Where does the buck stop when the CCN hands over responsibility to unqualified carers

1
Where does the buck stop when the CCN hands
over responsibility to unqualified carers?

• Mark Whiting,
• Consultant Nurse,
• Children with complex health needs
• West Hertfordshire Primary Care Trust

2
Who are these carers?

• Band 3 health care support workers employed by
  your own Trust
• Band 4 assistant practitioners employed by your
  own Trust
• Learning Support Assistants (LSAs and Mealtime
  Support Assistants employed by the Local
  Education Authority and working in school)

3
Who are these carers?

• Care workers based in Local Authority childrens
  homes and respite care facilities
• Transport staff employed or contracted by the
  Local Authority to accompany children in transit
  from home to school
• Shared carers.
• Care staff employed by 3rd Sector providers
  such as Mencap, NCH, Barnardos
• Individuals employed by parents on a Direct
  Payments basis.

4

• If you werent concerned before I started you
  might be now!

5
What sort of things might you be teaching? (RCN
2005)

• Administering prescribed medicine in pre-measured
  dose via naso-gastric tube or gastrostomy tube
• Bolus or continuous feeds via a naso-gastric or
  gastrostomy tube
• Tracheostomy care including suction and emergency
  change of tracheostomy tube
• Injections (intra-muscular or subcutaneous) with
  pre-loaded syringe
• Intermittent catheterisation and catheter care
• Care of a Mitrofanoff
• Stoma care

6
What sort of things might you be teaching? (RCN
2005)

• Inserting suppositories or pessaries with a
  pre-packaged dose of a prescribed medicine
• Rectal medication with a pre-packaged dose
• Administration of buccal or intra-nasal Midazolam
• Emergency treatments covered in basic first aid
  training
• Assistance with inhalers, insufflation cartridges
  and nebulisers
• Assistance with oxygen administration
• Basic life support/resuscitation

7
And perhaps you shouldnt be teaching

• Re-insertion of naso-gastric tube
• Re-insertion of gastrostomy tube
• Injections involving
• assembling syringe,
• administering intravenously
• controlled drugs.

• Programming of syringe drivers
• Filling of oxygen cylinders

8

• Are you worried yet?

9
Levels of teaching

• General observation to reduce anxiety the
  staff being taught are not expected to carry out
  the procedure
• Certificate of attendance you may be expected
  to sign and confirm the nature of the teaching
  and which individual staff members were present

10
Levels of teaching

• Statement of competence
• If you are delegating care to another unqualified
  person you may be asked to provide formal
  confirmation that you consider the person to be
  competent to undertake that care.
• If you are signing to confirm that a carer is
  competent to undertake a particular procedure you
  need to be confident that they are!
• Teaching/Learning
• Observation of competence
• Assessment of knowledge/skills

11
Levels of teaching

• The carer should also sign to confirm that they
  are accepting responsibility for the care which
  you are de facto delegating to them
• You should set and record an expiry date for
  that competence
• Make your own written (signed and dated) records
  and ensure that you have also provided clear
  written protocols/guidance.
• Parents (and the child if appropriate) should be
  as fully involved in the whole process as
  possible

12
Accountability I

• You may be expected to delegate care delivery to
  others who are not registered nurses or midwives.
  Such delegation must not compromise existing
  care but must be directed to meeting the needs of
  and serving the interests of patients and
  clients. You remain accountable for the
  appropriateness of the delegation and for
  ensuring the person who does the work is able to
  do it and that adequate supervision and support
  is provided. (Paragraph 4.6)
• Nursing and Midwifery Council, 2002 The NMC code
  of professional conduct standards for conduct,
  performance and ethics. London, NMC. (and NMC,
  2007, Advice on Delegation for NMC Registrants.
  London, NMC.)

13
Accountability II

• If a health professional were to give negligent
  advice to a patient or to the carers and, in
  reliance on that advice, harm was caused, then,
  if the advice was given knowing that it would be
  relied upon, the heath professional or employer
  could be held accountable (Page 140)
• Dimond B (2005) Legal aspects of the community
  care of the sick child. In Sidey A, Widdas D
  (eds) Textbook of Community Childrens Nursing
  (2nd edn) Edinburgh, Elsevier.

14
And who is doing the teaching?

• The Nurse Consultant?
• The Community Matron?
• The Team Leader?
• The Band 6 nurse?
• The Band 5 nurse?

