbothcommissionersandserviceproviders,andforthosewhocommissionandprovidepostregistrationeducationforchildren’snurses.
Thefocusofthedocumentisonchildren’snurses,theirrolesandtheirpractice.Ittakesintoaccountachangingchildhealthservice,whereinterdisciplinarycollaborationandnewwaysofworkingareessentialwhenprovidingservicesthatimprovehealthoutcomes.Aswellasdescribingthechangingenvironment,thispublicationwilldemonstratetheaddedvaluethatchildren’snursesworkingatanadvancedlevelofpractice,andinspecialistroles,canbringtochildhealthservices–enhancingpatientexperience,ensuringpatientsafety,andenablingeffectivecare.
Inordertodothis,thisguidanceexplainstheconceptsofadvancedpracticeandroledevelopmentinchildren’snursing,tothosewithinandoutsidetheprofession.Itcovers:
• whatismeantbyadvancedpracticeinCYPnursing
• thedistinctionbetweenadvancedpracticeandtherolesofnursespecialist,advancednursepractitionerandnurseconsultant
• theaddedvaluethatnursespractisingatanadvancedlevelcanbringtochildren,youngpeopleandtheirfamiliesandcarers
• theimpactthatnursesinadvancedpracticeandspecialistrolescanhaveonthehealthoutcomesofchildrenandyoungpeople
• thepromotionofpatientsafetyinachanginghealthcareenvironmentbydescribingarobustgovernanceframeworkforspecialistandadvancedpracticenursingroles.
BackgroundHealthoutcomesforchildrenandyoungpeopleintheUKare,inmanyways,inferiortothoseincomparableEuropeancountriessuchasSweden,theNetherlandsandGermany(Wolfeetal.,2011;DH,2012a).‘Allcause’childhoodmortalityintheUK(0to14years)hasthehighestrateofanycomparableEuropeancountry.Ithasbeenstated
thatifUKchildhealthcarewasequivalenttothatinSweden,oneofthebestperformingsystemsinEurope,itwouldmeanthatfivechildrenadaywhocurrentlydie(1,500ayear)wouldhavethepotentialtosurvive,developingintoindependentadulthood(Wolfeetal.,2011).
Afundamentalreviewofchildhealthservices,alongsidethewiderreformsofhealthandsocialcareacrossthefourcountriesoftheUK,requiresmodernisationoftheworkforcewhichwillprovidethoseservicesinthefuture.Theroleofthechildren’snurseisfundamentaltoeffectiveserviceprovisionacrossallsettings,withanincreasingrecognitionthatnursesworkingatanadvancedpracticelevel,inclearlydefinedandeffectivelyresourcedroles,canenhancehealthcareservicesandhaveapositiveimpactonhealthoutcomes(DH,2013;RCPCH,2011).
AdvancednursingpracticeintheUKhasevolvedsignificantlyoverthelast20years,withtheemergenceofincreasingautonomy,clinicaldecisionmaking,professionalresponsibility,nursingresearchandtheexpansionoftraditionalnursingroles(NMC,2005;RCN,2012).Asnursingroles,responsibilitiesandareasofpracticehavediversifiedandexpandedsomeoftheboundariesofprofessionalpracticeandcompetencehavebecomeblurred(DalyandCarnwell,2003;CouncilforHealthcareRegulatoryExcellence(CHRE),2009).Thereisinconsistencyintheuseoftheterm‘advancedpractice’andawiderangeofrolescarrythetitle‘nursespecialist’or‘advancedpractitioner’.
ThisdocumentwillbringclaritytothefieldofCYPnursingpractice.Informedbyarangeofnationalandprofessionalpolicydocuments,itsetsouttodefineandestablishthecompetencesandstandardsforadvancedpractice,aswellasrecognisethevalueofspecialistrolesacrosstheUK.ParticularattentionisgiventotheAdvancedNursingPracticeToolkitdevelopedbyNHSScotlandaspartoftheUK-wideworkonmodernisingnursingcareers(DH,2006;ScottishExecutive,2008).ThiscomprehensiveresourceisreflectedinstrategydocumentsfromtheotherUKcountries(DH,2010a;NationalLeadershipandInnovationAgencyforHealthcare(NLIAH)(Wales),2011;DepartmentforHealth,SocialServicesandPublicSafetyNorthernIreland(DHSSPSNI),2010a).
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HealthservicesforchildrenandyoungpeopleThereareanumberofhealth,socialandculturaldeterminantswhichcontributetothedifferencesinhealthoutcomesforchildrenandyoungpeoplebetweentheUKandcomparablecountries(Wolfeetal.,2011).Thewaythathealthservicesforchildrenareorganisedandledisrecognisedasoneofthekeydifferencesleadingtothisdisparityofoutcome,andtothegreatvariationinthequalityofservicesseenacrossthefourcountriesoftheUK(DH,2012a).
In2010,ProfessorSirIanKennedyproducedareport,Getting it right for children and young people(Kennedy,2010),inwhichhehighlightedthelackofprioritygiventochildren,youngpeopleandtheirfamilieswithintheNHS.Heidentifiedanumberofspecificissueswhichwouldneedtobeaddressediftheimprovementsneededinhealthcareandhealthoutcomesaretobeachieved.Theseincluded:
• GPshavinglittleornoformalpaediatrictraining
• caringforchildrenandyoungpeoplebeinglowonmostGPs’priorities
• widevariationsincare
• alackofco-ordinationandservicesnotworkingtogether
• aneedtoimproveworkforcecompetenceinarangeofareas,suchastheemotionalandmentalhealthneedsofchildrenandyoungpeople
• aneedtoimproveleadershipthroughoutchildren’sservices.
TheKennedyreportfocusedonhealthcareandhealthcareservicesforchildrenandyoungpeopleinEngland,butlookedatoutcomesandgeneralprincipleswhichapplyacrosstheUK.Manyofthethemesheidentifiedareaddressedintherelevantchildhealthstrategiesofthedevolvednations(WelshAssembly,2005;ScottishExecutive,2007;DHSSPSNI,2010b).
InEngland,theReport of the Children and Young People’s Health Outcomes Forum(DH,2012a)builtontheKennedyreportandsetouttheneedforafundamentalreviewofchildhealthservices,aswellastheprioritiesforbothpoliticalandprofessionalaction.Itsupportedtheprincipleofconfiguringchildhealthservicesaroundthechildandfamilyjourneyandthe‘patientpathway’,previouslysetoutintheNHSNextStageReviewledbyLordDarzi(DH,2008a).
TheGovernment,initsresponsetothereportoftheForum(DH,2013),acceptedthe‘compellingcaseforchange’itpresented.Alongsidetheneedtoimprovechildhealthservicesinordertoimprovetheirqualityandefficiency,isagrowingrealisationthatcurrentwaysofprovidingservicesareunsustainable.TheimpactoftheEuropeanWorkingTimeDirective(EWTD)andthereductionoftheworkingweektoamaximumof48hourshasputenormouspressureonmedicalworkforceplansandrotas.
Shortagesinboththeconsultantworkforceandtraineesrequiredtofillcurrenton-callrotas,haveledtoanacceptanceoftheneedtoreconfigurechildren’sservices–withacuteandspecialisedservicesprovidedbyasmallernumberofhospitalsandthedevelopmentofmanagednetworksofcare,providingarangeofservicesclosertothechildandfamily(RCN,2009;Wolfeetal.,2011;RCPCH,2011).
Anumberofdifferentmodelshavebeenproposedand,insomecases,implemented.Urgentcareisaparticularpriority,witharisingnumberofaccidentandemergencyattendancesoftenleadingtoinappropriateshortstayhospitaladmissions(Clements,2013).Solutionssuchasshortstayassessmentandobservationunits,providedinGPpractices,healthcentresorlocalhospitalshavebeenidentifiedand,insomecases,putinplace(RCPCH,2011).
TheRCNsubmissiontothePrimeMinister’sCommissiononNursing(RCN,2009)recognisedthatthereshouldbeasignificantdecreaseinchildrenbeingadmittedtoinpatientunits(possiblybyasmuchas50%),andthatmanyacutelyillchildrenarelikelytobecaredforonshortstayobservationandassessmentunits,whichwillbestaffedbyadvancedchildren’snursepractitioners,workingalongsideGPtraineesandotherdoctorsintraining.
Theincreasedemphasisinhealthpolicyonintegratedcareandcareclosertohomesuggeststhatchildrenwithacutehealthcareneedsshouldbemanagedinthecommunitywhereverpossible,ratherthanbeingadmittedtoaninpatientunit.Thisproposedshiftofacutelyillchildrenintoprimarycaresettingsrequiresnursesworkingalongsidemedicalcolleaguestodevelopandsustainnewservicemodels,aswellasadequateresourcesforcommunitychildren’snursingteams.
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Advancedpractitionersincommunitychildren’snursingteamsarelikelytoundertakeacuteassessmentofhealthandsocialneeds,actingasseniordecisionmakersanddirectingthepatientontotherightpathwayusinganintegratedapproach.Children’snurses,alongarangeof
pathwaysandinbothcommunityandacutecare,willincreasinglyundertakeclinicalassessments,diagnose,interpretX-raysanddiagnosticimaging,plan,prescribeandevaluatetreatment,makereferrals,dischargeandprovidefollow-upcare,oftenwithoutreferencetomedicalpractitioners.
