Policy on adherence to Clinical Nursing / Midwifery Procedures

Transcription

1 Policy on adherence to Clinical Nursing / Midwifery Procedures March 2012

2 Name of Policy: Purpose of Policy: Directorate responsible for Policy Name and Title of Author: Does this meet criteria of a Policy? Staff side consultation? Equality Screened by: Policy on adherence to Clinical Nursing / Midwifery Procedures To ensure that all registered nurses and midwives are aware of their responsibilities and apply the recommended clinical procedures guidance as set out in the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition, Executive Director of Nursing / AHP Fiona Wright, Assistant Director Nursing Service Governance Christine Armstrong, Practice Development Facilitator Yes Yes Fiona Wright, Assistant Director Nursing Service Governance Christine Armstrong and Marie Doran, Practice Development Facilitators Date Policy submitted to 23 rd March 2009 Policy Scrutiny: Reviewed 26 th March 2012 Members of Policy Scrutiny in Attendance: Vivienne Toal, Head of Employee Engagement & Relations (Chair), Anne Brennan, Senior Manager, Medical Directorate, Trevor Burns, Fire Safety Manager, (Specialist Estates), (for Danny McKevitt), Anita Carroll, Assistant Director of Acute Services Functional Support Services, Claire Graham, Head of Corporate Records (for Siobhan Hanna), Carmel Harney, Assistant Director of Allied Health Professionals, Governance & Workforce Planning, John Rafferty, Acting Head of Residential Care (for Brendan Whittle) Policy Approved/Rejected/ Amended Communication Plan required? Training Plan required? Implementation Plan required? Any other comments: Approved No No training required by directorates Yes/no/not applicable Date presented to SMT Director Responsible SMT Approved/Rejected/ Amended SMT Comments Date returned to Employee Engagement & Relations department for database/intranet/internet: Date for further review Mr. Francis Rice, Executive Director of Nursing / AHP N/A N/A 26 March year default SHSCT Policy on Adherence to Clinical Nursing/Midwifery Procedures Reviewed March 2012 Page 2 of 7

3 POLICY DOCUMENT VERSION CONTROL SHEET Title Supersedes Originator RM/Policy Committee & SMT approval Circulation Review Title: Policy on adherence to clinical nursing/midwifery procedures Version: 1_0 Reference number/document name: Supersedes: Description of Amendments(s)/Previous Policy or Version: Previous legacy Trust policies referring to clinical nursing procedures Fiona Wright, Assistant Director Nursing Services Governance Christine Armstrong, Practice Development Facilitator Referred for approval by: Date of Referral: RM/Policy Committee Approval (Date) SMT approval (Date) Issue Date: Circulated By: Issued To: As per circulation List (details below) Review Date: Responsibility of (Name): Mr. Francis Rice Title: Executive Director of Nursing / AHP Circulation List: Author Directorate responsible for this document Policy Number Fiona Wright, Assistant Director Nursing Service Governance Christine Armstrong, Practice Development Facilitator Executive Director of Nursing / AHP Date of Implementation March 2009 Date of Review March 2011 Screened by Screening Document Reference Number Approved by (Signature) Fiona Wright, Assistant Director Nursing Services Governance SHSCT Policy on Adherence to Clinical Nursing/Midwifery Procedures Reviewed March 2012 Page 3 of 7

4 Contents Section Page No. 1.0 Introduction Purpose Policy statement Scope of the policy Responsibilities Legislative compliance, relevant policies and procedures References Equality and Human Rights considerations Copyright Sources of advice and further information 7 SHSCT Policy on Adherence to Clinical Nursing/Midwifery Procedures Reviewed March 2012 Page 4 of 7

5 1.0 Introduction The Southern Trust is committed to supporting nurses 1 and midwives in delivering high quality, evidence based care to all patients/clients. All registered nurses/midwives have a duty of care to provide safe and effective care to all patients/clients and are personally accountable for ensuring that their practice is based on the best available evidence. They are also responsible for ensuring their knowledge and skills are up to date and for participating in appropriate learning and practice activities that maintain and develop competence. 2.0 Purpose This policy has been developed to ensure that all registered nurses and midwives are aware of their responsibilities and apply best clinical practice as recommended in the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition, In addition, registered nurses and midwives must take account of other nationally and regionally agreed guidance on clinical procedures, e.g., new born blood spot screening guidance or guidance on the administration of vaccines. 3.0 Policy Statement The Trust will ensure that nurses and midwives are supported in delivering safe and effective care to patients/clients through the adherence to clinical procedures set out in the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition, The Trust will support nurses and midwives by:- - Providing access to both online and paper-based copies of the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition, Providing access to online and paper-based copies of nationally and regionally agreed guidance to support adherence to clinical procedures; - Providing necessary training / update in relation to clinical procedures; Where clinical procedures are being carried out which are not included in Royal Marsden 7 th edition manual, e.g., those undertaken in oncology or specialist nursing/midwifery practice, these should be set out in writing with clinical practice supported by available best evidence and / or research. 4.0 Scope of the Policy This policy applies to all registered nursing and midwifery staff and appropriately trained non registered staff employed by the Southern Health and Social Care Trust. When a clinical procedure is delegated to a non registrant the registered practitioner remains accountable for the appropriateness of the delegated task and for providing the appropriate level of supervision in order to ensure competency to carry out the delegated task (NMC, 2008). 1 The term Nurse includes Specialist Public Health Nurses SHSCT Policy on Adherence to Clinical Nursing/Midwifery Procedures Reviewed March 2012 Page 5 of 7

