South Central Neonatal Network Education and training strategy: Continuing education and professional development Authored by Sue Turrill, School of Healthcare, University of Leeds, February 2012 Final Version July 2012
1. INTRODUCTION This Education and Training strategy has been produced to inform the development of a neonatal workforce which continues to provide high quality care for babies and their families within the South Central Neonatal Network. The differing elements of the strategy reflect the integration of a competent workforce which is fit for practice within a culture of life long learning and responds to the needs of babies and their families requiring specialised neonatal care. 2. AIMS AND PURPOSE The generic overarching principles aim to promote Network standardisation thus increasing clinical effectiveness, reducing risk and aligning to the priorities of workforce planning. This includes: Access to standardised training and education pathway for all registered nurses working in the Network Defining a career pathway for nursing linked to specific roles and responsibilities A logically sequenced approach to developing clinical nursing competence (skills and knowledge) from foundation/novice learning, specialist practice, to enhanced and advanced practice. A workforce that is able to work through common care pathways across organisational boundaries and service areas 2.1 Quality principles This strategy recognises the following principles presented in national quality frameworks: NHS Toolkit for high quality neonatal services (2009) National Institute for Health and Clinical Excellence: quality standard for specialist neonatal care (2011) Department of Health. Liberating the NHS: Developing the healthcare workforce, from design to delivery (2012) NHS outcomes framework 2012-13 (2011) Partnership working within Networks; Equity of access to care of the highest standard; Competency of the workforce to provide excellent care provided at the point of delivery; Equitable access to education and training for multidisciplinary team; Quality and productivity; Recruitment and retention of nurses Provision of a sufficient skilled and competent multidisciplinary workforce. Development of the workforce underpinned by strong academic links; Providing greater transparency, fairness and efficiency to investment in education and training; Ensure the workforce has the right skills, education and training to support the delivery of excellent healthcare and health improvements. Preventing people from dying prematurely reducing neonatal mortality Preventing avoidable harm reducing admissions of term babies to neonatal units 1
BAPM: Service standards for hospitals providing neonatal care (2010) RCN: competence, education and careers in neonatal nursing (2011) BAPM/NNA/SNNG: Matching knowledge and skills for qualified in speciality (QIS) neonatal nurses: a core syllabus for clinical competency (2012) Neonatal nurse staffing defining qualification in speciality; Knowledge acquisition developed through specific programmes of education; Practical development of core clinical skills directly related to responsibility for patient care; Mapped to NHS knowledge and skills framework. Criteria based, neonatal specific knowledge outcomes for QIS accredited course content; Standardised skills set detailing performance criteria; Development of portable portfolio of evidence of achievement to QIS level. In addition reference is made to local documents and more general nursing/department of health frameworks which influence the development of the workforce (appendix 1). 3. SCOPE High quality care relies on the integration of skills and knowledge of many different professional groups working together with a common goal in multi-disciplinary teams. This strategy will focus on the following two key elements 1. The registered nurse workforce 2. Essential Network focussed CPD training which benefits from a standardised approach This approach therefore aims to: Support partnership working throughout the Network, including education providers, in creating accredited programmes and modules of study; Underpin future post registration nurse education commissioning, recognising the changes to future education commissioning processes; Provide a framework for individual services to ensure standardisation of essential training and development that supports national quality drivers. 4. THE REGISTERED NURSE WORKFORCE 4.1 Education Pathways Competence (knowledge and skills) is developed through formal and informal routes. Formal routes utilise the quality framework of Higher Education Institutions whereby acquisition of new knowledge and skills are accredited. Informal routes develop generic nursing knowledge by applying this to different practice areas, and can be achieved via in-service professional development pathways. 4.11 Foundation registered nurse (new to specialist area) Newly registered nurses, from either adult, child or midwifery fields, who enter a neonatal service must all be considered as novices. This acknowledges a level of competence as a nurse but recognises the limitations in knowledge and skill development that are needed to practice safely within this specialised area. Therefore a programme of foundation learning must be provided for all nurses new to 2
