A Competency Framework for Nutrition Nurse Specialists First Edition

Transcription

1 A Competency Framework for Nutrition Nurse Specialists First Edition

2 Acknowledgements The NNNG would like to acknowledge earlier work on competencies undertaken by the Royal College Nursing (RCN) and Parkinson s disease Society. This existing work was used during the preparation of this framework. The NNNG would also like to thank those individuals who took the time to respond and comment on the various drafts of this document. Your help and advice is much appreciated. 1

3 Foreword These competencies have been developed by the (NNNG), the leading experts in this specialty. It has been developed in response to requests not only from their nutrition nurse members but also from organizations wishing to commission a nutrition nurse post. The aim was to develop key competencies for qualified nurses working in the area of nutrition support in any healthcare setting. This framework is therefore a collection of the core competencies that nutrition nurse specialists (NNS s) felt were central to their ability to provide effective care for those patients requiring nutritional support. It is intended to be developmental, enabling and aspirational. It can be used in the following ways; To facilitate continuing professional development on an individual level To help individual nurses and managers to identify any gaps in practice To support nurses in career planning within the specialty To support managers in workforce planning and preparing role requirements/job descriptions for specific posts To inform the commissioning, development and delivery of education and training related to nutritional support The NNNG would welcome specific feedback from the nurses who use the framework as evidence for further development. Lynne Colagiovanni, Consultant Nurse Nutrition Support and Jane Fletcher, Nutrition Nurse Specialist, Queen Elizabeth Hospital Birmingham on behalf of the. 2

4 Contents Acknowledgements 1 Foreword 2 Introduction 4 What is a competency framework? Agenda for Change Knowledge and Skills Framework Levels of Competence 5 Proficient Nurse (Band 6) Competent Nurse (Band 7) Expert Nurse (Band 7/8) Assessing Competence 7 Clinical Competencies Competency 1: Nutritional Assessment 8 Competency 2: Requesting & interpreting investigations 10 Competency 3: Clinical procedures. 12 Competency 4: Route and device selection 14 Competency 5; On-going patient management 16 Competency 6: Prescribing 18 Competency 7: Management of patients Receiving Home Parenteral Nutrition (HPN) 20 Non-clinical Competencies Competency 1: Decision making, consent and ethics 22 Competency 2: Education & Training 24 Competency 3: Management and Service Development 26 References 28 Endorsements 29 Page 3

5 Introduction What is a competency framework? Competencies are the building blocks that help to shape nursing work in many clinical settings. Competence can be described as: the state of having the knowledge, judgement, skills, energy, experience and motivation required to respond adequately to the demands of one s own professional responsibilities (Roach, 1992). The purpose of a competency is to enable an individual to: Clearly understand what is expected of them Identify personal development needs Provide evidence of achievements to support career progression. A competency framework is a group of competencies thought to be central to effective performance. This competency framework addresses, and links to, a number of professional issues and initiatives including: The need for leadership in specialist nursing Agenda for Change (DoH 2004) The NHS Knowledge & Skills Framework (DoH 2004) The NHS Plan (DoH 2000) The increased focus on lifelong learning The Code (NMC 2008) One of the proposals of the NHS Plan (2000) was to expand the role of the nurse to specialist and consultant level. Developing these new roles in the field of nutrition support generates the opportunity to expand the services we are able to provide to this group of patients as well as providing new and exciting career opportunities for nurses working in this field. Nurses new to nutrition support need a clear framework which will enable and support them to develop their skills and knowledge. Experienced NNS s require a framework to help them progress in their chosen specialty. Agenda for Change/Knowledge & Skills Framework The NHS Knowledge and Skills Framework defines the level of knowledge and skill staff require to deliver quality services, and provides a single, consistent framework on which to base review and development for all staff. As it is a broad generic framework it 4

