Supporting children s nurses working outside of designated children s wards

Supporting children s nurses working outside of designated children s wards Guidance for clinical professionals and managers of children s services CLINICAL PROFESSIONAL RESOURCE

SUPPORTING CHILDREN S NURSES Acknowledgements This document has been reviewed and updated by the RCN Children and Young People s Professional Issues Forum to provide practitioners with contemporary information, support and guidance for nurses and team members working outside of designated children s wards or departments or within other settings where children receive care and treatment. The need for guidance arose from a survey undertaken by the RCN Paediatric Nurse Managers Forum in 1999 which identified the isolation and governance issues experienced by children s nurses working in their posts outside of designated children s facilities. This update acknowledges the original document published in 1999 and revised guidance in 2013. Members of the RCN Children and Young People s Professional Issues Forum can be contacted through the RCN Professional Lead for Children and Young People s Nursing. Comments and contributions are welcomed on this document and other children s nursing and service issues. This publication will be reviewed in December 2020 to provide feedback on the contents or on your experience of using the publication. Please email publications.feedback@rcn.org.uk Publication This is an RCN service guidance. Service guidance are evidence-based consensus documents regarding the organisation, resourcing and delivery of health and social care services for specified populations and/or staff groups delivering care. Intended to support service commissioning, planning and provision as well as improvements in service quality and people s experience of health and social care services. Description This publication is designed as a checklist that can be used when considering the support, guidance, management and education framework required for children s nurses working outside of a designated ward/department. Publication date: December 2017 Review date: December 2020. The Nine Quality Standards This publication has met the nine quality standards of the quality framework for RCN professional publications. For more information, or to request further details on how the nine quality standards have been met in relation to this particular professional publication, please contact publications.feedback@rcn.org.uk Evaluation The authors would value any feedback you have about this publication. Please contact publications.feedback@rcn.org.uk clearly stating which publication you are commenting on. RCN Legal Disclaimer This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK. The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance. Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN 2017 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers. 2

ROYAL COLLEGE OF NURSING Contents 1. Introduction 4 2. Why is there an increase in children s nursing posts outside of the designated children s inpatient ward, department or other setting? 5 3. Good practice guidance framework for the support and supervision of children s nurses in posts that feel isolated 7 4. Summary 12 References 13 Online resources 15 Supporting children s nurses working outside of designated children s wards, departments and other settings where children receive care and treatment Guidance for clinical professionals and managers of children s services This guidance document will help: registered children s nurses and team members working in posts and delivering services to babies, children and young people outside of a designated children s inpatient ward, department or within another setting where children receive care and treatment managers of children s services towards achieving targets and implementing recommendations set by the Royal College of Paediatrics and Child Health, State of Child Health and Facing the Future Reports (RCPCH, 2017 and 2015); Maternity and Children's Quality Improvement Collaborative (MCQIC, 2016); the Leeds Children's Heart Surgery review (NHS England, 2014); the Bristol Royal Infirmary Inquiry Report (DH, 2001); the National Service Framework (Department of Health (DH, 2004); Every Child Matters (DFES, 2003); The Children s Plan: Building brighter futures (DH, 2007); Improving services for children in hospital (Healthcare Commission, 2007); Healthy lives, brighter futures the strategy for children and young people s health (DH, 2009); You re welcome: Quality criteria for young people friendly health service s (DH, 2011); Children and Young People s Health Outcomes Forum report (DH2012); and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013) promote effective leadership of senior children s nurses within health care organisations. RQIA Provider Guidance 2016-17 Independent Hospital Children's Hospice (RQIA, 2016); Children and Young People (Scotland) Act 2014, The Lenehan Review (Council for Disabled Children, 2016) the United Nations Conference on the Rights of the Child (UNCRC, 1995). 3

