2014
The design and development of a National Career
Framework for nurses caring for older people
with complex needs in England - Report
The design and development of a
National Career Framework for nurses
caring for older people with complex
needs in England - Report
Contents
The Project Team ................................................................................................................................ 3
Health Education North ...................................................................................................................... 3
Health Education England ................................................................................................................... 3
Acknowledgements............................................................................................................................. 3
Glossary of terms ................................................................................................................................ 4
Executive Summary............................................................................................................................. 5
Introduction ........................................................................................................................................ 6
Policy and Guidance ............................................................................................................................ 7
Background literature ......................................................................................................................... 8
Implications of an older population ................................................................................................ 8
Nursing older people....................................................................................................................... 9
Pre-registration education for nursing older people ...................................................................... 9
Continuing professional development .......................................................................................... 10
Data gathering and analysis: ............................................................................................................. 13
The Delphi process ........................................................................................................................ 13
First draft of proposed Framework of requirements for Foundation and Specialist level Curricula
...................................................................................................................................................... 22
Interviews...................................................................................................................................... 25
LETB discussions ............................................................................................................................ 28
Discussion and Implications .............................................................................................................. 30
Exemplars .......................................................................................................................................... 32
Joy (band 5 staff nurse in A & E) ................................................................................................... 32
Mike a band 3 support worker in stroke discharge team ............................................................. 33
Anne (Experienced Staff Nurse who works in an Ophthalmic Out Patient Department)............. 34
Joe a specialist Nurse in Cardiac Rehabilitation............................................................................ 34
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Sarah Charge Nurse in Continuing Care / Dementia Unit ............................................................. 35
Lynn a District Nursing Sister in Community................................................................................. 36
Final proposed Framework of requirements: ................................................................................... 37
Applying the framework: .................................................................................................................. 39
Joy (band 5 staff nurse in A & E) ................................................................................................... 45
Mike a band 3 support worker in stroke discharge team ............................................................. 46
.......................................................................................................................................................... 46
Anne (Experienced Staff Nurse who works in an Ophthalmic Out Patient Department)............. 47
.......................................................................................................................................................... 47
Joe a specialist Nurse in Cardiac Rehabilitation............................................................................ 48
.......................................................................................................................................................... 48
Sarah Charge Nurse in Continuing Care / Dementia Unit ............................................................. 49
Lynn a District Nursing Sister in Community................................................................................. 50
Framework use in commissioning ................................................................................................ 51
Implementation and Evaluation ....................................................................................................... 52
Conclusions and recommendations .................................................................................................. 53
References ........................................................................................................................................ 54
Appendices........................................................................................................................................ 59
1.Summary of provision by LETB................................................................................................... 59
2. NMC Standards for preregistration nursing.............................................................................. 61
3. Care certificate .......................................................................................................................... 66
4. Higher specialist (Fellow) programme ...................................................................................... 70
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The Project Team
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Pauline Pearson (Professor of Nursing, Northumbria University) has significant expertise in project
management and research on workforce change and educational development as well as aspects of public
health and primary care practice, mental health and the care of older people.
Alison Steven is Reader in Health Professions Education, Northumbria University. She has particular
expertise in practice learning and education, and knowledge translation.
Sue Tiplady is Senior Lecturer in Nursing with particular expertise in dementia and the care of older
people.
Isabel Quinn is Senior Lecturer in Nursing with expertise in cancer, dementia and palliative care.
Amanda Clarke (Professor of Nursing and Head of Department of Healthcare) has substantial expertise in
research and teaching about ageing with long-term conditions, and in developing more participatory and
innovative ways of working with older adults as service users, co-researchers and peer educators
Sheila McQueen (Head of Department of Public Health and Wellbeing) has considerable expertise in
curriculum design for continuing professional development
Joanne Atkinson is Principal Lecturer in Nursing with expertise in end of life and palliative care.
Barbara Harrington is Senior Research Assistant. She has considerable expertise in mixed methods
research.
Health Education North
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Elaine Redhead
Claire Ward
Health Education England
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Lisa Bayliss-Pratt, Director of Nursing
Acknowledgements
The team would like to thank all those who have contributed to this project, which would have been
impossible without a great deal of good will and active collaboration. There are many people who have
opened doors to us and responded within a short timescale. We are particularly grateful to all the many
people – academics, managers, educators and practitioners, as well as service users, carers and students who
have given up their time to be interviewed, to participate in focus groups, or to search out documentation.
Thank you to them all.
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Glossary of terms
LETB
Local Education and Training Board
HEE
Health Education England
HENE
Health Education North East
CPD
Continuing Professional Development
NICE
National Institute of Health and Clinical Excellence
DH
Department of Health
CQC
Care Quality Commission
BGS
British Geriatric Society
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Executive Summary
People aged 85 or older are the fastest growing age group in the UK. For a significant number of older people,
advancing age brings frailty; with many living with more than one long-term medical conditions. Their needs
are complex, requiring multiple agencies and professions working together across primary and acute care
settings. Older people constitute a majority of the people receiving nursing care - either in hospital or in the
community. Although this work was commissioned to address the needs of nurses, much of the thinking within
it could apply equally to other groups engaged in work with this group of people.