15
Skill-mix and grade-mix in CCN services
16
Grade mix and skill mix

• Grade mix
• A team of nurses who are paid on different
  salary scales (grades or bands) and whose levels
  of responsibility are determined by the grade
  which is attached to the post which they hold

• Skill mix
• A team of nurses within which the total range of
  skills which the team provide is determined in a
  systematic way in response to the needs of the
  population to be served and the services to be
  delivered to them

17
Community Paediatric Nursing in England in 1988

• 45 CCNs in the whole of England
• 40 employed at Sister/Charge Nurse grade
• 4 employed as Staff Nurse grade
• 1 District Enrolled Nurse
• 44 Registered Sick Childrens Nurses
• 1 Enrolled Nurse
• 23 also qualified as RGN
• 22 qualified as District Nurse
• 2 qualified as Health Visitors
• 1 qualified as both DN and HV
• (Only two held Degree qualifications)

18
Community Paediatric Nursing in England in 1988

• 23 CCN teams in the whole of England
• 11 teams made up of one CCN only
• 5 teams of two CCNs
• 5 teams of three CCNs
• One team of four CCNs
• One team of five CCNs (plus 1 x diabetes liaison
  nurse plus 1 x special school sister)

19
Community Paediatric Nursing in England in 1988

• 23 CCN teams
• 12 teams working 9-5 Monday to Friday
• 8 teams working 9-5 7 days per week
• 2 teams providing 24/7 cover
• 1 team working alternate weekends

20
Community Paediatric Nursing in England in 1988

• 23 CCN teams
• 23 teams caring for children with chronic disease
• 23 teams caring for children with acute medical
  problems
• 19 teams following up non-day case surgical
  patient
• 18 teams providing care to children with
  disabilities
• 11 teams providing day-case follow-up

21
Community Paediatric Nursing in England in 1988
22
Community Paediatric Nursing in England in 1988
23
Community Paediatric Nursing in England in 1988

• Experience and qualifications required to be a
  Community Paediatric Nurse?
• Qualifications
• RSCN - 21 out of 23
• DN cert - 10 out of 23
• DN or HV 1 out of 23
• Experience
• Paediatrics 15 out of 23
• Counselling 5 out of 23
• Community 3 out of 23

24
Wise decisions developing paediatric homecare
teams (RCN 1994)

• Identified a number of areas of practice where
  paediatric home care was becoming important
• Cancer and leukaemia
• Cystic fibrosis
• The sick neonate
• Asthma
• Diabetes
• Day admissions
• Respite care
• General nursing care at home

25
Qualifications and experience

• Grade G (as F plus)
• Community qualification essential
• CCN experience essential
• Specialist interest with appropriate
  qualification desirable
• Teaching and assessing (ENB 998) desirable
• First degree desirable

• Grade E
• RSCN/Child branch
• Minimum 1 year hospital paediatric experience

• Grade F (as E plus)
• Community qualification desirable
• Further paediatric experience hospital or
  community
• Commitment to formal academic development
  desirable

• Grade H (as G plus)
• Previous experience at G grade or equivalent
  essential
• Training in management skills essential
• Training as a community practice teacher desirable

26
Additional features

• Grade G
• Possible areas of specialist clinical knowledge
  with ability to lead the team in these areas.
• Mentor/assessor/supervisor of pre and post-
  Registration student nurses

• Grade E
• Should not make initial visits unaccompanied
• No independent responsibility for overall care of
  individual patients

• Grade F
• Higher level of clinical skills and knowledge
• Independent responsibility for overall care of
  individual patients but with day-to-day senior
  support to take on responsibility for care of
  groups of patients

• Grade H
• Leads team in all aspects of clinical practice
• Overall responsibility for team caseload
• Leads policy development
• Managers pay and non-pay budgets

27
1994-2004

• Major expansion in CCN services provision
• Growing range of specialist CCN services being
  provided in the community
• Shift in services from hospital to home
• Introduction of Specialist Practitioner
  Qualification in Community Childrens Nursing

28
Expansion in CCN Services Provision
29
Growing range of specialist CCN services being
provided in the community

• Community Childrens Nursing is now an umbrella
  term which may be applied to a wide range of
  roles and areas of specialist practice including
• Traditional community childrens nursing
• Disability Nursing
• Special School Nursing
• Palliative Care
• Diabetes Care
• Respiratory Care
• Oncology
• Continuing Care
• Advanced Practice

30
Shift in services from hospital to home

• Shifting the balance of care
• Care closer to home
• Hospital-at-home
• Intermediate care
• Ambulatory care
• Long term conditions care
• Modelling the future
• Darzi review Our NHS Our future

31
Specialist Practitioner Qualification in
Community Childrens Nursing

• Introduced in 1996, the course rapidly became
  established in all four UK countries
• First intakes tended to be experienced CCNs
  seeking to consolidate their experience through
  formal academic study
• In more recent years, an increasing proportion of
  students were relatively new to the community,
  some even gained sponsorship from hospital based
  posts.