SUPPORTING CHILDREN S NURSES 1. Introduction The RCN Children and Young People s Professional Issues Forum supports all nurses and team members working with children in an advisory, supervisory or managerial capacity. This guidance is particularly aimed at those nurses working at bands 6 (junior sister or charge nurse) and 7 (senior sister or charge nurse) and above, and those with continuing responsibility for care, including nurse consultants. A pilot survey relating to nurses working in settings outside of those designated for children s care and treatment was undertaken in 1999 by the RCN Paediatric Nurse Managers Forum and the results of the survey were reviewed again in 2013 by the RCN Children and Young People s Professional Issues Forum. In 2017 there continues to be concern about the overall decline in the number of children s nursing professional leadership posts above ward or departmental level. This is a dynamic document that we undertake to update, amend and expand. However, it is not intended to be prescriptive rather to stimulate thought and discussion, as well as inform local assessment of need. It offers a guide to key issues that require consideration before implementing a Framework to support children s nurses and team members that work in posts outside of a designated children s inpatient ward, department or within another setting where children receive care and treatment. Key issues: Children s nurses working in posts outside of a designated children s inpatient ward, department or other setting highlighted examples of good practice. Children s nurses reported that senior posts carried a trust-wide responsibility to ensure quality care for all children, this included services provided for children outside the designated children s inpatient wards and/or outpatient units. A number of key concerns were identified by the children s nurses including: having little or no influencing ability on practice poor support and supervision networks a lack of recognition for skills and expertise limited resources and facilities for children poor children s nurse staffing levels inadequate standards of practice minimal opportunities to help the individual practitioner to develop further paediatric skills and knowledge base. Whilst the survey was undertaken nearly two decades ago the findings continue to be relevant today. 4

ROYAL COLLEGE OF NURSING 2. Why is there an increase in children s nursing posts outside of the designated children s inpatient ward, department or other setting? There are two main reasons why there is an increase in the number of these nursing posts. 1. The increased need, as a result of national guidance, to provide appropriate health care services to children in all areas where they may be seen or admitted. Several key documents over recent years have emphasised the need for registered children s nurses to be employed in areas where children may be seen or admitted. In attempting to address this issue acute health care services are recruiting children s nurses to meet the various national guidance relating to children (see below). In those independent hospitals where children are to be admitted, registration criteria should stipulate that this can only be granted when the hospital is able to demonstrate that registered children s nurses are available to care for children throughout the 24 hour care cycle. (RQAI, 2016, RCN, 2011) A lead children s nurse must be employed at a senior level for the emergency setting to coordinate care for children, development of policy and practice, facilitate education of other staff and link with senior nurses in the inpatient department. (RCPCH, 2012) A registered trained children s nurse should be available within the A&E Department on all shifts. Children are major users of the A&E department and registered trained children s nurses are essential in recognising serious problems in children and working sensitively with them and their families. Royal College of Paediatrics and Child Health (RCPCH, 2010) District general hospitals receiving children have to be able to initiate level 2 paediatric intensive care whilst awaiting the arrival of the retrieval team. (DH, 1997; Paediatric Intensive Care Society (2010)). Day case services should meet the criteria laid down in the Department of Health document Welfare of Children and Young People in Hospital, and follow the guidance in the document Just for the Day, Caring for Children in the Health Services. (RCPCH, 1996) There should be a senior management focus for children s services in every hospital to ensure that the special needs of children and families are recognised in all aspects of care. This management team should consist of a consultant and a senior children s nurse, as well as having appropriate, financial support (Audit Commission, 1993) There is a registered children s nurse available 24 hours a day to advise on the nursing of children in other departments, for example, the Intensive care unit, the A&E department, outpatients (DH, 1991 and in Defining Staffing levels for children and young people (RCN, 2013). 5

SUPPORTING CHILDREN S NURSES 2. The increasing number of ambulatory care facilities being provided for children, often not on the same site as the children s inpatient beds. Fifty per cent of all emergency secondary care paediatric admissions remain in hospital less than 24 hours. Current health trends suggest a reduced need for children s inpatient beds, with an enhanced demand for ambulatory care facilities to incorporate other services such as outpatients, elective and emergency day care, rapid assessment and Emergency Departments (ED or A&E) NHS Institute for Innovation and Improvement (NHS, 2010); RCPCH (2015, 2010 and 1998); Beverley, Ball, Smith et al. (1997). 6

