Clinical Skills Passport for Relief and Temporary Staff in Neonatal Units This work is drawn from the Scottish Neonatal Nurses Group document The Competency Framework and Core Clinical Skills for Neonatal Nurses (2005) September 2009
Contents Introduction 2 The essence of neonatal nursing care 4 The clinical skills passport 5 Use of this clinical skills passport 6 1. Fluid, electrolyte, nutrition and elimination management 7 2. Drug administration 12 3. Neurological and pain management 14 4. Respiratory and cardiovascular management 17 5. Skin, hygiene and infection control management 19 6. Thermal control management 21 7. Investigations and procedures 23 8. Equipment 25 9. Additional skills 27 References 30 Acknowledgements 30 Notes 32 1
Introduction
Introduction A pandemic flu outbreak in Scotland might result in an increase in demand for core neonatal staff, but may also cause a decrease in their availability due to personal sickness or work absence through caring for a loved one affected by illness. There is therefore a need to identify and train relief and temporary staff to maximise skilled workforce capacity in all departments of the neonatal service in the event of a pandemic flu outbreak. The neonatal service is a critical care service in that it provides highly specialised care to a unique patient population. Consequently, neonatal staff possess a repertoire of knowledge and skills that cannot easily be replaced in the short term. Other staff, such as midwives, children s nurses and students who rotate through neonatal units, and former neonatal staff may be called upon to provide care in the short term, but there is likely to be a shortfall in the levels and currency of their knowledge and clinical skills. These relief and temporary staff will need training and up-skilling, but they will be more valuable to the service if some of this training can be provided before workforce shortfalls arise. Clinical skills updating will have to be delivered in a short time frame. It therefore needs to be focused on individual and local needs, with educational/clinical governance standards in the quality and delivery of the training being maintained. It is anticipated that the basic knowledge underpinning neonatal care will have been acquired and retained during individuals previous neonatal experience. A short period of updating would therefore aim to develop competence and confidence in the delivery of special neonatal care and some high dependency care, as this will most likely reflect the level of service the individuals will be asked to provide (depending on previous experience and the time interval since last working in this environment). It is important to stress that this updating and up-skilling does not replace specialist neonatal education and training. 3
The essence of neonatal nursing care Like all health care professionals, relief and temporary staff in neonatal units will be expected to conduct themselves in accordance with the standards and guidance defined by their governing body (in this case, the Nursing and Midwifery Council (NMC)) and undertake activities in a professional manner, especially in relation to respecting confidentiality, showing empathy, providing information and liaising with other staff. Effective communication with parents, carers and colleagues is essential for all staff in neonatal units, including relief and temporary staff. This is achieved through active listening, acknowledging, responding, explaining, questioning, negotiating, analysing and facilitating. Relief and temporary staff should be aware of how to contact relevant colleagues when required and understand the barriers and boundaries to effective communication. Planning, assessing and evaluating are essential elements of neonatal care. Accurate record-keeping is fundamental to all nursing and midwifery practice and is important in promoting high-quality care. Records and documents must be legible, accurate, concise and contemporaneous, and record-keeping practice must comply with NMC standards (NMC, 2009). Relief and temporary staff in neonatal units must be able to initiate and maintain accurate care plans and record the outcomes of nursing and other interventions. Relief and temporary staff should work in partnership with parents, families and carers. Nurses and midwives in neonatal units are in a unique position to act as advocates for the baby and can play a vital role in child protection. Relief and temporary staff should be aware of their responsibilities in relation to advocacy and child protection, raising concerns to senior/permanent staff as appropriate. In addition, relief and temporary staff: may be able to take responsibility for the administration of prescribed medicines, depending on previous experience and training (and with the proviso that the associated knowledge and skills would have to be assured locally) must have the knowledge and ability to rationalise the strategy chosen in the application of all clinical skills, seeking advice and guidance where they have a deficit. 4