Service exemplarsNorthern Ireland (Southern Health and Social Care Trust, Craigavon Area Hospital, Portadown) Asix-beddedPaediatricDecisionUnit(PDU)wasopenedinFebruary2013.Itiscurrentlystaffedbytwoadvancedpaediatricnursepractitioners(APNPs)andonestaffnursewithsupportfromseniormedicalstaff.AfurtherthreenursingstaffhavebeensecondedtoundertaketheAdvancedPaediatricNursingCourseand,oncompletion,willhelpinthefurtherdevelopmentofthisservice.ThePDUiscurrentlyopenMondaytoFriday(8amto10pm)andacceptsreferralsfromtheemergencydepartment,GPs,midwives,healthvisitorsandcommunitynurses.Apaediatricadviceline(PALmobile)isavailableandthereferringpractitionercancontactaconsultantpaediatricianforadviceand/ordiscussareferraltothePDU.ThePDUacceptsacutelyunwellchildrenwitharangeofchildhoodillnesses.
TheAPNPwillcarryoutaconsultationandexaminationofthepatientandthenformulateamanagementplan.Patientsareobservedfortimeperiodsofuptosixhoursandadecisionwillthenbemadetoadmit/dischargebytheAPNP.ThecommunitynursingteamworkinconjunctionwiththePDUandprovidecommunityfollowuptodischargedpatientswhenrequired.
Anauditconductedtoassesstheimpactofthisnewmethodofservicedeliverydemonstratedthatthemodelhasimprovedpatientflow,decreasedthepatient’sjourneyandreducedthenumberofinappropriateinpatientadmissions–improvingthequalityofcaredeliveredandreducingcosts.
SalfordTheSalfordChildren’sCommunityPartnership(SCCP)isaground-breakingprojectdevelopedtoimprovepaediatricacuteillnessmanagementinthecommunity.OriginallyfundedasaninnovationprojectbytheDepartmentofHealth,theprojectplacesanAPNPwithinageneralpracticesettinginordertoprovideanexpandedofferofcareto:
• decreasethepaediatricacuteadmissionspendforthepractice
• improvethequalityofacutechildren’sillnessmanagementinthecommunity
• providetothewiderNHSaneffective,scalablemodelforpaediatricacuteadmissionavoidancethatisgeneralpracticebased.
TheserviceprovidesaprimarycarealternativetoA&Eandshort-stayadmissions;earlyfeedbacksuggeststhatfamilieswilldefernon-emergencyA&Eattendanceforahighquality,child-specificserviceingeneralpracticewithexcellentaccess.Initialresultsfromthefirsttwoyearsofprojectdeliveryhaveshownthe:
• totalspendforpaediatricacuteadmissionsdecreased36%attheprojectpracticecomparedtothecontrolpractices
• admissionexpenditureperchildwithinthepracticedecreased40%comparedtotheothersites
• admissionrateper1,000childrendecreased43%comparedtotheothersites.
Satisfactionscoresonanationallyvalidatedassessmenttoolwerealmostdoublethenationalbenchmarkscoresforservicequalityingeneralpractice.Familiesexpressedtheirexceptionalsatisfactionwiththeinvolvementandcareofprojectstaffandthewaytheycommunicatedandlistened.
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ThechildhealthworkforceModernisationofchildhealthservices,aswellastheneedtodelivernewwaysofworking,requiresashiftinthechildhealthworkforceandintegratedworkforceplanningbetweenprimaryandsecondarycare,acrossdisciplinesandprofessions,includingmedicineandnursing.OneofthekeyprioritiesidentifiedbytheCYPHealthOutcomesForumwastheneedforanationalapproachtoachieveasustainableandcompetentworkforce,witharecommendationtoprioritiseworkforceplanning,alongwithqualityeducationandtrainingforthespecialistandcoreCYPworkforce.Thereconfigurationofservicesaroundthepatientjourneyhasmajorworkforceimplications,notonlyintermsofnumbersofcompetentprofessionalsbutalsothestateofreadinesstotakeonnewrolesinnewandchangingenvironments.
Duringtheconsultationwithchildren,youngpeopleandtheirfamilies,whichunderpinnedtheworkoftheCYPHealthOutcomesForum,theyspokeoftheirwishtoaccesshighquality,evidence-basedsafecareandtreatment,asclosetohomeaspossible.Childrenandyoungpeopletoldtheforumtheimportanceofthefollowingthemesthathaveparticularrelevancetoworkforcedevelopment.
1. Carebyprofessionalswhohavehadtraininginworkingwithchildrenandyoungpeople.
2. Concernthatgeneralpracticeandtransitionfromchildren’stoadultservicesdonotmeettheirneeds.
3. Awishforhealthcarestafftoshowrespecttochildrenandyoungpeopleandrecognisetheirrighttobeinvolvedindecisionsabouttheirhealthandcare.
4. Theneedforcaretobedeliveredbycompetentprofessionalswhocommunicatewellwithchildrenandyoungpeopleandprovideajoined-upapproachtotheircare.
Asservicesarereviewed,reconfiguredorsetupthereneedstobeadialoguebetweencommissionersandserviceproviderswhichmustputchildren,youngpeopleandfamiliesattheheartoftheprocess.Anychangesinnursingrolesorinservicedeliverymustensurepatientsafetyatatimeofproposedsystem-widechange(RCN,2013).Alltoooftenservicedevelopments,whichhaveenvisagedsuchnewwaysofworkingandincludedplansfornursestoworkatanadvancedpracticelevel,havenotinvestedinthetraininganddevelopmentrequiredtoundertakesuchroles.
Thereisarequirementfirstfornursestodemonstratetheircompetenceatinitialregistrationaschildren’snursesandtheninmovingbeyondregistrationtopracticeatanadvancedlevel.Therehasbeenanapparentdissonancebetweenmanagementandprofessionalexpectationsandalackofinvestmentinthedevelopment,trainingandeducation,andcontinuingcompetencyassessmentrequiredasnursesmoveonintorolessuchaschildren’sadvancedandspecialistpractitioners.Strategiesforchildren’snursingservicesandproposeddevelopmentsinnursingrolesshouldalwaysbeledbyseniorregisteredchildren’snurses.Theseshouldprovideachildfocussedandfamily-centredstrategicvision–withinandacrossorganisations–inrelationtoworkforceplanningandserviceconfiguration.
ReviewingnursingrolesDevelopmentsinnursingpracticeshouldbeaccompaniedbyarigorousprocessthatconsidersdriversbehindchangeandthewholeserviceneedsasoutlinedabove.Whendevelopingnewrolesornewwaysofworking,theneedhastobeassessed,resourcesallocatedandtheservicedeveloped.Itisdeliveredagainstaservicespecification,whichmayincludetheworkforcerequiredtodeliverthespecifiedcorecomponents.
InEngland,thedevelopmentofnationalservicespecificationsforanexpandedrangeofpaediatricspecialisedservices(NHSSpecialisedServices,2012)hasincludedpaediatriccancer,cardiac,renal,neurologicalandmanyotherspecialistfieldsofpractice.Theseservicespecificationssetoutbasicrequirementsfortheworkforce,includingspecialistnursingposts,andprovidersneedtodemonstratetheircompliancewithsuchspecificationsinorderfortheirservicestobecommissioned.
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Service specification exampleEachchildshouldhaveanamedchildren’scardiacspecialistnursewho,workingwithinacardiacliaisonteam,isresponsibleforco-ordinatingtheircareandliaisesbetweentheclinicalteam,theparent/carerandthechildthroughouttheircare.
Children’scongenitalcardiacservicesinEngland(NHSSpecialisedServices,2012).
Campbelletal.(1996)developedasafetynetmodelthathasastep-by-stepapproachtoensurethatallserviceandpersonalissuesareconsideredwhenplanninganyroledevelopment.TheRCNPaediatricOncologyNursesForumadaptedthisunpublishedmodelforuseinchildren’scancernursing(RCN,2000).Whilstthishasbeensupersededbythemorerecentdocumentsdiscussedbelow;thissimplestep-by-stepapproachstillhasvalue,ensuringthatbothserviceandpersonalconsiderationsaremet.
TheAdvancedNursingPracticeToolkit(ScottishExecutive,2008)highlightedtheimportanceofassessingtheserviceneedsfornursinginconjunctionwithotherroles.Itacknowledgedthatmanynursingroleshavedevelopedduetogapsintheavailabilityofanotherprofessionalgroup,principallydoctors.TheFramework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales(NLIAH,2011)includesamoredevelopedplanningmodeltoassistinestablishingworkforcerequirements.Thishasbeenbrokendownintoasix-stageprocessthatcanassistinensuringthatallaspectsoftheserviceareconsidered,includingroleuseandskillmix(seeAppendix1).