6 does not describe the exact knowledge and skills nurses need to develop for nutrition support nursing specifically. Along with specific training courses in nutritional support it is hoped that the following competency framework will help to do this. Whilst not being specifically designed to support the NHS KSF, the competency framework has been mapped to appropriate KSF dimensions and levels and the two may be used in a complimentary manner and may support career and pay progression. It is not however designed to be used to determine pay banding under Agenda for Change. It should be noted that the competencies within this framework focus primarily on those unique to the role of the NNS. So for example, although the six core dimensions of the KSF are all important to the role of NNS s only those aspects of each one which are unique to nutrition nursing are included. Levels of Competence Deciding what to title the levels within this document has proved to be difficult. There are many titles within the specialist nutrition nursing field; many of which are locally devised and do not always refer to a trained nurse. For example there are: Nutrition nurse specialists Clinical nurse specialists nutrition Senior nutrition nurses Advanced nurse practitioners in nutrition Consultant nurses- nutrition support Associate nurse practitioners in nutrition Rather than using titles we have based the competency levels around Benner s (1984) Novice to Expert work and the Skills for Health (2005) career framework. Whilst this document is not about assigning Agenda for Change (2004) pay scales to the competency framework, we have made some suggestions which we hope will provide guidance for both those seeking to move into the field and those looking to commission new posts 5

7 Proficient nurse (Band 6) This would be the entry point for nurses new to the specialty. The nurse should have developed expertise in using knowledge and skills to undertake a nursing assessment and should have some understanding of disease related malnutrition and its treatment. The nurse would be expected to work with the support of a more senior nutrition nurse colleague. Competent nurse (Band 7) Often regarded as the specialist, this is the expansion of the registered nurse role. It would be expected that those working at this level of practice would work according to local protocols to co-ordinate nutritional care of patients. The nurse can work autonomously without asking the advice of a doctor, providing s/he is working within the boundaries of her/his own knowledge and competence. Advice should be sought from senior nursing/medical colleagues for cases beyond her/his clinical competence. Expert nurse (Band 7/8) Sometimes defined as the highest level of practice, this level often reflects the role of a nurse consultant. However there may be other expert nurses working at this level who do not have the consultant nurse title. The role may involve team management and strategic development within the specialty. The competencies are cumulative so that competency at expert level builds on the two lower levels. Not all those working in the discipline will need to achieve expert level in all aspects of all of the competencies. Movement through the levels will depend on the individual nurse, the clinical context and the service needs of the area in which s/he works. For example a nurse working within primary care may need to become expert in caring for those needing enteral nutritional support, but may only need to be competent or proficient in care of patients needing parenteral nutrition. It is difficult to put any time scale on how long it should take a nurse to move through the competency levels; however it would seem reasonable to expect one to be proficient within the first year of coming into post, competent within 2-3 years and expert within 5 years. These are only intended as a guide and much will depend on the ability of the individual nurse, and the opportunities and support available. 6

8 Assessing competence This framework should be used for developing and enabling those nurses working within nutrition support nursing. It can also be used as a means of managing performance within the staff appraisal scheme. Within the NHS this should be undertaken alongside the KSF for the individual nurse s role. Those using the framework will need to provide evidence that they have achieved each competency. The type of evidence which would be acceptable includes: Observation of clinical skills and critical evaluation of everyday practice Case presentations Active contributions to guideline and policy groups Certificate of attendance at study days Contribution to local or national documents. This list is not exhaustive and other assessments and evidence may be appropriate in different care settings. 7