this area which will encompass preparation for specialist qualification courses. This foundation learning should reflect care across all dependency levels. As the level of responsibility for patient care decisions is limited at this stage, foundation level of preparation can exist within an in-service framework as part of, or following on from, a preceptorship programme. Defining and utilising a standardised Network foundation learning package will provide a portable measure of quality assurance and is an indicator of service commitment to learning. 4.12 Neonatal nurse Qualified in Speciality Once qualified in speciality (QIS) registered nurses play a key role in improving health outcomes through the influence of their knowledge on problem solving and decision-making, and in carrying out practical clinical skills. The impact of this level of responsibility for patient care must therefore be supported by a formal education pathway, which includes the development and accreditation of the unique skills and knowledge relevant to this specialism across all dependency levels. Standardised QIS programmes of study should deliver and assess the core content defined within the nationally agreed core syllabus of knowledge and skills (BAPM, 2012). This will ensure a standard of clinical competence whereby nurses working at this level plan, organise and deliver care of the highest quality within all service areas. Clinical competence and professional development exist in different parts of a combined pathway. The combination provides a framework to map to the KSF, (adapted into neonatal nursing within the RCN career and education framework (2011)), recognising the seven specified domains. Whilst formal education routes must be accredited, learning through professional development opportunities that exist within the practice setting (informal) may be either credit or non-credit bearing. Formal and informal learning opportunities combined together will allow for the development across all competence domains. For example at QIS level: FORMAL ACCREDITED 1 Specialist neonatal programme (40-60 credits level6) Clinical competence KSF/RCN (level 2) domain: Responsibility for patient care: skills set BAPM/NNA/SNNG: BAPM/NNA/SNNG: Knowledge criteria Knowledge + skills criteria INFORMAL 2 Network/Service managed Professional development KSF/RCN (level 2) domains: Communication & interpersonal relationships; Personal, professional & people development; Health safety & security; Service development; Quality; Equality, diversity & rights; QIS Nurse 1. South Central Neonatal Network understands formal accredited to mean accredited education by an institute of Higher Education. 2. South Central Neonatal Network understands informal education to mean both informal and planned education from a variety of sources which are not accredited by an institute of Higher Education. 3
Access to practice experience is essential for achievement of competence across the range of care situations. Organisation of suitable placements that allow sufficient time for competence development, rather than experience only, across the range of care situations, will be based on collaboration between all service areas and should be co-ordinated at Network level. This will include both high dependency/intensive care placements and special care placements depending on the experience available at the nurses home unit. Commissioning of formal education programmes of study, accredited through Higher Education Institutions, should reflect workforce requirements and national standards currently defined. 4.13 Enhanced and advanced neonatal nurse. QIS nurses may also enhance their clinical practice to work in roles whereby additional responsibility exists related to defined skills (eg cannulation, intubation, newborn infant physical examination). Workforce plans may recognise this role and if so, accredited education and training pathways should be developed to incorporate this range of skills and knowledge. Single skills outside the role of the QIS nurse may be developed on an individual basis within a similar framework. The role and responsibilities of the advanced neonatal nurse practitioners exists within both nursing and medical teams and may include stabilisation and transfer, independent prescribing, initiation of complex procedures and caseload management. Preparation for this exists typically within a Masters level formal programme of study which includes in-depth knowledge and skills acquisition, supported by skills assessment in practice. The pathway through these four elements of clinical competence for registered nurses can be seen within the neonatal nursing clinical career skills and knowledge escalator (appendix 2). 4.14 Senior nurse learning pathways Formal nurse education that prepares nurses to carry out more senior roles outside the field of practice, links knowledge of specialised areas to aspects of generic nursing principles, for example leadership, management or education. With the increase in graduate nurses, provision of this theory led learning is most commonly offered at Masters level. Education and training in these generic areas has also been developed through professional development training days within many NHS Trusts. Senior non-clinical roles may not require formal masters level learning to be achieved, therefore commissioning of education is likely to consider the most effective and relevant route to this role development. In terms of life-long learning, the collection of credits should be avoided unless completion of a specific programme of study leading to role improvement has been identified. 4