AfocusonhealthoutcomesThewhitepaperEquity and excellence: Liberating the NHS(DH,2010b)outlinestheGovernment’sintentiontoputpatientsattheheartofcare,deliverimprovedoutcomesandempowercliniciansandserviceuserstoensurehighqualityhealthcareisreceived.Inaresource-constrainedhealthsystemithasbecomeessentialthat
healthcareorganisationsensuremoneyiswellspent,bringingmaximumbenefittopatients.TheresponsetothereportoftheCYPHealthOutcomesForum(DH,2013)acceptedthat,wherepossible,children,youngpeopleandtheirfamiliesshouldbeinvolvedindecisionsabouttheircareandthedesignofservices.ThereportdescribedkeyelementsoftheNHSPublicHealthOutcomesFrameworksthatarerelevanttoCYP.
• Strengtheningworkonmeasurementofexperienceofcare.
• Integratedcare.
• Timetodiagnosis/startoftreatment.
• Transitiontoadultservices.
• Impactofpoorphysicalandmentalhealthordisabilityoneducation.
• Maternalmentalhealth(coping/resilience).
• Prevalenceofmentalhealthproblemsinchildrenandyoungpeople.
Thesuccessofanynursingroleshouldbeevaluatedinthelightofidentifiedoutcomes.TheaddedvaluethatnursesbringhasbeendemonstratedbyasurveyconductedbytheRCNthatlookedattheimpactofnursesworkingacrossarangeofspecialties(RCN,2010).InthemodernNHSthevalueofanyroleshouldbeconsiderednotjustintermsofqualitybutalsoasvalueformoney.Thismay,forexample,beintermsofpreventionofadmission,reductionofcomplicationsorreductionoflengthofstay.Patient-facingactivityshouldberecordedsothatadditionalincomecanbesecured.Specialistnurseshavetraditionallybeenhighlyregardedbyfamiliesandpatientsbutareincreasinglyatargetforscrutinyasorganisationsexpectareturnfortheirinvestmentinhighlybandednursingposts.Thereareseveralwaysofmeasuringthevalueofthespecialistnurse;thisincludesjobplanning,patientsurveys,activitydatacollectionandrecordingofnurse-ledclinicsorotherinterventionsforclinicalcodingandfinancialremuneration.
OneexampleofanevaluationtoolisthePANDORAdatabase.Thisisdesignedaroundactivitydatasourcescollectedfromnursesacrossdifferentspecialties(Learyetal.,2008).PANDORAexaminesrolecomplexityandresultssuggestthatthedatabaseissensitivetoidentifyingthehiddenelementsofspecialistnursingactivityandtoconnectingthemtopatientoutcomesandorganisationalpriorities(for
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example,preventinganunscheduledadmissionoridentifyingcomplicationsearly).PANDORAdoesnotspecificallycharacteriseadvancedorspecialistpractice,butratherhelpsto‘paintapicture’ofspecialistnursingwork(ScottishGovernment,2008).
AresearchprojectconductedbySheffieldHallamUniversitysetouttocapturetheimpactofthenurseconsultantrole(Gerrish,McDonnellandKennedy,2011).Aspartofthisworkanevaluationtoolkithasbeendevelopedthatprovidesaframeworkforcapturingtheimpactofnursingroles.Threedomainsaredescribedwhereimpactonoutcomescanbedemonstrated,providingavaluableframeworkwhenevaluatingnursingrolesandservices.
1. Clinicalsignificance
a. Returntonormalfunction.
b. Interventionsimprovehealthorabilityto selfcare.
c. Reductioninhospitaladmission/ reductioninlengthofstay.
2. Professionalsignificance
a. Enhancementofownandothers competencebydevelopmentofskills/ knowledgeandconfidence.
b. Colleagues’perceptionsandimpactofthe advancedpractitioneronthem.
3. Organisationalsignificance
a. Achievementoforganisationalobjectives, forexample,reductionofinfectioncontrol rates,cliniccapacity,emergencycare targets.
b. Successionplanning/workforce.
c. Cost-effectiveservices.
AdefinitionofadvancedpracticeWhenplanningorevaluatingnursingroledevelopment,itiscriticalthatcommissionersandserviceprovidershaveasharedunderstandingofwhatismeantbybothadvancedandspecialistnursingpractice.
Thereisverylittleinformationavailabletocommissionersorfamiliesthathelpsexplainhownurses(andotheralliedhealthprofessionals)maypracticeatanadvancedlevel.Manydefinitionsareavailable–thesehavecommonthemesthatrelatetoexperiencedandhighlyeducatednurses,withskillsandcompetencedevelopedtoahighstandardthatenablesthemtomakecomplexclinicaldecisions.Thefollowingdefinitionsareusefulinunderstandingtheroleoftheadvancedpractitioner.
International Council of Nurses (ICN) “A registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level.”(ICN,2002)
Career Framework for Health People at level 7 of the career framework have a critical awareness of knowledge issues in the field and at the interface between different fields. They are innovative, and have a responsibility for developing and changing practice and/or services in a complex and unpredictable environment. Indicative or Reference title: Advanced Practitioner (SkillsforHealth,2010;Appendix2)
Nursing and Midwifery Council “Advanced nurse practitioners are highly experienced and educated members of the care team who are able to diagnose and treat healthcare needs or refer to an appropriate specialist if needed.”(NMC,2005)
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Inaddition,theproposedNMCdefinitionoftheadvancednursepractitionersetsoutthefollowingkeyfunctionsoftherole.
• Takesacomprehensivepatienthistory.
• Carriesoutphysicalexaminations(this has been modified in other policy documents to reflect that the examination required will reflect the client group such as those with mental health problems).
• Usestheirexpertknowledgeandclinicaljudgmenttoidentifythepotentialdiagnosis.
• Referspatientsforinvestigationswhereappropriate.
• Makesafinaldiagnosis.
• Decidesonandcarriesouttreatment,includingtheprescribingofmedicines(includingindependentprescribing)orreferspatientstoanappropriatespecialist.
• Usesextensiveexperiencetoplanandprovideskilledandcompetentcaretomeetpatient’shealthandsocialcareneeds,involvesothermembersofthehealthcareteam.
• Ensurestheprovisionofcontinuityofcare,includingfollow-upvisits.
• Assessesandevaluates,withpatients(andfamilies),theeffectivenessofthetreatmentandcareprovidedandmakeschangesasneeded.
• Worksindependently,althoughoftenaspartofahealthcareteam.
• Providesleadership.
• Makessurethateachpatient’streatmentandcareisbasedonbestpractice.
Advanced practice as a level of practice
Thedefinitionsoutlinedabovesupporttheemergingconsensusaroundtheconceptofadvancedpracticeasalevelofpracticeratherthanaspecificrole.Thisisanapproachthatencompassesthoseworkinginresearch,educationormanagementandleadershiproles,aswellasinclinicalpractice.Itcanalsoapplytoprofessionsotherthannursing(BrookandRushforth,2011).
Itcanbearguedthatadvancedpracticeisaparticularstageonacontinuumbetweennoviceandexpert(Benner,1984).Theadvancedrole
profileischaracterisedbyhighlevelsofclinicalskill,competenceandautonomousdecisionmaking.Itreflectsaparticularbenchmarkontheclinical,professionalandcareerdevelopmentladder.ThisisillustratedinFigure1.Figure1:Relationshipbetweenspecialistandadvancedpractice
Expert Practice
Advanced Generalist
Junior Specialist
Novice Practice
Specialist Practice
Generalist Practice
ReproducedwithpermissionfromAdvanced Nursing Practice Toolkit(2008),publishedbytheScottishExecutive.
Thismodelrecognisesthatthepathwaytowardsadvancedlevelpracticemaybedifferentforindividualpractitioners.Somemayfollowaspecialistroute,focusingonhigh-levelskillsanddecisionmakingwithinaparticularclinicalcontextorclientgroup.Otherswilldevelopaportfoliothatreflectsawiderbreadthofgeneralistexpertise.
Thediagramhighlightsthecontinuumfromspecialisttogeneralistpracticeandthepotentialtoachieveexpertoradvancedlevel.Thecirclesdenoteajuniorspecialistinthebottomleftcornerandanadvancedgeneralistinthetoprightcorner.Ajuniorspecialistmightbeanursewithinaspecialistclientgroupworkingatanovicelevel,suchasanewlyappointedchildren’snursewithinpaediatricdiabetes.Anadvancedgeneralistmightbeanurseworkingwithinageneralistsettingatanexpertlevel,suchasaconsultantnurseinurgentcare.
Topromoteclarityinroledefinitionsthetermspecialistshouldrelatetoaparticularclientgrouporpatientswithdisease-specificconditions(suchasdiabetesorrheumatoidarthritis)oraparticularintervention(suchasendoscopy),asopposedtoalevelofknowledgeoraroledefinition.Itisthenpossibletomap
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theprogressionandacquisitionofknowledgeandskillsalongthenovicetoexpertcontinuuminasimilarwaytothe Career Framework(SkillsforHealth,2010).Thisframeworkdifferentiatesbetweenspecialistorseniorpractitionerandadvancedpractitioner(seeAppendix2).Thismodelrecognisesthatspecialistknowledgeorskillsdonot,inthemselves,characteriseanadvancedlevelofpractice(NLIAH,2011).