9 A Competency Framework for Nutrition Nurse Specialists CLINICAL Competency 1: Nutritional Assessment Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 Uses assessment methods that are based on available evidence, are appropriate for the patient group concerned, and which s/he has the knowledge, skills and experience to use effectively. These should include; Anthropometry Weight Height Body Mass Index (BMI) Nutrition Risk score Mid Upper Arm Circumference (MUAC) Percentage weight loss Biochemistry Urea & Electrolyte s (U&E s) Uses assessment methods that are suitable for patients with more complex needs, are based on available evidence, and for which s/he has the knowledge, skills and experience to use effectively. Uses assessment information gained from other healthcare professionals, e.g. dietitians and Speech and Language Therapists. This assessment may include; Anthropometry Knee height Demi span Mid Upper Arm Muscle Circumference (MUAMC) Triceps Skinfold Thickness Grip strength Uses and expertly interprets all of the assessment methods and information available to make an informed justifiable assessment of the patients nutritional status. This may involve forming an opinion and developing a subsequent plan of care which is not always wholly supported by the evidence. Decides and leads on the development of a plan of care in conjunction with other members of the multi professional team where there may be more than one course of action available. Nutrition History Recent intake/ food charts Dietary preferences Food allergies/dislikes Special diets Appetite Biochemistry Liver Function Tests (LFTs) Magnesium (Mg) & Phosphate (PO 4 ) C Reactive Protein (CRP) Full Blood Count (FBC) Medical history 8

10 Difficulties with swallowing Medical History Notes previous and current diseases/surgery which may affect nutritional intake and/or requirements Normal bowel habits Clinical Examination Condition of; Skin Mouth Hair Ability to swallow Evidence of oedema Evidence of muscle wasting Abdominal scaring Cognitive function Hand to mouth co-ordination Uses the above to identify nutritional needs and care required. Implications of previous/current illness/surgery on nutritional intake, requirements, losses Clinical Examination Chest examination Abdominal examination Drug History From the above can identify a patient at risk of re-feeding problems In conjunction with the patient and other members of the multi-professional team, uses the above to prioritize a plan of care for the patient. Indicative KSF dimensions & levels Core 1 level 3 IK2 level 2 HWB2 level 3 HWB4 level 3 HWB5 level 3 Indicative KSF dimensions & levels Core 1 level 3 IK2 level 3 HWB2 level 3 HWB4 level 3 HWB5 level 3 Indicative KSF dimensions & levels Core 1 level 4 IK2 level 4 HWB2 level 4 HWB4 level 4 HWB5 level 4 9

11 Competency 2: Requesting & interpreting investigations Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 Requests appropriate blood/other fluid tests and can interpret results for patients with more complex needs in line with local/national guidelines/policies. Uses local/national guidelines/policies to request appropriate blood tests to establish a non complex patient s baseline nutritional and hydration status. These should include; U&E s LFT s FBC Clotting studies Calcium (Ca), Mg, PO 4 Documents and reports investigations requested to other members of multiprofessional team. Requests some radiological investigations in line with local policy. These should include include; Trace elements Vitamins Urinary electrolytes/osmolarity B 12 & Folate and may include; Chest X ray following naso-gastric (n/g) tube insertion Chest X ray to confirm correct position of Central Venous Access Device (CVAD) Request for Percutaneous Endoscopic Gastrostomy (PEG) insertion Uses information gained from above to develop/change patient care/management plan in conjunction with other members of nutritional team. Requests/ expertly interprets, blood/other fluids tests/results in highly complex patients where correct interpretation requires in depth knowledge and experience in this patient group, and where there may be no local/national guidance. Requests/expertly interprets radiological investigations which may require the use of contrast medium. These should include: Contrast study to confirm correct positioning of gastrostomy/jejunostomy tubes Radiological insertion of gastrostomy/jejunostomy/nasojeju nal (n/j) feeding tube Uses information gained from above to develop/change patient management plan where there may be no obvious course of action or where there may be conflicting views between healthcare professionals. Uses the above to inform decisions regarding his/her prescribing of enteral/parenteral nutrition. 10

12 Core 1 level 3 IK2 level 2 HWB6 level 3 HWB5 level 3 HWB2 level 3 Core 1 level 3 IK2 level 3 HWB6 level 3 HWB5 level 3 HWB2 level 3 Core 1 level 4 IK2 level 4 HWB6 level 4 HWB5 level 4 HWB2 level 4 11