4.2. Neonatal nurse career pathways Neonatal nurses are able to specialise into a diverse range of career pathways depending on their role in the workforce. Common to all is foundation/preceptorship level followed by formal qualification in speciality (QIS). Appendix 3 shows the career pathways from novice to expert roles. Identification of formal/informal training linked to each role development should be agreed at Network level. An example of this for outreach services may include: Foundation learning QIS Role development in SC environment Junior outreach team member accesses: 1. Network led 3 day attendance study programme: Nutrition, feeding & growth Family nursing & discharge planning Safeguarding Resuscitation training 2. Work based learning project linked to aspect of practice. 3. Mentoring and competence assessed by senior member of outreach team 4.3 Developing education provision: A full audit of current education and training provision within each unit/trust will be necessary prior to future planning. This will enable elements of existing education and training provision, which map to the strategy, to be recognised and developed for use across the Network. 5
Development of common E & T provision will include: Foundation Learning (Informal) Agreed principles of preceptorship Competences at novice level including skills and knowledge development throughout all care category settings and within family nursing. This may include o Knowledge based e-learning packages, for example linked to normal neonatal o physiological principles; utilising evidence in practice Network based study days, for example principles of resuscitation, thermoregulation, respiratory support, feeding, screening programmes; communicating with families in neonatal care; Safe use of equipment. Achievement of RCN/KSF competence domains (Novice level) including skills set level 1. Developed as standard for all units through links with unit practice educators; Support for learner practicing under indirect/direct supervision identified NMC/QIS mentor Qualification in speciality (Formal + Informal) Formal: Accredited programmes of study (60 credits) of specialist level knowledge and skills development to include : Clinical decision making skills, across the range of all dependencies. Integration of BAPM/NNA/SNNG core syllabus content (BAPM, 2012) Achievement of portfolio of evidence of theory, integration of theory into practice and practical skills. Informal: Achievement of RCN/KSF competence domains (QIS level) Support for learner by QIS/NMC mentor (Updating of mentor specialist practice knowledge) Enhanced clinical skills (Formal + Informal) Formal: Accredited module to include knowledge and skills related to: Physical examination of the newborn, health assessment & diagnostic reasoning Stabilisation & management of respiratory status (to include intubation) Fluid and electrolyte management (to include venous access) Support for learner in practice by QIS/NMC mentor who has completed enhanced or advanced practice skills Advanced practice education is provided by Southampton University through the MSc Advanced practice programme. 5. ESSENTIAL NETWORK FOCUSSED CPD TRAINING WHICH BENEFITS FROM A STANDARDISED APPROACH. 5.1 Common care pathways Identification of key areas of service delivery where care pathways may be standardised across all units in the Network has the potential to reduce mortality and morbidity. The collection of clinical data supporting these priorities can occur via the use of dashboards. Consequent development of Network agreed evidence based 6
care pathways should then form the basis of parts of the Network CPD mandatory training opportunities. This cross organisational working can reduce repetition, allow for economies of scale and create partnerships based on common goals of best clinical practice. Priorities considered for initial development may include: Early care guidelines Delivery room management defined by gestational age, First hour care: Thermoregulation, respiratory & circulation management, communication, Preparation & transfer to NNU Admission, subsequent care up to to 7 days of age. Initial enteral feeding management Guidelines for introduction of enteral feeds for differing gestational ages, BWs and clinical presentations. Stabilisation in preparation for transfer Guidelines based on safe control of patients condition (eg airway, breathing, circulation, drugs, environment), Communication between referring and receiving hospitals, inclusion of the family communication needs When developing care pathways wider networking with other neonatal Networks would allow for adoption or adaptation of their existing published guidelines. 