ROYAL COLLEGE OF NURSING 3. Good practice guidance framework for the support and supervision of children s nurses in posts that may feel isolated Following communication with forum members and a review of current literature, four key areas are identified as crucial in the establishment of a framework to support children s nurses in posts outside of a designated children s ward, department or other setting where children receive care and treatment. Effective structures Develop communication links. Build and maintain effective working relationships. Child and parent/carer involvement. Minimise risks. Professional support and guidance: Establish clinical supervision sessions. Advice and support in developments and practice. Continuing professional development (CPD) and Revalidation Lifelong learning. Engaging in activities. Recruitment and retention Career structures. Pay and reward. 1 Effective structures Develop communication links It is essential that effective and efficient communication links are established and maintained between the designated children s department and all areas where: children receive care registered children s nurses are employed across the organisation. These links will prove useful for the: dissemination of information, for example, research highlighting evidencebased practice, nationally recognised pathways of care, reports, new local protocols, policies or guidance, and details about training events identification of any concerns and potential differences in practice that may need to be clarified in order to ensure consistency across the organisation representation of staff on key child health forums, for example, safeguarding children/ child protection team meetings. Build and maintain effective working relationships To help communicate information on support, supervision and advice on children s issues, the senior children s nurse of the designated children s ward/department/unit should organise regular meetings with other department managers where a service is provided to children, and where registered children s nurses are employed. 7

SUPPORTING CHILDREN S NURSES These communication forums will help to address those issues that have been raised by children s nurses working outside of designated children s wards/departments, as well as providing support to change practice in order to meet national guidance. This will be essential in ensuring national standards for children s health care are incorporated and implemented in all areas where children are provided a service, thereby reducing variations in service standards. Child and parent/carer involvement The public must be involved in all aspects of the NHS and the perspectives of patients and the general public heard and taken into account wherever decisions affecting the provision of health care are made (RQAI, 2016, BRI Inquiry, 2001; Francis report, 2013). Minimising risks Patients are entitled to expect that their care will be of such quality as is consonant with good practice and based on sound evidence, for example, Leeds Children's Heart Surgery Services (NHS England, 2014). Standards for Children and Young People's Emergency care (RCPCH, 2012), Bristol Royal Infirmary Inquiry 2001; Francis report, 2013). To help this achievement, lessons have to be learned from previous mistakes through an effective clinical governance and risk management strategy. To enhance the quality of service provision and minimise clinical and nonclinical risks the senior children s nurse, in collaboration with individual registered children s nurses, should ensure systems are established to identify, manage and monitor risks or potential risks for children and their families. To facilitate this process the individual registered children s nurse should have the responsibility to use their expert knowledge and skills to monitor standards of practice and to review all critical incidents, nearmisses or complaints that involve children within their area. They should be facilitated in this by a supportive learning environment. The senior children s nurse, in collaboration with the individual registered children s nurse and appropriate service managers, should jointly devise and communicate recommendations for actions. These could incorporate: training sessions practice changes development of protocols and policies resource bids for service developments risk assessment training and incident reporting training patient pathways (Patient Safety and Health Improvement, 2016). 2 Professional support and guidance Establishing supervision sessions The most senior children s nurse of the designated children s ward, department or setting should initiate and develop a system to enable all registered children s nurses employed within the organisation to reflect upon practice, analyse critical incidents and assess complaints. This should include a monthly supervision session for all registered children s nurses working outside of a designated children s ward or department. As a minimum the supervisor should be: a registered children s nurse employed at band 7 or above employed by the health board/hospital/trust. Safeguarding children Supervision in particular is a term used to describe a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance child protection and safety in complex child protection situations. These sessions will help identify any deficiencies in practice or service delivery and make sure the reasons why are analysed and acted upon in order to ensure excellence. As highlighted by the Bristol Royal Infirmary Inquiry, and more recently by the Francis report, staff are often not encouraged to share their problems or to speak openly. Those who tried to raise concerns 8

