Specialist and advanced children's and young …€™s nursing practice in contemporary health ......

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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Royal colleGe of nuRsinG

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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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.

22


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.

23


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.

24


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.

25


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.

27


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

28


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TheRCNrepresentsnursesandnursing,promotesexcellenceinpracticeandshapeshealthpolicies

June 2014, Review date: June 2017

PublishedbytheRoyalCollegeofNursing20CavendishSquare London W1G0RN

02074093333

RCNOnlinewww.rcn.org.uk

RCNDirect www.rcn.org.uk/direct03457726100

Publicationcode:004579

ISBN978-1-910066-23-2

www.twitter.com/thercn

www.facebook.com/royalcollegeofnursing

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