5.2 Standardised approach to training Dissemination of care pathway guidelines, and integration into Trust practices, can take place with a programme of multidisciplinary CPD training days. These may also incorporate other common care practices which could benefit from standardisation. For example: Palliative care pathways; On-going post-surgical care following back transfer; Research and guideline development; Safeguarding children Training linked to the transport and transfer of babies and their families occurs through the provision of theoretical and simulation training days. Collaborative working between North and South Network transport centres, allows for agreed common core principles to be delivered through multiprofessional training days. 5.3 Use of simulation. Simulation training can enhance learning experiences and is utilised in NLS and critical incident scenarios with both high and low fidelity equipment. This may be expanded to include the use of video recording and debriefing sessions. The recent appointment of a clinical simulation fellowship position will allow for increased use of simulated practice tailored to individual units requirements. Simulation may also be offered as part of theory-practice learning within CPD related to generic neonatal specific scenarios for example: 7
Counselling for parents whose babies are in critical clinical situations or who have life limiting conditions; Leadership and effective team working; Communication and behavioural skills development. 6. STRATEGY IMPLEMENTATION Prior to implementation of the strategy it will be essential to create a picture of the current workforce. The use of a Network qualification and training database will allow both the Network and Units to develop a training needs analysis thus planning their future workforce education and development requirements. In addition to this identifying areas of current training provision, mapped to the strategy, that could be rolled out across the Network recognises excellent work already developed in specific areas. 6.1 The role of the Network Educator: Agreeing clear lines of responsibility for the differing elements of the strategy will ensure success in implementation. The appointment of a Network Educator, with responsibility for the ongoing monitoring and management of Education and Training needs, will allow for a standard of excellence in practice to be embedded in all units whilst ensuring the continued development of this essential aspect of service provision. Key responsibilities will include: Implementation of education and training strategy to reflect multiprofessional working Development and leadership of Network Nurse Education Forum Development and monitoring of qualification, education & training database Involvement in training needs analysis Collaborative working with partners in Higher Education Institutions to ensure the development and commissioning of relevant modules/programmes of study in response to training needs analysis Ensure formal and informal education programmes at all levels of nursing reflect the principles of the RCN career framework (and formally map to BAPM/NNA/SNNG knowledge content for QIS level (BAPM, 2012)) Partnership working with all trust to ensure practice placements allow for achievement of competence development across all dependency levels. Provision of informal Network based, neonatal specific professional development training days in line with the KSF domains of the RCN career framework Development of a Network foundation learning package to include o o Common principles of preceptorship, Achievement of Novice level skills and knowledge throughout all dependency areas leading to agreed standard of competency Implementation and monitoring of foundation package for all novice nurses within the workforce, achieved within an agreed timeframe. This will form preparation for entry to formal QIS education programmes. Working in partnership with all neonatal units to ensure integration of learning in practice and promotion of evidence utilisation into care practices Involvement in multidisciplinary research projects 8
6.2 Nurse champions Introducing Champions in nursing has increased the transfer of knowledge and evidence into practice, thus increasing clinical effectiveness of staff. Their role is one of leadership based on dedication and the ambition to improve care, thus championing the needs of babies and their families in specific areas of practice. By working with identified unit facilitators they can instigate projects based around knowledge transfer eg, following local audits, developing e-learning packages or Network-based study days, negotiating individual unit need. Examples of special areas of interest may include: Parent support and empowerment Breast feeding and nutrition Palliative care On-going post surgical care Safeguarding children Developing parent-infant relationships Nursing research 7. KEY POINTS Creation of standard Trust qualification and training database feeding into Network database. Recognition of good practice areas for Network wide dissemination Training needs analysis Appointment of Network Educator Multi-disciplinary Network education forum Cross organisational common care pathways Identification of Nurse champions supported by unit facilitators Develop systems which monitor and audit quality and effectiveness of E & T in relation to role expectations, fitness to practice and workforce planning 9