32
Specialist Practitioner Qualification in
Community Childrens Nursing

• Arguably course had a limited appeal for CCNs in
  specialist roles. Curriculum was relatively
  inflexible as UKCC (then NMC) regulations placed
  significant restrictions on many aspects of
  programme design.
• Latterly, uncertainty over training monies, lack
  of explicit support/direction from NMC and
  inertia arising from DOH Modernising Nursing
  Careers have seen a significant reduction in HEIs
  offering the programme and students coming
  forward for the programme.

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(No Transcript)
34
And then came

• AGENDA FOR CHANGE

35
Band 5

• Grade D and Grade E (roughly)
• Entry level to qualified nursing practice in CCN
  team
• RCN Band 5 Community staff nurse profile
• Assesses patients, plans, implements care in the
  community, provides advice maintains associated
  records
• Carries out nursing procedures
• May provide clinical supervision to other staff,
  students
• Is it appropriate to appoint to a CCN post
  immediately upon registration or is some prior
  experience in hospital essential?
• Is it possible in small CCN teams to provide
  appropriate mentorship/preceptorship/support?

36
Band 6

• Band E and F (roughly)
• From RCN Band 6 District Nursing Sister profile
• Assesses patients, plans implements care in the
  community provides advice to patients/clients
  maintains associated records
• Carries out nursing procedures
• Co-ordinates nursing team workloads
• Should there be a requirement that Band 6 nurses
  hold a CCN qualification?

37
Band 7

• Band G and H (roughly)
• From RCN Band 7 District Nursing Sister (Team
  Manager) profile
• Manages team of community nurse specialists and
  other staff covering a geographical area,
  including recruitment, appraisal
• Assesses patients, plans implements care
  maintains associated records
• Carries out nursing procedures
• Or is this the level at which CCN qualification
  should be an essential requirement for the job?

38
Band 8

• Band H and I (roughly)
• From RCN Band 8 Community Matron profile
• Manages and provides leadership for managers,
  specialist nurses/midwives and other staff in a
  primary care setting
• Ensures patient/client/carer involvement in
  development of services and promotes better
  health, social care and medicines management
• Provides specialist education and training to
  other staff
• Maintains compliance with, and development of,
  policies, procedures and guidelines, including
  case management co-ordinates care in a community
  setting

39
Modernising Nursing Careers (DoH, 2006)

• The nursing workforce will need to work in a
  range of settings, crossing hospital and
  community care
• Nurses will start their careers in the
  community
• There will be many opportunities for nurses in
  acute settings to work wholly or partially
  outside hospital.
• We also need to address current inflexibilities
  and barriers in nursingthese currently exist
  between the branches
• The health departments will work with key
  stakeholders to review the career pathways and
  education preparation required for nursing in the
  community

40
Towards a framework for post-Registration nursing
careers (DoH 2007)
41
Careers in the five care pathways

• The Children, Public and Family Health Pathway
  will help build dedicated public health capacity
  and capability into the system. The emphasis will
  be on intervening at a population level and in
  working in partnership to address the
  determinants of health. Health needs assessment
  for populations, communities, groups, families
  and individuals will be a key component and will
  provide the basis for intervention to improve
  health, reduce health inequalities and support
  for vulnerable families and individuals. This
  pathway will also encompass the maintenance and
  improvement of children and young peoples health
  within a philosophy of family centred care in a
  range of settings.

42
Community and Primary Care Nursing

• There is likely to be a greater impact on
  community and primary care nurses whose careers
  are built on and loosely organised around adult
  nursing, services for children and families and
  nursing in general practice.
• The future of the specialist community and public
  health practitioner qualification also needs to
  be considered, which has provided a benchmark of
  competency for some nurses working in primary and
  community care.

43
Grade mix and skill mix

• Skill mix
• A team of nurses within which the total range of
  skills which the team provide is determined in a
  systematic way in response to the needs of the
  population to be served and the services to be
  delivered to them

• Grade mix
• A team of nurses who are paid on different
  salary scales (grades or bands) and whose levels
  of responsibility are determined by the grade
  which is attached to the post which they hold

44
So for a child population of 50,000

• Skill mix
• Range of specialist clinical knowledge and skills
  including oncology, diabetes, respiratory care
  etc
• Broad range of advanced practice skills
  Assessment, Diagnosis and Treatment, Non- medical
  prescribing, Nurse- lead clinics
• Providing a service 7 days per week from 8 am to
  8 pm
• Commitment to CPD, teaching, preceptorship and
  research

• Grade mix
• 1 x Band 8 Modern Matron
• 2 x Band 7 Team Leaders
• 1 x Band 6 Senior Staff Nurse/Junior Sister
• 3 x Band 5 Junior Staff Nurses