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 children’s 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, Barnardo’s • Individuals employed by parents on a Direct Payments basis.

4. If you weren’t concerned before I started you might be now!

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

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

7. 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 And perhaps you shouldn’t be teaching

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 Children’s 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 “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” Grade mix and skill mix

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 Children’s 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. Grade E RSCN/Child branch Minimum 1 year hospital paediatric experience 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 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. Grade E Should not make initial visits unaccompanied No independent responsibility for overall care of individual patients 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 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 Children’s Nursing

28. Expansion in CCN Services Provision

29. Growing range of specialist CCN services being provided in the community • Community Children’s Nursing is now an ‘umbrella’ term which may be applied to a wide range of roles and areas of specialist practice including: • ‘Traditional’ community children’s 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 Children’s 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 Children’s 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.

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 nursing…these 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 people’s 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 “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” Grade mix and skill mix

44. 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 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 So for a child population of 50,000