Appendix: 1 KEY DOCUMENTS BAPM (2010) Service standards for hospitals providing neonatal care. BAPM. London. BAPM (2012) Matching knowledge and skills for qualified in speciality (QIS) neonatal nurses: a core syllabus for clinical competency. BAPM. London. DH (2012). Liberating the NHS: Developing the healthcare workforce, from design to delivery. DH. London. DH (2011) The government s response to the recommendations in front line care: the report of the prime ministers commission on the future of nursing and midwifery in England. DH. London. DH (2011) NHS outcomes framework 2012-13. DH. London. DH (2010) Preceptorship framework: for newly registered nurses, midwives and allied health professionals. DH.London. DH (2009) NHS toolkit for high quality neonatal services. DH. London. DH (2008) Framing the nursing and midwifery contribution: driving up the quality of care. DH London. DH (2008) Towards a framework for Post-registration nursing careers: consultation response report. DH. London. Flannigan, C, Toland, U & Hogan, M. (2010) Dashboards in neonatology. Clinical Audit 2010:2, 79-81. NHS (2010) The nursing roadmap for quality: a signposting map for nursing. DH. London. NICE (2011) National Institute for Health and Clinical Excellence: quality standard for specialist neonatal care. NICE. London. RCN (2011) Competence, education and careers in neonatal nursing: an RCN guidance. RCN. London. 10
Appendix 2 CLINICAL COMPETENCE SKILLS + KNOWLEDGE ESCALATOR Neonatal nursing Advanced Neonatal Nurse Practitioner (Expert): Novice/new entrant: Qualified in speciality neonatal nurse (QIS): Enhanced skills and knowledge (Proficient): Integrating more complex care pathways with enhanced decision making skills Formal education defining roles and responsibility related to full range of complex care needs. Foundation Network learning package to include skills set level 1 (appendix 4) and supporting knowledge across range of care. Practice principles under direct supervision. Network study days & mentor support to include assessment of knowledge in relation to skills. Formal accredited modules of study to include QIS skills set & core syllabus of knowledge ; Rationalising judgments and clinical decision making; Modules of study to cover complete range of clinical care and situations ; Formal achievement of Network portfolio of evidence. Defined role to include: Health assessment, physical examination & diagnostic reasoning Stabilisation & management of respiratory status (to include intubation) Fluid and electrolyte management (to include venous access) 11
Appendix 3: Career pathway for registered nurses Consultant Nurse HE Lecturer HE Researcher Network Manager 7-8 MSc Advance d ANNP Network Educator (MSc/PGCE) Researcher Academic profile Network Family Lead Network transport Lead Network Lead Nurse 6-7 NHS Leadership management Expert Enhanced practice skills course Practice development leader Unit Nursing Research & evidence Lead Outreach Team Leader Transport team leader Matron/Unit co-ordinator 5-6 NMC mentorship 5 Proficien t QIS Novice Experienced QIS clinical facilitator QIS mentor Member of research team QIS completes accredited 60 credit specialist programme; Development of portfolio detailing evidence of achievement of skills+ knowledge; Network competences linked to RCN/KSF New entrant Preceptorship period; Completes Network Foundation Learning package across all dependencies 12 Member of outreach team Member of transfer team Area co-ordinator
Appendix 4: RCN level 1(New entrant) skills set Fluid, nutrition and elimination management Recognise normal gastro-intestinal function, urinary tract function and bilirubin elimination, reporting deviations Implement interventions to sustain homeostasis according to unit guidelines Assist the mother to breast feed according to evidence base/unit guidelines Assist parents/carers in other enteral feeding techniques Safely carry out all forms of enteral feeding (except breast) according to evidence base/unit guidelines Administer nutritional supplements according to prescription Safely administer intravenous therapy according to unit guidelines, recognising and reporting deviations/complications Monitor input and output Measure and record weight and head circumference Obtain capillary blood sample to measure and monitor blood glucose levels, reporting deviations Neurological, pain and stress management 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 Respiratory and cardiovascular management 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 the incubator, head box, nasal cannulae and facially, including adequate humidification as prescribed Use safe and effective oral and nasal suction techniques Skin, hygiene and infection prevention management Implement correct hand washing and other infection prevention measures as per local guidelines Ensure compliance with infection prevention 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 including stoma care as advised Management of thermoregulation Assess neonatal body temperature using appropriate method and site and report deviations from normal Use appropriate strategies to maintain body temperature within normal limits, including environmental aspects, clothing and equipment 13
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