6 Registered practitioners should adhere to the guidance on delegation of care provided by the Nursing and Midwifery Council (2008) and Department of Health, Social Services and Public Safety, Northern Ireland (2006), Central Nursing Advisory Committee (CNAC). 5.0 Responsibilities 5.1 Responsibility of the Chief Executive As Accountable Officer the Trust Chief Executive has overall responsibility for ensuring that staff are compliant with this policy. 5.2 Responsibility of Senior Management. All Trust Directors, Assistant Directors, Heads of Service and Senior Managers have responsibility for the effective implementation of this policy and should ensure that all nursing and midwifery staff have access to the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition, 2008, either in hard copy or through the Trust s Intranet site. Heads of Service / Team Mangers should guide and support nurses and midwives in developing and evidencing those clinical procedures which are not included in Royal Marsden 7 th edition manual, This Southern HSC Trust policy supersedes all legacy Trust policies referring to clinical management procedures. Heads of Service / Team Managers must ensure the removal of all related legacy trust policies no later than 4 weeks after the date this policy is ratified by the Senior Management Team (SMT). All Royal Marsden 6 th edition manuals must be removed once access to 7 th edition is available. Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition online version 5.3 Responsibility of Trust Nurses and Midwives All Trust registered nurses and midwives employed within the Southern Trust have a responsibility to adhere to the principles and aims of this policy and to comply with any direction necessary to ensure compliance with this policy. 6.0 Legislative Compliance, Relevant Policies, Procedures and Guidance Staff must take cognisance of relevant legislations and guidance, including: - Department of Health, Social Services and Public Safety, Northern Ireland (2006): Central Nursing Advisory Committee (CNAC) Guidance on the delegation of specific aspects of nursing care - Nursing and Midwifery Council (2008), The Code Standards of conduct, performance and ethics for nurse and midwives. - Nursing and Midwifery Council (2008) Advice on delegation for SHSCT Policy on Adherence to Clinical Nursing/Midwifery Procedures Reviewed March 2012 Page 6 of 7

7 7.0 References None registered nurse and midwives. - Nursing and Midwifery Council (2009), Guidelines for Records and Record Keeping. - Nursing and Midwifery Council (2004), Midwives Rules and Standards. - The Royal Marsden Hospital (2011) Manual of Clinical Nursing Procedures, 7 th edition. 8.0 Equality and Human Rights Considerations Equality Considerations This policy has been screened for equality implications as required by Section 75, Schedule 9, of the Northern Ireland Act, Equality Commission of Northern Ireland Guidance states that the purpose of screening is to identify those policies that are likely to have a significant impact on equality of opportunity so that greatest resources can be targeted at them. Using the Equality Commission s screening criteria no significant equality implications have been identified. This policy will therefore not be subject to an equality impact assessment. Human Rights Considerations This policy has been considered under the terms of the Human Rights Act, 1998, and was deemed to be compatible with the European Convention of Human Rights contain in that Act. This policy will be included in the Trust s register of screening documentation and maintained for inspection whilst it remains in force. This document can be made available on request in alternative formats, for example Braille, disc, and audio-cassette and in other languages to meet the needs of those who are fluent in English. 9.0 Copyright The supply of information under the Freedom of Information does not give the recipient or organization that receives it the automatic right to re-use it in any way that would infringe copyright. This includes, for example, making multiple copies, publishing and issuing copies to the public. Permission to re-use the information must be obtained in advance from the Trust Sources of advice and further information Further advice and information regarding this policy can be obtained from the Assistant Director of Nursing Services Governance. SHSCT Policy on Adherence to Clinical Nursing/Midwifery Procedures Reviewed March 2012 Page 7 of 7