In November 2013 a national accelerated solution event was held involving NHS and HE experts in the care of
older people with complex needs. At the event it was agreed that a National Career Framework should be
developed for nurses caring for older people with complex needs, to ensure that nursing staff involved in
caring for older people, albeit in a variety of ways, have the right levels of skills and expertise. It was envisaged
that the Framework would be linked to three levels of continuing professional development curriculum –
Foundation, Specialist and Higher Specialist.
The team used a Delphi survey with a response rate of 31% (67/218) at round one, and 37% of those (25/67)
at round two, supplemented by interviews (n=22) and a focus group (n=20) to coordinate national
stakeholders from NHS Trusts, professional organisations, HEIs and LETBs in reaching consensus on CPD
requirements at qualification and for nurses who work predominantly with older people or who specialise in
relevant areas.
In an iterative process, a framework was developed, covering clusters around values and behaviours, end of life
care, caring for carers, clinical skills, safeguarding, cultures of care, clinical leadership, interprofessional working
and nursing practice.
A number of issues emerged in the development of the framework. It was submitted that the boundaries
between generalists and specialists are permeable, with, many contended, all nurses needing to act as
specialists at some points. A model which assumes a one-off educational input, the attainment once for all of
clinical skills, takes no account of changes in policy and context. The impact of CPD may be enhanced by using
interactive, practice based and practice related approaches. Responding to individual learning needs is
important. The need for organisational support and feeling empowered to make changes is also important for
learning to transfer to practice.
The framework proposed therefore offers a degree of flexibility but can be used to facilitate a conversation
with every adult nurse, and potentially other groups, to generate a justifiable and transparent plan and focused
commissioning.
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Introduction
During the past two years, a large number of reports (e.g. Francis 2013; Keogh 2013; DH (Winterbourne)
2012) on the provision of health and social care in hospitals and in other settings have found that despite
some outstanding practice, there remain a number of institutions which are failing to deliver good care,
particularly to older people. At the same time, the proportion of older people (over 65) and of the very old
(over 80) within the population is increasing as life expectancy lengthens
(http://www.statistics.gov.uk/focuson/olderpeople/). People aged 85 or older are the fastest growing age group
in the UK. In 1984 there were 660,000 people aged over 85. In 2009 this had more than doubled to 1.4
million. This trend is set to continue and by 2034 the number of people aged 85 or over is expected to be 3.5
million (Office of National Statistics 2014). For a significant number of older people, advancing age brings
frailty; with many living with more than one long-term medical conditions. Their needs are complex, requiring
multiple agencies and professions working together across primary and acute care settings. Indeed, although
this work was commissioned to address the needs of nurses, much of the thinking within it could apply equally
to other groups engaged in work with this group of people. As people age, they tend to use health and social
services more: the majority of patients in hospital and in the community are over 75 with the average age of
hospital patients being over 80 (Cornwell 2012).
As the older population increases so, too, does the need for greater understanding of the specific needs of
older people, however many health professionals were educated and trained for a different era (Cornwell
2012). It is essential that nurses are equipped to care for older people who now form the majority of patients.
Nursing frail older people with complex needs requires knowledge, skill and sensitive, compassionate care.
This requires nurses to listen and respond to the older person (and their families or carers). Being
compassionate involves being alongside someone- from Latin literally, ‘suffering’ with them - and not just being
with them, but being motivated to make a difference for them. Effective delivery of healthcare involves
collaboration- which requires communication and trust between team members and across professional
groups. Building capacity for health improvement needs people within teams and between agencies to listen to
each other and to draw on each other’s strengths. Berwick (2013) recommended that the NHS ‘Foster wholeheartedly the growth and development of all staff, including their ability and support to improve the processes
in which they work’. Nowhere is this more important than in the care of older people.
In November 2013 a national accelerated solution event was held involving NHS and HE experts in the care of
older people with complex needs. At the event it was agreed that a National Career Framework should be
developed for nurses caring for older people with complex needs, to ensure that nursing staff involved in
caring for older people, albeit in a variety of ways, have the right levels of skills and expertise. It was envisaged
that the Framework would be linked to three levels of continuing professional development curriculum –
Foundation, Specialist and Higher Specialist.
The authors of this report were funded to deliver on two core tasks with a series of supplementary tasks. The
two tasks in bold were the main focus:
 To coordinate national stakeholders from NHS Trusts, Professional organisations, HEIs
and LETBs in reaching agreement on the Foundation and Specialist level specifications
which will form the basis of CPD content at these levels, and the first two levels of in
effect a national core curriculum
 To work with each LETB area to review existing provision locally and consider how it
maps to the agreed specifications, and to identify what action is needed to fill any gaps in
provision identified.
 Higher Specialist level CPD is intended to be separately developed, for a cohort of 24 people in the
first instance. Within this tender it will be important to liaise with colleagues developing the Higher
Specialist level specifications and content to ensure that the National Career Framework forms a
coherent learning pathway.
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Given current workforce profiles it will also be important to link in with current national work on the
development of Care Certificates for the bands 1-4 workforce and other pre-registration
programmes and pilots to ensure that the Foundation Level specification builds from this
appropriately.