AdvancedpracticevaluesPolicyguidancerevealcommonthemesofthosepractisingatanadvancedlevel,indicatingtheyareexperiencedandhighlyeducatednurses,withskillsandcompetencedevelopedtoahighstandardwhichenablethemtomakecomplex,clinicaldecisions.ThesethemesareechoedinthefiveunderpinningprinciplesoftheFramework for advanced nursing, midwifery and allied health professional practice in Wales,adaptedbyNLIAHfromworkundertakenbyNHSEducationScotland(NES,2007;NLIAH,2011).
1. Autonomous practiceAdvancedpractitionerspracticeautonomously.Thisinvolvesthefreedomtoexercisejudgementaboutactions,inturnacceptingresponsibilityforthem,andbeingheldtoaccount.
2. Critical thinkingPractisingautonomouslyrequireshigher-levelcriticalthinkingskills.Criticalthinkingallowsadvancedpractitionerstoexploreandanalyseevidence,casesandsituationsinclinicalpractice,enablingahighlevelofjudgementanddecisionmaking.
3. High levels of decision making and problem solving Anadvancedpractitionercandemonstrateexpertiseincomplexdecisionmakinginrelationtotheirrole.Thisinvolvesdeterminingwhattoincludeinthedecision-makingprocess,aswell
asmakingadecisionbasedonjudgementandcriticalthinking/problemsolving.This,inturn,affectstheabilitytopracticeautonomously.
4. Values-based careAtthislevelofpractice,individualsarerequiredtohaveahighlevelofawarenessoftheirownvaluesandbeliefs,andtoworkwithserviceusers/carersasequalpartners.
5. Improving practice Advancedpracticeinvolvesactingasapositiverolemodeltoenablechangeandpracticeimprovement.
Theapplicationoftheseprinciplesallowsthecontributionofadvancedpracticetobebetterarticulatedacrossdifferentcontexts,andmorewidelyusedandtransferablewithinthefourdomainsofnursingpractice.Inherentwithinchildren’snursingpracticearetheadditionalprinciplesandvalueswhichpromotetheprimacyofthechildandfamily-centredcare.
DomainsofpracticeTherearemanypractitionersworkingatanadvancedlevelwhodonotnecessarilyworkinaspecificclinicalrole.Fourover-archingdomainsofnursingpracticehavebeenidentifiedanditisessentialtoconsidertherelationshipbetweenthesedifferentspheres.Advancedlevelpracticeencompassesaspectsofeducation,researchandmanagementbutisgroundedindirectcareprovision(DH,2010a).
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Figure2:Thespheresofnursingpractice
Education
Research
Clinical practice
Managementand
leadership
Clinical
ManagementLeadership
Education
Research
Clinical
Education
Research
ManagementLeadership
Pillars of Advanced Practice
Fewnursingpostsarerestrictedtoonesphere,withmostcoveringatleasttwoormoreaspects.Certaindomainsmaybemoreprevalentinanindividualroleorday-to-daywork,butadvancedlevelpracticeshouldincludeelementsofthemall.Children’snursesworkingatanadvancedpracticelevelinallfourofthesedomainsarerequiredtoleadinnovativedevelopmentsacrosschildhealthservices.
TheFramework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales (NLIAH,2011)illustratesthisconceptofthe‘pillars’ofadvancedpractice,whichrecognisesadvancedroleswhicharenotpurelyclinical.Therelativeprominenceofclinicalpractice,research,education,andmanagementandleadershipwillvarydependingonlocalserviceneedsandindividualrolerequirements.However,alladvancedpractitionersshould,“havedevelopedtheirskillsandtheoreticalknowledgetothesamestandardsandshouldbeempoweredtomakehigh-leveldecisionsofsimilarcomplexityandresponsibility,”(NLIAH,2011).
Figure3:Thepillarsofadvancedpractice
Reproducedwithpermissionfrom:Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales(2011),page14.Thepillarsofadvancedpractice.
PublishedbytheNationalLeadershipandInnovationAgencyforHealthcare(NLIAH).TheWorkforceEducationDevelopmentServicehassincereplacedtheNLIAH,forfurtherinformationseewww.weds.wales.nhs.uk
Appendix3setsoutinmoredetailthekeycharacteristicsofadvancedpracticeacrosseachofthesefourdomains.
Thedefinitions,principlesandcharacteristicssetoutabovedemonstratethatadvancedpracticeisasetofattributesthatmaybeascribedtonursesandotherprofessionalspracticingatanexpertlevel.Thoseattributescanbeidentifiedinarangeofnursingroleswhichencompassbothspecialistandgenericareasofpractice.
Advancedpracticeandspecialistnurses:rolesandtitlesArangeofdifferenttitleshavebeenascribedtorolesthathavewithinthemelementsofadvancedpractice,specialistskillsandknowledge.Theserolesinclude:clinicalnursespecialist;nursepractitioner;advancednursepractitionerandconsultantnurse.Thesetitleshavebeenappliedinconsistentlyacrossallfourcountriesofthe
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UK,leadingtoconfusionandalackofclarityinthequalificationsandcompetencerequiredtoundertakethem.Theneedforimprovedgovernanceinthedevelopmentofrolesandtheconfermentoftitlesissetoutbelow,followedbyguidanceontheknowledgeandskillsrequiredtoundertakethem.Itshouldbeselfevidentthatallnursesworkingatanadvancedpracticelevel,orinaspecialistrolewithchildrenandyoungpeople,mustberegisteredchildren’snurses.
Specialist nurse AspecialistnurseworkingwithCYPassessespatients,plansandimplementscare,providesspecialistadviceandmaintainsassociatedrecords.Theycarryoutspecialistnursingassessmentsandinterventionsrelatedtotheirspecificareaofpracticeorpatientgroup.Clinicalsupervisionofotherstaffandstudentsispartofthisroleandtheymayalsoundertakeresearchandleadclinicalauditsintheirownspecialistarea.
Exemplar nursing roles: Specialist nurse
Paediatric renal nurse coordinator (Northern Ireland)Thepaediatricrenalnurseco-ordinatorisanursespecialistdeliveringcarethatisbothhospitalandcommunitybased.Educationisamajorcomponentofthisrole,preparingfamiliesfordialysis,transplantationandcareofchildrenwithcomplexmedicalneeds.Homeassessmentsarecarriedoutpriortocommencementofhomeperitonealdialysisandalbumintherapy.Staffandparentshavecompetencytrainingfromthenursespecialistpriortotreatment.Frequentliaisonwiththecommunityteamisessentialforhomesupportforbothpracticalandpsychologicalissues.Thenursespecialistco-ordinatesaweeklydialysis/transplantclinicandcarriesoutnurse-ledreviewswhenneeded.Anincreasinglydemandingremitoftheroleislive-relateddonorprogrammesworkup,includingvaccinationprogrammes,requiringliaisonlocallywithadultunitsandnationallywithunitstransplantingchildren.Anassistedperitonealdialysisprogrammewithacommunityagencyhasaddedtrainingandreviewsofhealthcareassistantstotheeducationalcomponentoftherole.Other
responsibilitiesinclude:transitionofyoungadultstoadultunits;on-calltelephoneadviceserviceforstaffcaringforrenalinpatientsandalsoforparents;linklectureratthelocaluniversityforpreandpostregistrationprogrammes;co-ordinationofaregionalhaemodialysis,peritonealdialysisandrenaltherapiesserviceandmanagementofthenursingteamdeliveringthatservice.(SeeAppendix4foradditionalexemplarofthespecialistnurserole.)
Exemplar nursing roles: Advanced nurse practitioner
Secondary care (paediatric assessment and observation unit – Calderdale and Huddersfield)Ashort-staypaediatricassessmentandobservationunit(PAOU)openedatHuddersfieldRoyalInfirmaryin2008.ThisunitwasinitiallystaffedbyAPNPswithsupportfromspecialistregistrars(SPRs),however,withreducednumbersofSPRsitisnowstaffedandmanagedbysixAPNPs,withsupportfrompaediatricstaffnursesandprovidesa24hour,sevendaysaweekservice.
TheunittakesmostofitsreferralsfromA&E,withGPreferralsgoingtotheCalderdaleRoyalHospital(CRH).TheAPNPsattendpaediatricemergenciesintheresuscitationunit,assessacutelyunwellchildrenintheA&Edepartmentanddecidewherethechildshouldbenursed,followingastrictoperationalpolicy.Consultantinputisavailable24hoursaday.Telephoneadviceisavailablefromeithertheon-callconsultantpaediatricianorthespecialistpaediatricregistraratCRH.Anaesthetistsareavailableintheeventofanemergency.Theunithas12beds;medicalpatientscan
Advanced nurse practitioner AnadvancednursepractitionerworkingwithCYPisahighlyexperiencedandknowledgeablenurse,educatedtomaster’slevelandabletouseclinicaljudgementandautonomousdecisionmakinginrelationtotheassessment,diagnosis,managementandevaluationofcare.Advancedchildren’snursepractitionerrolesmayencompassaspectsofeducation,researchandmanagementbuttheyarefirmlygroundedindirectcareprovisionorclinicalworkwithpatientsandfamilies.