13 Competency 3: Clinical procedures. Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 Should contribute to the planning and undertaking of clinical procedures that are evidence based, in line with national and local guidance and which s/he has the knowledge and experience to perform safely and effectively. This should include discussion with the patient, involving them in shared decision making and obtaining verbal consent for any procedures in line with local/national guidance. Such procedures should include; Passing of fine bore nasogastric tubes for enteral feeding Changing of balloon retained gastrostomy tubes (non obturator) Taking of blood cultures from CVAD Removal of gastropexy sutures Measuring of stoma tract for low profile insertion Plans and undertakes more complex clinical procedures, that are evidence based, in line with national and local guidance and which s/he has the knowledge and experience to perform safely and effectively. This should include discussion with the patient, involving them in shared decision making and obtaining verbal/written consent for any procedures in line with local/ national guidance. Such procedures should include; Venepuncture Peripheral venous cannulation Nasal bridles Insertion of Peripherally Inserted Central Catheters (PICC) Re-intubating a gastrostomy/jejunostomy tract following accidental tube removal Insertion/removal of low profile devices with obturator Unblocking CVAD CVAD repair Elective removal traction removable gastrostomy tubes Plan and undertake highly complex clinical procedures often in seriously ill patients, where there are no local/national guidelines, or where the procedure may be innovative and with little evidence base. This should include discussion with the patient, involving them in shared decision making and obtaining verbal/written consent for any procedures. Such procedures should include; Passing of n/j tubes Abdominal operator during PEG insertion Insertion of direct access CVAD Removal of tunnelled CVAD 12

14 Core 1 level 3 HWB7 level 2 HWB6 level 3 IK2 level 2 HWB5 level 3 HWB2 level 3 Core 1 level 3 HWB7 level 3 HWB6 level 3 IK2 level 3 HWB5 level 3 HWB2 level 3 Core 1 level 4 HWB7 level 4 HWB6 level 4 IK2 level 4 HWB5 level 4 HWB2 level 4 13

15 Competency 4: Route and device selection Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 As part of the multi professional team, and following patient assessment, should contribute to decisions regarding the most appropriate route by which to provide nutritional support for non complex patients requiring enteral or parenteral nutrition. This may include decisions around; Type of nasogastric tube Type of nasojejunal tube Type of gastrostomy/jejunostomy device Type of CVAD This will require a basic knowledge of gut anatomy and physiology, venous access, and the underlying disease process or surgical history of the individual patient Following patient assessment, uses and interprets all information available and may take the lead on decisions regarding routes of feeding in more complex patients to include; Enteral or parenteral Gastric or jejunal Central or peripheral This will require a more in depth knowledge of gut anatomy and physiology, venous access, and the underlying disease process or surgical history of the individual patient Following patient assessment uses and interprets all information available and may take the lead on decisions regarding device selection in more complex patients. This may include those requiring Home Parenteral Nutrition (HPN) This will require a detailed knowledge of enteral and parenteral access devices available both locally and nationally, and an understanding of the availability of local resources to purchase and place them. Uses and expertly interprets all information available, including gut anatomy and physiology, venous access and underlying disease process/surgery, to make an informed justifiable decision regarding route of feeding. This may involve forming an opinion and developing a subsequent plan of action which is not always wholly supported by the evidence. This should include decisions regarding; Enteral or parenteral Gastric or jejunal Central or peripheral Method of device insertion (endoscopic/radiological/surgical) Following patient assessment uses and expertly interprets all information available and should take the lead on decisions regarding device selection in highly complex patients. This should include those requiring Home Parenteral Nutrition (HPN) This may involve forming an opinion 14