Training should include re-familiarising relief and temporary neonatal staff with daily routines, current documentation and other non-patient responsibilities they would be expected to fulfil. The clinical skills passport In developing this clinical skills passport, it has been useful to draw on the comprehensive work of the Scottish Neonatal Nurses Group (SNNG) which details clinical competencies and core clinical skills appropriate to different levels of care within the neonatal service. Orientation and induction programmes from neonatal units in Scotland have also been accessed. The SNNG competencies and core clinical skills are divided into four levels, based on the neonatal career structure the group devised in 2004. As a general principle, it is proposed that competence in Level 1 and some, but not all, Level 2 skills would be realistic target achievements for relief and temporary staff. Following on from the categorisation of skills defined by NES (NES, 2002), the SNNG working group presented the core clinical skills under the following headings: 1. fluid, electrolyte, nutrition and elimination management 2. neurological and pain management 3. respiratory and cardiovascular management 4. skin and hygiene management 5. thermal control management 6. bereavement management 7. investigations and procedures 8. equipment. For the purpose of this clinical skills passport for relief and temporary staff in neonatal units, these headings, relating to levels 1 and 2, have been modified in response to consultation with neonatal professionals. 5
Use of this clinical skills passport The clinical skills passport is intended as a guidance document for clinical neonatal staff and, especially, new relief and temporary staff in a particular set of circumstances. It can be used to guide: individual practitioners to benchmark their own skill base, identify learning needs and chart progress service managers to assist in the recruitment of relief and temporary staff for the neonatal service educators to establish training programmes to meet particular service needs clinical teams in the deployment of relief and temporary staff. Individual skill items may be added or removed from the passport depending on the needs of individual services at a particular time. Individuals using the clinical skills passport should: review their experience and practice to date, identifying relevant skills and knowledge appraise themselves against relevant skill levels, identifying those that are not met agree with their manager or supervisor and education provider a programme that meets their learning needs to achieve all clinical skills relevant to their post and position set goals and devise an action plan to achieve the desired clinical skills collect documented evidence of achievement in meeting identified clinical skills. 6
1. Fluid, electrolyte, nutrition and elimination management
1. Fluid, electrolyte, nutrition and elimination management These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Associated activities* Recognise normal gastro intestinal function, reporting deviations. These include: bile aspirates, large gastric aspirates, delayed passage of stool, abdominal distension or abnormal stool colour or passage. Recognise normal urinary tract function including frequency, colour and volume of urine excreted. Be aware of reasons for neonatal jaundice and normal bilirubin excretion; recognise deviations from physiological jaundice and report findings Perform basic care, including oral and umbilical care. Assist the mother to breastfeed according to evidence base/unit guidelines. Be able to cup-feed and be familiar with storage and use of breast milk. * To be added according to needs of individual and local unit. 8
LEVEL 1 Associated activities* Assist parents/carers in other enteral feeding techniques: - bottle - cup - nasogastric - orogastric Safely carry out all forms of enteral feeding according to evidence base/unit guidelines. Pass nasal and oral feeding tubes. Safely administer intravenous therapy according to unit guidelines, recognising and reporting deviations/complications. Monitor input and output of fluids. Measure babies weight and length. Obtain capillary blood sample to measure and monitor blood glucose levels, reporting deviations. * To be added according to needs of individual and local unit. 9
LEVEL 1 Associated activities* Care for baby requiring phototherapy. * To be added according to needs of individual and local unit. 10
LEVEL 2 Associated activities* Inform and advise on storage of breast milk, breastfeeding, hand and mechanical expression and supplementary methods of feeding. Inform and advise on all aspects of other enteral feeding methods. In collaboration with core neonatal staff, assess enteral feeding needs, devise plan and review appropriately. Calculate intake requirements according to guidelines and measure output. Monitor growth and development through measurement of weight and length, reporting deviations. Implement interventions according to unit guidelines for blood glucose regulation. Initiate phototherapy according to predetermined criteria. * To be added according to needs of individual and local unit. 11
2. Drug administration
2. Drug administration These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Associated activities* Be familiar in the use of the Neonatal Drug Formulary or monographs. Be familiar with, or be able to check, routine drugs and their recommended dosages in special neonatal care. Ensure the required nutritional supplements are prescribed. Administer drugs via oral, topical, rectal and intramuscular routes, according to professional and local policies. Assess the therapeutic response. Identify side-effects and report appropriately. Administer oral nutritional supplements according to prescription. Teach parents about the administration of oral medicines in preparation for discharge. * To be added according to needs of individual and local unit. 13
3. Neurological and pain management