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Exemplar nursing roles: Consultant nurse
Acute care – Children’s consultant nurse (Salford NHS Foundation Trust)SalfordRoyalNHSFoundationTrust(SRFT)isateachinghospitalwithamajortraumacentreforadultsandtraumaunitforchildren;ithasnoinpatientchildren’sservices.Inresponsetolocalpopulationhealthcareneeds,achildren’sobservationandassessmentunithasbeendevelopednexttothemainemergencydepartment.ThePaediatricAssessmentandDecisionAreaunit(PANDA)clinicallymanages20,000acutelyillorinjuredchildrenannually.PANDAisopen24hoursadayandchildrencanbeadmittedforshortstayupto24hours.
Itisstaffedjointlybyadualrotaofemergencyphysiciansandconsultantpaediatricians,andalsoincludesachildren’sconsultantnurse.Theconsultantnursebothleadsandmanagesateamofadvancedpractitionerswhodeliver24hourcaretosickandinjuredchildren.PANDAhasnomiddlegradedoctorsbutdoeshavejuniordoctorswhoareGPtrainees.Theconsultantnursenotonlyleadsthenursingteambysettingthequalityandstandardofbedsidecare,butalsoengagesinorganisationalandoperationaldevelopmentatlocal,regionalandnationallevel.
involvedwithseveralnationalworkinggroupsonpolicydevelopmentwithinthefieldofpaediatricdiabetesandnursing.(SeeAppendix4foradditionalexemplaroftheadvancednursepractitionerrole.)
Consultant nurse AconsultantnurseworkingwithCYPprovidesexpertclinicalcareasanautonomouspractitioner.Theyleadonresearchintheirareaofpracticeandprovideeducationandtrainingtothewholeofthemultidisciplinaryteam.Aconsultantnursehashighlydevelopedexpertknowledge,underpinnedbytheoryandexperienceandisabletodevelopspecialisedprogrammesofcare,initiatecarepackagesandprovideexpertadviceconcerningcareneeds.Consultantnurseswillleadonpolicyimplementationandservicechangeswithintheirownserviceandmayadviseonservicedevelopmentorpolicybeyondtheirownarea.Theywillprovidestrategicleadershipatthelocal,regional,nationalandinternationallevels.
stayforthedurationoftheirillness,unlesscomplicationsarise,inwhichcasetheyaretransferredtotheCRHpaediatricward.
AstudybyBasuandGarside(2012)showedthattherewasnosignificantdifferenceinpatientoutcomefromthosepatientsseenbydoctorscomparedtoAPNPsandnosignificantdifferenceindischargeandreadmissionrates,whichinstilsconfidenceinitsabilitytosafelycaterforanincreasedthroughputinthefuture.Theaddedbenefitforparentsandchildrenisthattheyarenearertohomeand,inrecentaudits,parentshavecommentedonthebenefitofbeingonasmallerunitwheretheyareassessedandtreatedmuchmorequickly.
Exemplar nursing roles: Advanced nurse practitioner
Specialist care – paediatric diabetes (Manchester)TheroleofadvancedpractitionerindiabetesatRoyalManchesterChildren’sHospital(RMCH)wasestablishedin2007toprovideserviceconsistencyanddevelopment.ThiswasinresponsetogapsinmedicalstaffworkingrotasasaresultoftheEuropeanWorkingTimeDirective(EWTD)andtheshortageofmiddlegrademedicalstaffrecruitedintopostsfollowingchangestomedicaltraining.Theadvancedpractitioneriseducatedtomaster’slevelandisanon-medical,independentprescriber.Therolecrossesprimary,secondary,tertiaryandquaternarycareforchildren,youngpeoplewithallformsofdiabetes,andtheirfamilies.
Theroleencompassesarapidaccessnurse-ledclinic;thedevelopmentandinitiationoftreatmentplansforpre,periandpost-operativediabetesmanagementforCYPundergoingsurgicalproceduresandtheexamination,assessment,diagnosisandtreatmentofhyperglycaemiaand/ordiabetesinresponsetodrugtherapies,inCYPundergoingtreatmentsandproceduresforothermedicalandsurgicalconditionsfromacrosstheregion.ItalsoincorporatesthecareofCYPwhodevelopdiabetesasasecondaryconditionorasacomplicationofaprimarydiseaseprogressionsuchascysticfibrosis-relateddiabetes.
Indirectpatientcaretimeinvolvesresearch,audit,andeducationalaspectstotherole–bothlocallyandnationally.Thepostholderis
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Educationisamajorpartoftheconsultantnurserole,deliveringevidence-basedideastothemultidisciplinaryteam.Researchandauditareundertakenintothecareofacutelyillandinjuredchildren,withtheultimateaimofimprovingclinicaloutcomesforchildrenandfamilies.
Thephilosophyofthechildren’sserviceiscareclosertohome.Oncereadytogohome,dischargeisledbytheacutechildren’scommunitynursingteam(CCN).Theunithasdemonstratedaneffectiveservicemodel.
• Eightyfivepercentofchildrenareseenandtreatedwithinthefourhouremergencycarestandard.
• Lessthan13%ofchildrenwithacuteillnessorinjurywillbeadmittedtoanobservationbedonPANDA,withtheaveragelengthofstayofaroundelevenhours.
• Therehasbeenareductionfrom16%to2%ofchildrenbeingadmittedfromanemergencydepartmenttopaediatricinpatientbed.
(SeeAppendix6foradditionalexemplaroftheconsultantnurserole.)
GovernanceandadvancedpracticeAdvancednursingpracticeintheUKisnotcurrentlyregulatedeitherbystatuteorbytheprofessionalregulatorofnursing,theNursingandMidwiferyCouncil(NMC).TheNMChas,sofar,resistedcallsfromtheprofessiontointroduceanadditionaltierofregulationforadvancednursesandhasbeensupportedinthisbythefindingsoftheCouncilforHealthRegulatoryExcellence(CHRE)whichhasarguedthatprofessionalcodesofconduct,suchasthatgoverningnursing,provideadequatesafeguardstothepublicthroughitsstatementthatpractitionersmustpracticewithintheboundsoftheirknowledge,skillsandcompetence(CHRE,2009;NMC,2008).
Whilstthishasbeentakenasanargumentagainstregulation,theNMCitself,andanumberofothercommentatorshavearguedthattheremay
besomesituationswherenewrolescarrywiththemsuchsignificantchangesinprofessionalboundariesthattheymayindeedcarryriskstothepubliciftheyarenotregulated.ThisissupportedbyafurtherstatementfromtheCHREthat,“wherethenatureofaprofession’spracticechanges…tosuchasignificantextentthattheirscopeofpracticeisfundamentallydifferentfromthatatinitialregistration,regulatorybodiesmayneedtoconsiderwhetheractionisnecessarytoassuretheprofessional’sfitnesstopracticeinthecontextofaverydifferentnatureofpracticewhererisktothepublicisevident,”(CHRE,2009).
Thereisaperceiveddegreeofriskassociatedwiththehigherlevelsofautonomy,rolecomplexityanddecisionmakinginvolvedinadvancedlevelpracticeandthereforelocalandprofessionalgovernanceframeworksrequirerecognisedandagreednationalstandardstoensurepublicprotection(BrookandRushforth,2011).TheGovernment’smostrecentguidanceonprofessionalregulationsetoutinthecommandpaperEnabling excellence – autonomy and accountability for health and social care staff(DH,2011),confirmedthepositionthatemployersandcommissionersareprimarilyresponsibleforensuringthattherearerobustorganisationalgovernancearrangementssurroundingalltypesandlevelsofpractice.ThereportoftheMidStaffordshireNHSFoundationTrustPublicInquiry(2013)(knownastheFrancisInquiry)highlightedtheneedforaccountabilityandpatientsafetyatalllevelsofahealthcareorganisation.Asaresultofthereporttherehasbeenafocusonprofessionalregulation,particularlytheunregisteredworkforce.However,theprinciplesofaccountability(embeddedinthereport’srecommendations)makeitimperativethatorganisationsestablisheffectiveframeworksofclinicalgovernanceinallaspectsofservicedelivery.
Robustgovernanceisthereforerequiredtosupportthedevelopmentandimplementationofroleswhichrequireanursetoworkatanadvancedlevel(Rutherfordetal.,2005;ScottishGovernment,2010).Effectivegovernanceshouldenableemployerstoplanforserviceredesign.Theyshouldbeabletodevelopnewadvancednursingrolesinatargetedway,articulatingtheminimumrequirementswhendeterminingtheplanning,implementation,evaluationandon-goingmonitoringofanadvancedorextendedscopeofpracticerole(RCN,2012;RCN,2013).Nursingrolesshouldbebasedondemonstrablepatientandserviceuserneed.Governanceshould
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beconsistentwithbenchmarkingoftheserolesatrecognisedlevelsofpractice,bothintermsofexpectationsofcompetenceandeducationalpreparation.Robustgovernancebybothemployersandprofessionalbodiesisrequiredtoensurethatrolesaremonitoredandtopreventtheuseoftitlesbynursesthatinferlevelsofclinicalexpertisethatcannotbeverified(RCN,2012).