16 and developing a subsequent plan of action which is not always wholly supported by the evidence. This will require an in depth knowledge of enteral and parenteral access devices available both locally and nationally, and an understanding of the availability of local resources to purchase and place them. Core 1 level 3 HWB7 level 2 HWB6 level 3 IK2 level 2 HWB5 level 3 HWB2 level 3 Core 1 level 3 HWB7 level 3 HWB6 level 3 IK2 level 3 HWB5 level 3 HWB2 level 3 Core 1 level 4 HWB7 level 4 HWB6 level 4 IK2 level 4 HWB5 level 4 HWB2 level 4 15

17 Competency 5; Ongoing patient management Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 Within own knowledge and competency identifies patients who require ongoing support with their artificial nutrition, either in the community or the acute setting. Organises caseload to ensure timely and appropriate follow-up of in-patients. On discharge from acute setting refers patients to the appropriate agencies for follow-up, taking into account the individual patient s requirements and locally available resources. Resources may include: District Nurse Practice Nurse Community Nutrition Nurse Dietitian Enteral feeding company nurse Local nutrition nurse led out patient clinic Liaises with appropriate agencies to arrange ongoing management of patients, considering how their artificial nutrition impacts on their wider medical, physical and social needs. Agencies may include: Community Care Teams Palliative Care Teams Nurse Led Clinic May organise the review of patients as appropriate within their own nutrition nurse led clinic. Troubleshooting Within own knowledge and evidence base should manage and give advice on more complex problems related to artificial nutrition. Identifies when a patient requires referral to other members of the multi-disciplinary team and makes arrangements for this. As Band 7 Troubleshooting Within own knowledge, competence and locally agreed guidelines: 16

18 Manages telephone queries regarding problems with artificial nutrition devices and offers appropriate advice. Identifies when patients with problems require intervention. Identifies when it is necessary to refer queries to a more senior member of staff. Core 1 level 3 HWB2 level 3 HWB5 level 3 HWB6 level 3 Core 1 level 3 HWB2 level 3 HWB5 level 3 HWB6 level 3 Core 1 level 4 HWB2 level 4 HWB5 level 4 HWB6 level 3 17

19 Competency 6: Prescribing Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 As part of the multi professional team, and following patient assessment, should contribute to decisions regarding parenteral nutrition formulation and other related medicines. May administer medicines under a Patient Group Direction. Within own knowledge and competency and after undertaking a recognized course of study, may prescribe as a supplementary or independent prescriber within own speciality: Parenteral Nutrition Home Parenteral Nutrition Agents for unblocking central venous catheters Following discussion with the multidisciplinary team and following local microbiology guidelines, may prescribe: Intravenous antibiotics for the treatment of catheter related blood stream infections (CRBSI). Oral antibiotics for peri-stomal (gastrostomy/jejunostomy) infection Oral antibiotics for CVAD exit site infection Within own knowledge and competency and after undertaking a recognized course of study, should prescribe as an independent prescriber: Parenteral Nutrition Home Parenteral Nutrition Agents for unblocking central venous catheters Other medicines related to patients nutritional problems Following discussion with the multidisciplinary team, and following local microbiology guidelines, should prescribe: Intravenous anti-biotics for the treatment of catheter related blood stream infections. 18

20 HWB2 level 3 HWB7 level 3 HWB2 level 3 HWB7 level 3 HWB 2 level 4 HWB7 level 4 19

21 Competency 7: Management of patients Receiving Home Parenteral Nutrition (HPN) Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 Has an understanding of the issues surrounding HPN which should include: Indications for HPN Safe/aseptic practice in the administration of HPN Therapy associated complications such as catheter related blood stream infection (CRBSI) Supply of HPN and ancillaries to patients Can act within own competency and locally agreed guidelines when responding to patient enquiries which may include: Who to seek advice from regarding suspected CRBSI or other clinical concerns Dealing with supply problems Has knowledge of the complex issues surrounding HPN. Pre-discharge management should include: Assessing patients requirement for HPN Assessing patients social circumstances and ability to manage HPN Informing patients about the purpose of HPN including potential complications, such as CRBSI, thrombosis, and liver disease Carrying out patient education on safe/aseptic practice in the administration of HPN and care of central venous catheters Pre-discharge management may include: Liaising with appropriate agencies to secure funding for HPN Liaising with Home Care Providers and organising supply of HPN and Has an in depth knowledge and understanding of the highly complex nature of HPN, both clinical and organizational. Management should include: Assessing patients requirements for HPN taking in to account the wider clinical and psycho-social picture Recommending alternative methods of feeding that may be novel or unproven, for example distal feeding. Liaising with appropriate agencies to secure funding for HPN Selecting a suitable Home Care Provider and liaising with them in organising supply of HPN and ancillaries to patients Prescribing PN tailored to the patients individual needs Admitting patients, where felt 20