3. Neurological and pain management These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Associated activities* Recognise normal behaviour in babies of different gestations, including sleep/ awake states. Report deviations from normal. Complete available/appropriate assessment tools and report findings. Anticipate potentially adverse events and minimise their impact. Recognise and report overt signs of pain. Provide routine nursing care to alleviate pain and stress to the baby. Recognise behaviour associated with neonatal abstinence syndrome (NAS). Provide routine nursing care to alleviate the effects of NAS. Use developmental care strategies, including environmental aspects, positioning and handling. * To be added according to needs of individual and local unit. 15
LEVEL 2 Associated activities* Alleviate baby s discomfort, pain etc. using standard nursing strategies. Interpret outcomes of assessment and implement strategies according to local guidelines. Implement strategies that minimise the effects of NAS. Adapt strategies that minimise the effects of NAS. * To be added according to needs of individual and local unit. 16
4. Respiratory and cardiovascular management
4. Respiratory and cardiovascular management These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Associated activities* Recognise normal respiratory/ cardiovascular function. Report deviations from normal. Observe resuscitation of the baby. Initiate basic life support measures. Recognise need for, and request, assistance. Safely administer oxygen therapy via nasal cannulae, including adequate humidification as prescribed. Use safe and effective oral and nasal suction techniques. LEVEL 2 Associated activities* Perform basic life support. Recognise the need for, and request, assistance. * To be added according to needs of individual and local unit. 18
5. Skin, hygiene and infection control management
5. Skin, hygiene and infection control management These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Associated activities* Implement correct hand washing and other infection control measures as per local guidelines. Ensure compliance with infection control guidelines. Perform aseptic and non-touch techniques. Examine skin and mucous membranes, eyes and cord base for deviations from normal and report. Implement treatment for deviations as prescribed. Use appropriate measures to maintain hygiene and skin integrity. LEVEL 2 Associated activities* Implement strategies to prevent iatrogenic damage and potential injury. * To be added according to needs of individual and local unit. 20
6. Thermal control management
6. Thermal control management These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Associated activities* Assess neonatal body temperature using appropriate method and site for babies who require special care and high dependency, and record and report deviations from normal. Use appropriate strategies to maintain body temperature within normal limits, including environmental aspects, clothing and equipment for babies who require special and high dependency care. Use appropriate interventions to correct temperature deviations for babies who require special and high dependency care LEVEL 2 Associated activities* Monitor central and peripheral temperature gap, and report deviations from normal. Anticipate the baby s risk of temperature deviations and implement preventative strategies. * To be added according to needs of individual and local unit. 22
7. Investigations and procedures
7. Investigations and procedures These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Associated activities* Perform or assist with routine diagnostic and therapeutic procedures, such as blood glucose and X-rays, according to protocols and guidelines. Implement prescribed management. Assist in the care of babies requiring special and high dependency care undergoing non-invasive investigations and procedures, such as venepuncture. Measure blood pressure using non-invasive techniques, reporting deviations from normal. Care for baby receiving blood or blood products transfusion. * To be added according to needs of individual and local unit. 24
8. Equipment
8. Equipment These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. LEVEL 1 Necessary equipment* Clean and store equipment necessary for the care of babies requiring special and high dependency care in accordance with local and manufacturer s instructions. Set up and test equipment necessary for the care of babies requiring special and high dependency care in accordance with local and manufacturer s instructions. Efficiently and safely use the equipment necessary for the care of babies requiring special and high dependency care in accordance with local and manufacturer s Be able to set, check and interpret significance of equipment alarms in babies requiring special and high dependency care and respond appropriately. * To be added according to needs of individual and local unit. 26
9. Additional skills
9. Additional skills These skills should be performed under supervision of the trainer or neonatal nurse/midwife until the relief and temporary staff member is competent. You can add items of equipment used in your unit that you want the relief and temporary staff to use. LEVEL 1/2 Associated activities* 28
LEVEL 1/2 Associated activities* * To be added according to needs of individual and local unit. 29
References, Acknowledgements & Notes
References Nursing and Midwifery Council (2009) Record keeping: guidance for nurses and midwives. London: Nursing and Midwifery Council NHS Education for Scotland (2002) A route to enhanced competence in neonatal nursing. Edinburgh: NES Acknowledgements The developers of this clinical skills passport would like to thank the following for their support and advice: Elizabeth Mansion Scottish Neonatal Nurses Group Neonatal professionals in clinical service and higher education. The is published by: NHS Education for Scotland Central Offices Thistle House 91 Haymarket Terrace Edinburgh EH12 5HE www.nes-hai.info 31
Notes 32