ROYAL COLLEGE OF NURSING in Bristol found it hard to get their voice heard (BRI Inquiry, 2001) Likewise, the Francis report (2013) reported that the culture at the Mid Staffordshire Trust was not conducive to providing good care for patients or providing a supportive working environment for staff. There was an atmosphere of fear of adverse repercussions, low staff morale, lack of openness and an acceptance of poor standards. One of the recommendations from the report states the board should give priority to ensuring that any member of staff who raises an honestlyheld concern about the standard or safety of the provision of services to patients is supported and protected from any adverse consequences, and a culture of openness and insight should be fostered. Advice and support in developments and practice The major problem facing registered children s nurses working outside of a designated children s ward or department is that many of the areas are often adult focused, which means difficulty in: getting recognition from fellow work colleagues for specialist children s nursing knowledge and skills helping children to be viewed as a unique client group, with individual needs and requirements implementing changes in practice to improve the quality of care for children and their families. Suggested good practice to help support registered children s nurses working outside of a designated children s ward or department in the development of services and practice should include regular meetings between the most senior children s nurse of a designated children s ward or department, registered children s nurse and their immediate line manager. These meetings will help: highlight national guidance and associated requirements negotiate joint action plans, time scales and resources for service developments/practice enhancements ensure the resources for service developments are incorporated within both the children s departments and the individual services business plans. use risk assessment and patient safety tools as a lever to ensure high quality care infection control regular feedback on the progress of agreed service developments. develop and review agreed protocols between the designated children s wards, department and other areas where children are cared for establish formal arrangements for peer support with lead clinicians, nurses and play specialists working in designated children's wards, departments and other facilities. 3 Continuing professional development (CPD) and Revalidation Lifelong learning Children and their families place their trust in health professionals. They need to be assured that the care they receive is delivered by staff trained and skilled to meet their needs, and that practice is up to date with the latest research and new techniques (RCN, 2001a; BRI Inquiry, 2001; RCN, 2011; RCN, 2013.) Continuing professional development is a process of life long learning for all individuals to enable them to grow and develop as individual practitioners as well as helping them to continue to adapt to meet the needs of children and their families. All members of staff should receive support from their employers to fulfil requirements of clinical governance and revalidation (DH, 2000). This includes maintaining practice, skills and knowledge within children s nursing to fulfil requirements for reregistration. Revalidation with the Nursing and Midwifery Council (NMC, 2016). The following examples of good practice should be supported and initiated across the 9

SUPPORTING CHILDREN S NURSES organisation by the most senior children s nurse of the designated children s ward/department. 1. Annual rotation of all registered children s nurses working outside of a designated children s ward/department to the local children s inpatient unit for a period to update their general children s nursing knowledge and skills. 2. Mandatory attendance at annual update days within a designated children s ward/ department to include: safeguarding children/child protection oral and intravenous drug therapy recognition of illness and deterioration of health state paediatric resuscitation pain assessment and management moving and handling. Engaging in activities The most senior children s nurse of a designated children s ward, department or setting should encourage the individual registered children s nurse to participate in the activities of not only their individual clinical environment but also those of the local children s inpatient unit. Such activities could include: research groups education groups clinical guidelines/policy groups clinical governance and working groups national and local children s health care forums. This activity will help the: development of children s services standardisation of practice professional development of the individual registered children s nurse establishment of communication systems development of support networks. 4 Recruitment and retention Improving the working lives of staff through improved recruitment and retention contributes directly to better patient care; patients want to be treated by wellmotivated, fairly rewarded staff (DH, 2000). To ensure the recruitment of children s nurses in to posts outside of the designated children s ward/departments it may be necessary to offer staff rotational posts in to children s wards and departments, review roles and ensure that expertise is valued and skills used and maintained appropriately (Hogg, 1997). This could be facilitated through career progression and appropriate pay and rewards. A senior children s nurse should be fully involved in the recruitment process, including developing all job descriptions for children s nurses, and interviewing all children s nurses outside of the designated children s wards/departments. In England, outcome 14 ( Supporting Workers ) of the Care Quality Commission Essential Standards for Quality and Safety, has a specific subsection for children s services (CQC, 2010). Section 14B states that children who use services can be confident that they are treated by staff who are appropriately trained to provide care, treatment and support for children, including Children s Workforce Development Council Induction Standards. Career structures As part of the process of improving working lives of staff, a career structure needs to be identified and negotiated by the senior children s nurse of the designated children s ward, department or setting. Career framework and revalidation is highlighted in the Shape of Caring (2015) 2020 Vision (2013). This should include: role development. enhancing autonomy and responsibility. skills and knowledge development. promotion prospects. annual rotation to designated children s ward, department or other setting. 10