22 ancillaries to patients Decision-making regarding individual s prescription for PN Post-discharge management should include: Participating in multi-disciplinary out patient clinics where HPN patients are regularly reviewed clinically indicated, without reference to others and ordering appropriate investigations such as x-rays. Leading in the ongoing organisation of a multi-disciplinary HPN follow- up clinic HWB6 level 3 HWB7 level 2 Monitoring patients overall clinical condition and reviewing biochemistry. In conjunction with the multidisciplinary team, deciding on a plan of action where biochemistry is abnormal Recommending admission and/or investigations in accordance with local policy where CRBSI is suspected, for example blood cultures. HWB6 level 3 HWB7 level 3 HWB6 level 4 HWB7 level 4 21

23 NON CLINICAL COMPETENCIES Competency 1: Decision making, consent and ethics Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 Has an understanding of the legal and ethical aspects of nutrition support. Able to discuss legal and ethical issues in uncomplicated situations e.g. where the patient has capacity. Gains verbal and/or inferred consent before carrying out procedures, in accordance with the Mental Capacity Act (2005), Department of Health (2009) and local guidelines. Clearly documents the information given to patients, if the patient gave consent or not and how this was expressed i.e. verbal or inferred. Has a clear understanding of legal and ethical issues associated with nutrition support and can apply these to complex and emotive situations for example: Nutrition at the end of life Consent issues in patients lacking capacity Can undertake an assessment of capacity, in accordance with the Mental Capacity Act (2005). Can lead discussions with the multidisciplinary team in arriving at a best interests decision where indicated by the Mental Capacity Act (2005). Gains written consent for invasive procedures which may include: Percutaneous Endoscopic Gastrostomy (PEG) placement Non-endoscopic removal of PEG s Peripherally inserted central venous catheters Has a thorough understanding of legal and ethical issues associated with nutrition support, can apply these to highly complex situations and can advise others on these. Can recognize when highly complex ethical or legal issues require advice or intervention from outside agencies, for example: Trust s legal department Independent Mental Capacity Advisors (IMCA) Gains written consent for invasive procedures which may include: Placement of direct access central venous catheters Removal of tunnelled central venous catheters 22

24 Insertion of Radiologically Inserted Gastrostomy (RIG) HWB7 level 2 HWB6 level 3 HWB7 level 3 HWB6 level 3 HWB7 level 4 HWB6 level 4 23

25 Competency 2: Education & Training Proficient Nurse Band 6 Proficient Nurse Band 7 Expert Nurse Band 8 Develops skills and knowledge of others within nutrition, contributing to the education and training of the multidisciplinary team. This may include: Helping others to identify: their current level of knowledge and skills within nutrition their learning needs and preferences good practice within nutrition based on available evidence and agreed guidelines Supporting others to develop and apply their knowledge and skills in practice through: Mentoring Informal or ward based teaching Contributing to a formal nutrition education programme within their organisation Training patients and carers in aspects of self-care appropriate to their needs and ability. This may include: Gastrostomy/jejunostomy care Care and/or insertion of fine bore naso-gastric feeding tubes Develops nutritional knowledge and clinical practice of others within an organisation through: Sharing of own knowledge and skills Challenging actions within nutrition practice which are unsafe or not in the patients best interest Devising formal, multi-disciplinary teaching programmes to address identified areas of need Devising and implementing clinical competency based teaching packages which may include: Care of central venous catheters Administration of Parenteral Nutrition Insertion of fine bore naso-gastric tubes Insertion of nasal bridle Replacing percutaneous gastrostomy tubes May teach as a specialist lecturer at higher education institutions within clinical knowledge and practice. Shares expert knowledge and skills in nutrition support across professional, organisational and geographical boundaries. Takes a lead in identifying learning opportunities and develops education and training programmes within and outside of the workplace. Key contacts should include: Higher education institutions National forums such as the British Association of Parenteral and Enteral Nutrition (BAPEN) and the (NNNG) Presents at national and international nutrition meetings. 24