Whilstorganisationshaveresponsibilityforestablishingaframeworkwithinwhichtheiremployeespractice,theindividualpractitionerremainsaccountablefortheirownactionsanddecisionmakingwhenworkingwithinthatframework.
TheNLIAHadvisedthataspartofanationalgovernanceframework,healthboardsinWalesshoulddevelopandmaintainadatabaseofadvancedpractitioners(NLIAH,2011).TheScottishGovernmenthasrecommendedthatadvancedpracticelevelshouldbedemonstratedthroughaportfoliooflearningtoverifyroledevelopmentandcompetency(ScottishGovernment,2010).Intheabsenceofanycentralregulationoftrainingorregistrationofadvancedpracticenurses,portfoliosalsoprovidearobustmechanismoflocalmonitoring(Dean,2013).Localandprofessionalgovernanceframeworksmustincludetrainingandeducationstrategies.Theseshouldincludecontinuingprofessionaldevelopment,withassessment(andreassessment)criteriaandcompetencyframeworksagreedonbyclinicians,managers,practitionersandassessors(Bartonetal.,2012;RCN,2012).Itisrecommendedthatsuchframeworksshouldnotincludeonlythenursingprofession,butshouldbesharedwithmultidisciplinaryteams.Sharedmodelsofgovernanceenabletheorganisationtoensurethatthe,“rightclinicianisperformingtherightservicetotherightclientattherighttimeintherightplace,’’(SouthAustraliaDepartmentofHealth,2013).
Benner’s level Role Educational level
Novice Newlyregisteredstaffnurse
Degree,plusinitialregistration
Advancedbeginner
Staffnurse Completedin-houseeducationprogramme
Competent Specialistpractitioner
Degree/moduleinspecialistpractice
Proficient Advancedpractitioner
Master’s
Expert Consultantnurse
PhD
EducationtrainingandprofessionaldevelopmentTheeducationalpreparationofspecialistandadvancedpractitionersiscriticalinensuringthattheirclinicalpracticeissafe,evidencebasedandeffective.ManyadvancedpracticeandspecialistrolesinCYPnursinghavedevelopedtomeetveryspecificserviceneeds,ratherthandevelopingaspartofacoherentlocalornationalworkforceplan.Duetoalackofstrategicdirectionbyemployersandregulators,nursesundertakingsuchrolesmayhaveundergoneverydifferenteducationalpreparation.Therearenowagreednationalandprofessionalstandardsthatshouldbemetbythoseundertakingadvancedpractitionerroles(NMC,2006;ScottishExecutive,2008;NLIAH,2011;DH,2011;RCN,2012).Thefollowingtableshowstherelationshipbetweenlevelsofexperience,clinicalrolesandeducationallevel.Table1:Therelationshipbetweenlevelsofexperience,clinicalrolesandeducationallevel
Adaptedfrom:Benner(1984)Novice to expert: Excellence and power in clinical nursing practice.MenloParkCA,Addison-WesleyPublishingCompany,pp13-34.
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Exemplar: Education programme CardiffSchoolofHealthcareSciencesatCardiffUniversityprovidesanMScinadvancedclinicalpractice.Thisisagenericcourseprovidingveryspecificadvancedpracticeoutcomes,whicharealignedtotheclinicalspecialty.Thiscourseisvalidatedsothatgenericadvancedpracticecompetencesarealignedwiththestudent’sclinicalareaofpracticeandtherequirementsoftheiremployer.Aclinicalmentorisappointed(normallyamedicalconsultantoranotheradvancednursepractitionerfromthespecialty)whoundertakesclinicalteachingandassessmentwiththestudent.Alongsidethis,thestudentcompletesmodulesinevidence-basedpractice,advancedpracticeandaworkplace-basedproject,allofwhichencouragethestudenttoexploreadvancedpracticewithintheirspecific(actualorplanned)roleandclinicalsetting.
Core components of educational programmesAdvancedpractitionerprogrammesmayvaryinhowthecurriculumisconstructed,howeverthefollowingcorecomponentsshouldbeeasilyidentifiable(RCN,2012).
• Comprehensivehealthassessmentincludingphysical,psychological,emotionalanddevelopmentalassessmentacrossthelifespan.
• Managementofhealthandillnessacrossthelifespanincludingphysical,sociological,psychological,emotionalandculturalaspects.
• Historytakingandclinicaldecision-makingskills/clinicalreasoning.
• Appliedpharmacologyandevidence-basedprescribingdecisions.
• Publichealthandhealthpromotion.
• Research/evidence-basedpracticeandapplication.
• Organisational,interpersonalandcommunicationskills.
• Accountability–includinglegalethicalandgovernanceissues.
• Qualityassurancestrategiesandprocesses.
• Advancedchangemanagementandleadershipskills
Nursespractisingatanadvancedlevelshouldbeabletodemonstrateclinicalexpertise,applyin-depthknowledgeandmakeclinicaldecisionsthroughhighlevelsofanalysisandcriticalthinking(ScottishExecutive,2008).Thislevelofpracticeissimilartotheeducationaldescriptorsformaster’slevellearning,andprogrammespreparingadvancedpractitionersarethereforebasedinhighereducation.Therearemanyadvancedpractitionersworkingwithchildrenandyoungpeoplewhohavenotyetundertakenmaster’slevelpreparationduetothewaytheirrolehasdeveloped.Theyshouldbeabletodemonstratemaster’slevelthinkinganddecisionmakingthroughthedevelopmentofaportfolio.Theymaychoosetoundertakesomeformofpostgraduateeducation,makingfulluseofsystemsfortheaccreditationofpriorexperientialandlearning(APEL).NotallconsultantnurseshaveaPhD,buttheytooshouldbeabletodemonstratethattheirpracticeisatthelevelalignedtoaclinicaldoctorate.
Choice of programmeWhendecidingwhichadvancedpracticeeducationalprogrammetoundertakeCYPnursesfacealimitedchoiceofprogrammesthatspecificallyaddresstheneedsofchildrenandyoungpeople.Wherespecificprogrammesareavailable,forexample,theadvancedneonatalpractitionercourse,thesemaynotbegeographicallyconvenient.ManyadvancedpracticeprogrammesaremuchmoregenericinnatureandCYPnursescanundertakethesetoachievetheeducationallevelrequired;itisthentheroleofthestudentadvancedpractitionertoapplythecontentofthecoursetotheirareaofpractice.ForCYPnursesworkinginmentalhealth,forexample,themajorityofprogrammesarelargelyadultfocussed.Althoughthisischallenging,therangeofrolesandcareenvironmentsthatadvancedpractitionersworkwithinmeansthatmanystudentsundertakingthesecoursesfacesimilarissues(seeExemplarbelow).ThoseundertakingadvancednursingroleswithCYPshouldhaveinitialpreparationandregistrationasachildren’snurseandappropriatementorshipfromwithintheirpracticearea.
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Mentorship and clinical assessmentItisessentialthatadvancedpractitionersmeetboththedesirededucationalandclinicallevelofcompetence.Advancedpractitionerprogrammeswillnormallycontainaclinicalassessmentandthesetakemanyforms.Commonly,aportfolioapproachisusedandstudentsdemonstratetheirachievementofadvancedpractitionercompetencesduringtheirclinicalwork.Theremaybearequirementforasetnumberofclinicalhourstobeachievedduringtheprogrammeofstudy.Thismaybecomplementedbyclinicalexaminationsthattakeplaceinasimulatedenvironmentorinthestudent’sareaofpractice.Assessmentofclinicalcompetenceatthislevelisoftenatripartiteactivityinvolvingthestudentadvancednursepractitioner,thementorandauniversitylecturer.
WithinCYPnursing,interdisciplinaryrolesandeducationarebecomingmorecommonplacethaneverbefore.Withinthismatrixofeducationallevel,clinicalskillsandinter-professionalroles,itisessentialtoensurethatmentorshipforthoseaspiringtospecialistandadvancedpracticerolesisundertakenbyprofessionalswithprofession-specificeducationalpreparationandclinicalpracticeroleswithCYP;thementormustpossesstheclinicalskillsandknowledgetheadvancepractitionerisseekingtodevelop.Thismeansthatmentorsshouldnormallyalsohaveundertakentherelevantprofessionalpreparationtoworkwithchildrenandyoungpeople.
Oncetheadvancedpractitionerisinpostitisessentialthattheygainsupport,supervisionandfurthermentorshipintheirrole.Nursesworkingatanadvancedlevelwillneedsupportfromtheiremployertoensurethattheycanaccessrelevantcontinuingprofessionaldevelopment(CPD).Manyemployerssetaratioofclinical,managerialandCPDtimetoensurethatadvancedpractitionersremainuptodate,forexample,50%clinical,25%managerialand25%CPD.ItisvitalthatcommissionersandemployersrecognisetheneedforCPDandbuildthisintofundingandplanningofadvancedpracticeposts.CPDmayconsistofmanydifferentactivitiesandmaybemulti-professional,forexample,attendingauditmeetingsorconductingjointclinics.Itmaybemoreformal,includingCPDmodulesandonlinelearning.Currently,nursesregisteredwiththe
NMCarerequiredtoundertake35hoursofCPDeverythreeyears.TheforthcomingNMCsystemofrevalidation1willrequirenursestodemonstratetheirfitnesstopractiseandwillrequirethenurse’smanageroremployertovalidatetheiron-goingcompetenceandabilitytodeliversafeandeffectivecare.Thiswilltakeplaceatthepointofre-registration,everythreeyears.