ROYAL COLLEGE OF NURSING annual appraisal to include SMART objectives and personal development plan. Pay and reward Job descriptions should be reviewed to ensure they cover the nursing skills and knowledge that registered children s nurses can offer to a service. This should include: continuing professional development of children s nursing skills and knowledge training and education of other staff children s nursing advice supervision by a senior children s nurse practice development relating to children s nursing care. The pay scales should be commensurate with the job description. 11

SUPPORTING CHILDREN S NURSES 4. Summary Throughout this guidance emphasis has been placed upon: the value of building relationships and communication networks to enable the quality of children s care and services to be enhanced the important and crucial role of the most senior children s nurse of the children s ward, department or within other settings in facilitating this quality enhancement and ensuring national standards are followed. The implementation of this best practice guidance will lead to: improved care through the development of services and nursing practice for children in services outside of a designated children s ward, department or within other settings where children receive care and treatment improved support mechanisms and professional leadership for registered children s nurses working outside of a designated children s ward or department. The key to achieving the above is the appointment of high quality, senior children s nursing leaders with the ability to work across departmental and organisational boundaries in order to ensure national standards and guidance are followed in all areas where children receive care and treatment. 12

ROYAL COLLEGE OF NURSING References Beverley DW, Ball RJ, Smith RA et al (1997) Planning for the future: the experience of implementing a children s day assessment unit in a district general hospital,. Arch Dis Child, 77(4) pp. 287293. Bindler R (2012) Clinical skills manual for Principles of Paediatric nursing: caring for children, Pearson: NJ. Care Quality Commission (2011) Guidance about compliance: essential standards of quality and safety, London: CQC. Available at:www.cqc.org. uk (accessed 20 September 2017). Davies, A. and Davies, R. (2011) Children s and Young People s Nursing: principles for practice, London: Hodder-Arnold. Department of Health (1997) Paediatric intensive care: a framework for the future, London: DH. Available at: http://webarchive. nationalarchives.gov.uk (accessed 20 August 2013). Department of Health (1991) Welfare of children and young people in hospital, London: HMSO. Department of Health (1997) A bridge to the future: nursing standards, education and workforce planning in paediatric intensive care: report of the chief nursing officer s task force, London: DH. Available at: http://webarchive. nationalarchives.gov.uk/+/http://www.dh.gov. uk/en/publicationsandstatistics/publications/ PublicationsPolicyAndGuidance/DH_4005506 (accessed 20 September 2017). Department of Health (1999) Making a difference: strengthening the nursing, midwifery and health visiting contribution to health and healthcare, London: DH. Available at: http:// webarchive.nationalarchives.gov.uk (accessed 20 September 2017). Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform, London: Stationery Office. Available at: http:// webarchive.nationalarchives.gov.uk (accessed 12 September 2017). Hogg C (1997) Emergency Health Services for Children and Young People: A Guide for Commissioners and Providers, London: Action for Sick Children. NHS England (2015) National Safety Standards for Invasive Procedures (NatSSIPs), London: NHS England. NHS Institute for Innovation & Improvement (2010) A Whole System Approach to Improving Emergency and Urgent Care for Children and Young People guide, London: NHS Institute of Innovation and Improvement. NHS Institute for Innovation & Improvement (2008) Focus on: Children and Young People Emergency and Urgent Care Pathway, London: NHS Institute of Innovation and Improvement. NHS Improvement (2016) Serious Incident Framework, London: NHS Improvement. Royal College of Nursing (1998) Acute children s services: UK wide report. London: RCN. Royal College of Nursing (2000) Children in acute independent sector hospitals, London: RCN. Royal College of Nursing (2001a) Children s services: acute health care provision a report of UK survey with a focus upon children s nursing leadership, London: RCN. Available at: www.rcn.org.uk/publications (accessed 20 September 2017). Royal College of Nursing (2001b) Developing an effective clinical governance framework for children s acute health care service, London: RCN. Available at: www.rcn.org.uk/publications (accessed 20 September 2017). Royal College of Nursing (2014) Health care service standards in caring for neonates, children and young people, London: RCN. Available at: www.rcn.org.uk/publications (accessed 20 September 2017). Royal College of Nursing (2013) Defining staffing levels for children and young people s services, London: RCN. Available at: www.rcn.org.uk/ publications (Accessed 20 September 2017). Royal College of Nursing (2016) Briefing paper Inequalities experienced by children in the UK accessing the right care, at the right time, in the right place, London: RCN. Publication code 005619. Royal College of Nursing (2013) Standards for assessing, measuring and monitoring vital signs in infants, children and young people, London: RCN Pub code 003196 Royal College of Paediatrics and Child Health (1998) Ambulatory paediatric services in the UK: report of a working party, London: RCPCH. 13