26 Administration of enteral feeds Changing balloon retained gastrostomy devices Presents at local and national nutrition meetings C6 level 2 C6 level 3 C6 level 4 25

27 Competency 3: Management and Service Development Proficient Nurse Band 6 Competent Nurse Band 7 Expert Nurse Band 8 Contributes to the daily running and overall development of the nutrition nurse service. Has an awareness of resource management. For example, appropriate use of replacement gastrostomy tubes. Supports other members of staff to meet their development objectives related to nutrition. For example, working with and supervising Nutrition Link Nurses. Co-ordinates the overall activity of the nutrition nurse service. Manages resources to ensure the most effective and efficient use of budgets, for example in ordering enteral/parenteral feeding devices. Contributes to team discussions when commissioning for nutrition related services, for example, supply of parenteral nutrition or enteral feeding tenders. Takes a lead role across the trust in championing the importance of nutrition for the entire patient population. Takes a lead role in ensuring the Trust is aware of and complies with current, nutrition related national guidance. Leads or is actively involved in the Nutrition Steering Committee where one exists. Where there is no steering committee, actively seeks to establish one as per national guidance. Identifies the wider, strategic service requirements in terms of ongoing management of both in and out patients. Innovates new ways and partnerships in the management of patients which may include: Considering a new skill mix for the team, for example, incorporating Nutrition Support Workers or Assistant Practitioners where appropriate Establishing links with community partners such as G.P. practices, community hospitals and other care facilities Establishing cross-boundary working by, for example, providing a nutrition nurse service which is fluid between both primary and secondary care Identifies areas where the nutrition nurse team may expand and diversify 26

28 services, in order to improve the patient experience. For example: Establishing a nurse led clinic Indicative KSF dimensions & levels Core 4 level 2 G6 Level 2 G5 Level 2 Establishing a nurse led central venous access device insertion service Indicative KSF dimensions & levels Core 4 level 3 G6 Level 3 G5 Level 3 Indicative KSF dimensions & levels Core 4 level 3 G6 Level 3 G5 Level 3 27

29 References Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Addison Wesley, California Department of Health (2000). The NHS Plan: A plan for improvement. A plan for reform. DoH, London. Department of Health (2004). Agenda for Change. DoH, London. Department of Health (2004) The NHS Knowledge & Skills Framework and the Development Review Process. DoH, London Department of Health (2009) Reference guide to consent for examination or treatment 2nd edition. DoH, London Mental Capacity Act (2005) Nursing and Midwifery Council. (NMC). (2008). The Code - Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC Roach (1992) The human act of caring: a blueprint for the health profession. Ottawa: Canadian Hospital Association Press cited by Royal College of Nursing (2009) Royal College of Nursing & Parkinson s Disease Society (2008) Competencies: A competency framework for nurses working in Parkinson s Disease management.2 nd Edition. Royal College of Nursing. London Skills for Health (2005) 28

30 Endorsements This competency document has been endorsed by the British Association for Parenteral and Enteral Nutrition. 29

31 For more information contact: Design: Jane Fletcher on behalf of NNNG Front cover photographs for illustrative purposes only Illustrations with Standard and Royalty Free Printed by: Manchester Metropolitan University 30