Educating others Advancedpractitionersarewellplacedtoplayaroleineducatingothers.Practisingatanadvanced,autonomouslevel,theadvancedpractitionerwillhavetheskillsandknowledgethatcanassistothernursesandhealthcarepractitionerstodeveloptheirownskills.Educationwillbemulti-professionalandadvancedpractitionersmaybeinvolvedinthesupervisionandeducationofjuniormedicalstaffandotherprofessionals.Advancedpractitionersarealsowellplacedtodevelopclinical/academicorclinical/researchcareers,contributingtobothclinicalcareandeducation/researchwithintheirrole.
Career frameworksFlexibleandtransparentcareerpathways,whichareresponsivetochanginghealthcareneeds,havethepotentialtoimprovethepatientexperiencethroughensuringhighqualityevidence-basedcareattherighttime,intherightplaceandbytherightperson(ScottishExecutive,2006).Careerframeworkscanalsoclearlyindicatetocommissionersthekeyattributesofaspecialistnurseoranadvancedpractitionerandcandemonstratetheacquisitionoftherelevantknowledgeandskillstofacilitatedeliveryofeffectiveprovisionofcareattherequiredlevel.
National generic competency-based frameworksSkillsforHealthisanationalgovernmentinitiativewhichaimstodeliveraskilled,flexibleworkforcethroughacompetency-basedcareerframework(SkillsforHealth,2010).Theframeworkidentifiesninelevelsofpractice(1=entry,throughto9=seniorstaff)thatarealignedtojobrolesandcompetences(SeeAppendix2).KeyelementsoftherolehighlightedatLevel7foradvancedpractitionersinclude,“Experiencedclinical
1Atthetimeofpublicationrevalidationwasonlyaproposaltobeimplementedby2015.Theexactnatureoftherevalidationprocesswillnotbedecideduntilnearerthattime.www.nmc-uk.org/Nurses-and-midwives/Revalidation/
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professionalswhohavedevelopedtheirskillsandtheoreticalknowledgetoaveryhighstandard.Theyareempoweredtomakehighlevelclinicaldecisionsandwilloftenhavetheirowncaseload.”
CompetenceswithintheSkillsforHealthframeworkarealsolinkedtoNationalOccupationalStandards(NOS)andNationalWorkforceCompetence(NWC);bothofwhichareworkstreamsofSkillsforHealth.TheyarealsolinkedtotheNHSKnowledgeandSkillsFramework(KSF).NOSarecurrentlyonlymandatoryinScotland,althoughtheyareincreasinglyconsideredgoodpracticeastheyfacilitateclosealignmentbetweeneducationalprovisionandworkforcelearningneeds,andtheymustbeapprovedbyeducationalregulatorybodies.Capabilityframeworkshavealsobeenputforwardasameansofdevelopingbeyondcompetencetosupporttheapplicationofknowledgeandskillsacrossarangeofcomplexandchangingsettings,butagainareonlycurrentlyincommonuseinScotland(ScottishExecutive,2008).
Specialty specific competency frameworksCondition-specificintegratedcareerandcompetencyframeworkshavebeendevelopedinareassuchasdiabetes,epilepsyandoncology(TREND,2011;Deakin,2011;RCN,2012).Theseframeworksprovideusefulinformationforcommissionersandemployersregardingthelevelofstaffandtheskillsrequiredtomeetpatientneedsatvariousstagesoftheirillness.Theseframeworkscanfacilitatepersonaldevelopmentastheyhelpidentifykeymilestonesincareerprogression;forhighereducationinstitutions(HEI)theyhelpidentifytheskillsandknowledgerequiredatvariouslevelsofcare,whichcaninformeducationandtrainingneeds;foremployerstheycangiveassurancethatpractitionershaveacquiredtheskillsandknowledgerequiredforaparticularrole.
Clinical academic training pathway Theimportanceofintegratingeducation,researchandpractice,andincreasingresearchcapabilityinordertoensurebestpatientcarehasbeenhighlightedinrecentpolicyinitiativesfromboth
theNationalInstituteforHealthResearch(NIHR,2013)andtheDepartmentofHealth(DH,2012b).TheCareerPyramid(SeeAppendix5)seekstoillustratetheimportanceofclinicalpracticeexpertiseandacademicachievementdevelopingintandem.Manyorganisationshaveimplementedblendedclinical/academicrolestoachieveintegrationintheseareas,however,practicalandcontractualdifficultieshavetobeovercomeinordertoestablishtheseroleswithintheNHS,otherhealthcaresettingsandHEIs.
TheDepartmentofHealthandtheAssociationofUKUniversityHospitals(AUKUH)havedevelopedaNationalClinicalAcademicDevelopmentGroupforNurses,MidwivesandAlliedHealthProfessionalswhichfocusesonclinicalacademictraining(AUKUH,2013).Appendix6illustratesacareerpathwaymappedbyAUKUHtofacilitatecareerprogressioninadvancedrolesfornursesandotheralliedhealthprofessionalsfrommaster’sthroughtoclinicaldoctorateandclinicalfellowshipawards(AUKUH,2013).
Role of the clinical academic researcher AccordingtoAUKUHaclinicalacademicis, “anurse,midwifeoralliedhealthprofessionalwhoengagesconcurrentlyinclinicalpracticeandresearch,”(DH,2012b).Theroleprovides,“clinicalandresearchleadershipinthepursuitofinnovation,scholarshipandtheprovisionofexcellentevidence-basedhealthcare.”Acentralfeatureofaclinicalacademic’sresearchisthatitaimstoinformandimprovetheeffectiveness,qualityandsafetyofhealthcareprovision.Theclinicalacademic’sfocusisonbuildingaresearchandevidence-ledcareenvironment,includingthedevelopmentofresearchcapacityandcapability.Theychallengeexistingpracticeaswellasworkingwithin,andcontributingto,aresearch-richenvironmentthatisintendedtoleadthewaytowardsachievingexcellenceinhealthcareandhealthoutcomes.
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Exemplar role: Clinical academic researcher Thischildren’sdiabetesnursespecialistholdsajointappointmentwiththeRoyalManchesterChildren’sHospitalandtheUniversityofManchesterasaclinicalacademicresearcher.AftersuccessfullycompletingaPhD,shecontinuestobuildonherresearchpositionandclinicalexperiencetoachieveherultimateambitionofdevelopingacareerasaclinicalacademicnurseresearchleaderinCYPhealthcare.Hercurrentresearch-relatedactivityinvolvesengagementwithschoolsandthesupporttheyprovidetoCYPwithtype1diabetes(T1D).LackofsupportinschoolsforCYPwithdiabetesisanationalclinicalpriorityandasacliniciansheiscommittedtoworkingtowardsimprovingstandardsofcareforCYPwithT1Dinschoolslocallyandnationally.Workingasaclinicalacademicnurseresearchermeansthatshecandevelophigh-qualityevidenceandresearchthathasaspecificfocusonthecareCYPandtheirfamiliesreceive,aswellastheeffectivenessandproductivityofclinicalservices.Therefore,thedualroleoftheclinicalacademicnurseresearcherenablesclinicalpracticetoinfluenceresearchandresearchtoinfluencepractice.
ConclusionItisincreasinglyacknowledgedthatchangeisneededtomakehealthcareservicesforchildrenandyoungpeoplesafeandsustainable,andtoimprovetheirhealthoutcomes.Thesechangescannothappenwithoutchildren’snursesdevelopingtheirlevelofpracticealongsidemedicalcolleaguesandothermembersofintegratedmultidisciplinaryteams.
Children’snursesworkingatspecialist,advancedandconsultantlevelacrossarangeofhealthcaresettingsmakeasignificantcontributiontothehealthandwellbeingofCYPandtheirfamiliesandtotheirexperienceofhealthcareservices.Theyworkasautonomouspractitionersandintegralmembersofmultidisciplinaryteams,atallstagesinthepathwaythroughawidediversityofcaresettings.Theydevelopservices,leadteams,educateothersandleadorparticipateinresearch.
Thedevelopmentofsuchinnovativenursingroles,workingatanadvancedlevelofpractice,requiresaplannedapproachtothecommissioninganddevelopmentofservices,andoftheworkforcethatisabletodeliverthem.Robust,flexibleandaccessibleeducationalprogrammesandthedevelopmentofcomprehensivecareerframeworksareneededtoenablenursesatalllevelstoaspiretotheserolesinordertomeettheneedsofchildren,youngpeopleandtheirfamilies,andtoimprovetheirhealthoutcomes.