SUPPORTING CHILDREN S NURSES Royal College of Paediatrics and Child Health (1998) Children s surgical services: report of an adhoc multidisciplinary children s surgical liaison group, London: RCPCH. Royal College of Paediatrics and Child Health RCPCH (1999) Accident and emergency services for children: report of a multidisciplinary working party, London: RCPCH. Royal College of Paediatrics and Child Health (2015) Facing the Future: standards for paediatric services, London: RCPCH. Available at:www.rcpch.ac.uk (accessed 2 November 2017). Royal College of Paediatrics and Child Health (2012) Standards for Children and Young People in Emergency Care Setting, London: RCPCH Scottish Government (2013) Everyone Matters 2020 Workforce Vision Healthier Scotland, Edinburgh: Scottish Government. The Bristol Royal Infirmary Inquiry (2001) The report of the public inquiry into children s heart surgery at the Bristol Royal Infirmary 19841995: Learning from Bristol, London: The Stationery Office. Cm 5207 Available at: http:// webarchive.nationalarchives.gov.uk (accessed 20 September 2017). The Department of Health (2014) Social Services and Public Safety s (DHSPPS) Minimum Care Standards for Healthcare Establishments, London: DH. The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, London: The Stationery Office. Available at: www.gov.uk/government/publications/reportof-the-mid-staffordshire-nhs-foundation-trustpublic-inquiry (accessed 2 November 2017). The Paediatric Intensive Care Society (2010) Standards for the Care of Critically Ill Children (4th edition, Version 2), London: PICS. Available at: www.ukpics.org.uk (accessed 20 August 2013). The Regulation and Improvement Authority (2011) (Independent Health Care) (Fees and Frequency of inspections) (Amendment) Regulations (Northern Ireland), Northern Ireland: RIA. 14

ROYAL COLLEGE OF NURSING Online resources www.gov.uk/government/uploads/system/uploads/attachment_data/file/216852/cyp-report.pdf www.unicef.org.uk/what-we-do/un-convention-child-rights www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2014/03/leeds-review1.pdf www.scottishpatientsafetyprogramme.scot.nhs.uk/programmes/mcqic www.rqia.org.uk/rqia/files/ef/ef4ad967-1de8-4df9-9d9b-002832d18a12.pdf www.revalidation.nmc.org.uk/ www.rcpch.ac.uk/improving-child-health www.rcpch.ac.uk/emergencycare www.actionforsickchildren.org.uk www.nice.org.uk www.nhsemployers.org/your-workforce/plan/education-and-training/shape-of-caring-review www.gov.scot/resource/0042/00424225.pdf 15

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