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Appendix1:Workforceplanningtool
Workforce planning tool
Stage 1 - define the future service provision and plans
Stage 4 - planning for delivery
Stage 5 - proposals for performance management review
Stage 6 - recommendations for workforce development
Stage 2 - analysis of current vision, workforce configuration
Stage 3 - forecast workforce requirements and configuration to meet service need (including risk assessment)
ReproducedwithkindpermissionofWorkforce,EducationandDevelopmentServices,NHSWales.
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Appendix2:Keyelementsofthecareerframework
Reproducedwithpermission.SkillsforHealth(2010)The Career Framework.
Career Framework Level 9People working at level 9 require knowledge at the most advanced frontier of the field of work and at the interface between fields. They will have responsibility for the development and delivery of a service to a population, at the highest level of the organisation. Indicative or Reference title: Director9Career Framework Level 8People at level 8 of the career framework require highly specialised knowledge, some of which is at the forefront of knowledge in a field of work, which they use as the basis for original thinking and/or research. They are leaders with considerable responsibility, and the ability to research and analyse complex processes. They have responsibility for service improvement or development. They may have considerable clinical and/or management responsibilities, be accountable for service delivery or have a leading education or commissioning role. Indicative or Reference title: Consultant
8Career Framework Level 7People at level 7 of the career framework have a critical awareness of knowledge issues in the field and at the interface between different fields. They are innovative, and have a responsibility for developing and changing practice and/or services in a complex and unpredictable environment. Indicative or Reference title: Advanced Practitioner7Career Framework Level 6People at level 6 require a critical understanding of detailed theoretical and practical knowledge, are specialist and /or have management and leadership responsibilities. They demonstrate initiative and are creative in finding solutions to problems. They have some responsibility for team performance and service development and they consistently undertake self development. Indicative or Reference title: Specialist/Senior Practitioner
6
Key Elements of the Career Framework
Career Framework Level 5People at level 5 will have a comprehensive, specialised, factual and theoretical knowledge within a field of work and an awareness of the boundaries of that knowledge. They are able to use knowledge to solve problems creatively, make judgements which require analysis and interpretation, and actively contribute to service and self development. They may have responsibility for supervision of staff or training. Indicative or Reference title: Practitioner
5Career Framework Level 4People at level 4 require factual and theoretical knowledge in broad contexts within a field of work. Work is guided by standard operating procedures, protocols or systems of work, but the worker makes judgements, plans activities, contributes to service development and demonstrates self development. They may have responsibility for supervision of some staff. Indicative or Reference title: Assistant/Associate Practitioner
4Career Framework Level 3People at level 3 require knowledge of facts, principles, processes and general concepts in a field of work. They may carry out a wider range of duties than the person working at level 2, and will have more responsibility, with guidance and supervision available when needed. They will contribute to service development, and are responsible for self development. Indicative or Reference title: Senior Healthcare Assistants/Technicians
3Career Framework Level 2People at level 2 require basic factual knowledge of a field of work. They may carry out clinical, technical, scientific or administrative duties according to established protocols or procedures, or systems of work. Indicative or Reference title: Support Worker2Career Framework Level 1People at level 1 are at entry level, and require basic general knowledge. They undertake a limited number of straightforward tasks under direct supervision. They could be any new starter to work in the Health sector, and progress rapidly to Level 2. Indicative or Reference title: Cadet1
© Skills for Health, 2010. All rights reserved.
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Appendix3:Keycharacteristicsofadvancedpracticeacrossthefourdomains
1. Management and Leadership• Identifyneedforchange,utilisechangemanagementskillstoimplementchangeeffectivelyto
aidservicedevelopment
• Negotiationskills
• Networking
• Teamdevelopment
• Escalation/takingactionwhenpoorpracticeidentified
• Clinicalsupervision
• MentoringandCoaching
2. Education• Principlesofteachingandlearningtoserviceusersandcareproviders
• Supportothersindevelopmentofknowledgeandskills
• PromoteaneffectivelearningenvironmentandimpactofeducationDevelopmentofpolicy/protocols/guidelinesandeducationalmaterials
• Teaching,mentoring,supervisionandcoaching
• Influenceeducationalcurriculum
3. Research• Abilitytoaccessandutiliseinformationsystems
• Skillsincriticalappraisalandevaluationofresearch
• Involvementinresearch/audit
• Implementationofresearchintopractice
• PublicationsandConferencepresentation
• Dissemination
4. Advanced Clinical Practice• Criticalthinking,decisionmaking/advancedclinicaljudgementandproblemsolving
• Analyticalskillsincludingcriticalreflection
• Managingcomplexityincludingethicaldecisionmaking
• Clinicalgovernance/riskmanagement
• Assessment,diagnosis,referral,discharge
• Assessmentandmanagementofrisk:seeabove
• Non-medicalprescribing
• Higherlevelcommunicationskills
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Appendix4:Exemplarnursingroles
Specialist nursePaediatric epilepsy nurse specialist (Calderdale and Huddersfield) Thisroleiscomplexandvaried,providingexpertsupportforchildrenwithepilepsy,includingclinicalinterventions,psychologicalandsocialsupporttoparentsandfamilies,deliveringeducationandraisingawareness.Thenursespecialistisanindependentnurseprescriberanddeliversmanyofthesameactivitiesasapaediatricconsultant–suchasmedicationreviewsandmonitoring;clinicalassessments;safetyissues;adviceonlifestyle,futurecareers,relationshipsandsexualhealth.Thenursespecialistvisitsschoolstoeducateteachersandpeers,aswellasGPsurgeriestoadviseonmanagementandmedication.Therolealsoinvolveshomevisits,telephoneadviceandactsasalinktootherservices.Sheprovidesspecialisedknowledgeatclinicsandliaiseswithadultteamstoevolveappropriatetransitiontoadultcare.Thisroleoffersastreamlinedandholisticservice,iseasiertoaccessforpatientsandreducesconsultantworkload,whichleadstocostsavings.
Advanced nurse practitionerSecondary care – ambulatory and high dependency (NHS Ayrshire and Arran)Thechildren’sservicehasdevelopedtwoAPNProles;oneforambulatorycareandoneforhighdependencycare.TheAPNPshaveprovidedanidealopportunitytoenhancethechild’scarejourneybyblendingtheirtraditionalnursingskillswiththoseusuallydeliveredbyjuniorandmiddlegrademedicalstaff.Theydeliveradvancedpaediatricknowledge,skillsandcompetencesinallhealthcaresettingswherechildrenareseen,assessedandtreated.Theabilityofthepostholderstotakeamedicalhistory,undertakeaclinicalexamination,orderinvestigations,interpretresults,reachadiagnosisandprescribemedicationhaveimprovedthequalityandsafetyofcaredelivered.Theyhaveprovidedleadership,educationofselfandothers,andusedtheirresearchskillsintheclinicalarea.
Theserviceisnowsupportingtheeducationandtrainingoftheir‘WellChildNurse’onacareerpathwaytoanAPNP.Thisrolewilldeliveraholisticservicespanningchildrenandyoungpeople’s
healthcareneedsinacuteandcommunitysettings,helpingpreventchildren’shospitaladmissionsandtofacilitatetimelyandappropriatedischarges/transfersofcarefromhospital.
Consultant nurseNurse consultant for paediatric and adolescent diabetes (University College London)ThedesignatedleadnurseforchildrenandyoungpeoplewithdiabetesatUCLHprovidesprofessionaladvice,leadershipanddirectiontotheclinicalnursespecialistdiabetesteamandpaediatricdiabetesdietician.Thisleadershipremitalsoextendstoawideraudience,withanexpectationtoimproveandinfluencenationalpolicymakingforchildrenwithdiabetes.Thenurseconsultantalsocontributestoanumberofnationalworkinggroups.
TheremainingportionoftheroleisspentdevelopingeducationalandresearchprogrammestosupportthepostandisalsoanhonoraryseniorlectureratCityUniversity.Thisrolewasestablishedtodecreasewaitingtimesandoptimisethepathwayfornewreferralsintotheservice,specificallyforinsulinpumptherapy.Therolehasreducedwaitingtimestolessthantwoweeksfornewappointmentsandhassignificantlyshortenedthewaitingtimeforchildrenandyoungpeopletoinitiateinsulinpumptherapy.
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Appendix5:CareerPyramidCareer framework
Band 8
Band 9
Band 7
Band 6
Band 5Degree
Masters
PhD
Professor
Level M module
Consultant
Advanced Generalist or Specialist
Generalist or Specialist
Registered Practitioner
Clinical Professor
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Appendix6:AUKUHClinicalacademiccareerpathway
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Reproducedwithpermission:AUKUH (2013) AUKUH Clinical Academic Careers Group Report of Activity 2011 to 2012.London:AUKUH.Availableat:www.aukuh.org.uk/index.php/affiliate-groups/nmahps/progress-report[Accessed22January2014]
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TheRCNrepresentsnursesandnursing,promotesexcellenceinpracticeandshapeshealthpolicies
June 2014, Review date: June 2017
PublishedbytheRoyalCollegeofNursing20CavendishSquare London W1G0RN
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