To link in with the current national mandated priority to deliver better quality care and treatment for
people with dementia, and HEE work to expand training for dementia care, to ensure that the
Foundation and Specialist Level education/learning specifications from this work align.
To provide regular updates to and ensure that the Project (virtual) National Steering Group (NSG)
and the Nursing and Midwifery HEE Advisory Group (N&M HHAG) are able to input their strategic
advice and guidance to the education/learning specifications.
To advise HEE on the marketing of the National Career Framework through appropriate
conferences, presentations, publications and workshops.
To outline an evaluation plan to follow initial piloting to assess the effectiveness of the National
Career Framework.
To work alongside HEE and HENE leads and senior health and academic leads working in the older
care arena to draft and publish details of the developments in CPD for nurses caring for older people
with complex needs in peer reviewed academic journals.
Policy and Guidance
In recognition of the complexity of older person’s care, successive governments have introduced a plethora of
policies and guidance. There has been a National Service Framework (NSF) for older people for more than a
decade (Department of Health 2001). There is a National Dementia Strategy (Department of Health 2009),
and the National Institute of Health and Clinical Excellence (NICE) has produced guidance and quality
standards for what are termed ‘geriatric syndromes’ including: instability, incontinence , dementia and
confusion. Despite this, there has been a great deal of public concern about both hospital nursing and the care
of older adults at home (Abraham 2011; Care Quality Commission 2011; Equality and Human Rights
Commission 2011; Francis Inquiry 2009; Nicholson and Oliver, 2012; Tadd et al., 2011). These and related
reports have highlighted that the care of older people is often suboptimal and unacceptable (Francis 2013;
Cavendish 2013; Cornwell 2012), with Francis (2013) calling for the creation of an explicit status of ‘registered
older person’s nurse’. Many health professionals were educated and trained for a different era and many
hospitals run with service and staffing models that have changed little over the last decade (Cornwell 2012).
Since the publication of these reports, government, professional organisations and others have responded in
making recommendations for improving the care of older patients (Nursing and Midwifery Council 2013; Royal
College of Nursing 2013; General Medical Council 2013). All identify the need for all staff working with older
people to be equipped with the right education, knowledge and skills to be able to care for older people and
their carers (Age UK 2013, RCN 2013). The RCN (2013) has argued that rather than having a separate part
of the register for nurses working with older people, there should be a nationally recognised career pathway
for those for wish to develop their skills in older people’s nursing at the post-registration stage, and that all
those seeking to be a nurse should understand how to deliver excellent care for older people. The recent
update of the NHS Mandate (DH 2013) identified that providing excellent care for older people and their
carers is a national priority, whilst the NHS Commissioning Board’s objective is to “pursue the long-term aim of
the NHS being recognised globally as having the highest standards of caring, particularly for older people and at the end
of people’s lives.”
Older people, many of whom have multiple long-term co-morbidities including dementia, disability and frailty,
often using multiple services and reliant on carers, are now the biggest users of the NHS and will continue to
be so. Nurses, with a range of others, provide, promote and deliver skilled holistic care to older people across
boundaries in a variety of settings. The knowledge and skills required to understand the interdependency of
the biological, social and emotional needs of older people is wide and diverse, and nurses are at the forefront
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of this care. Care for older people must be promoted as a role that requires great skill but also an explicit
values base, informed by clinical and applied knowledge. Excellent care can only be realised if it is based on a
framework of education that identifies and addresses the complexity of interactions between age-related
changes and the multiple factors that influence older people’s experiences, needs and aspirations.
Caroline Nicolson (a Post-Doctoral Research Fellow focusing principally on end of life care at the National
Nursing Research Unit, Kings College London) says:
“The difference between ordinary and extraordinary is a question of recognition. The extraordinary work of
caring and being cared for”
We must recognise the extraordinary value and skills of older people’s nursing and never take it, or let it be
taken, for granted.
Background literature
The following narrative review of a range of pertinent literature, while not systematic or comprehensive, gives
a flavour of the implications of an aging population, identifies educational initiatives and highlights relevant
issues.
Implications of an older population
Whilst many older people will continue to live healthy and independent lives, for some, living longer does not
necessarily mean living in good health. Healthy life expectancy has not increased in keeping with the ageing
profile. Many older people live with one or more long-term medical conditions and, for a significant number
advancing age brings frailty and disability. As we age, we tend to use health and social services more; the
majority of patients in hospital and in the community are over 75 and the average age of hospital patients is
now over 80. By 2051, as many as one in four people (25 per cent) will be aged 65 or over and one in 15
people (7 per cent) aged 85 or over (ONS 2013). It is predicted that over three million older people will have
three or more long-term conditions by 2018, the result of which will further increase use of the National
Health Service (Cracknell 2010, NHS 2013).
Older people constitute a majority of the people receiving nursing care - either in hospital or in the
community - with nearly two-thirds of people admitted to hospital aged 65 or over, and the average age of
hospital patients now over 80 (Tadd et al 2011, Cornwell 2012, Age UK 2013). Eight in ten (77 per cent)
people aged 85 or over accessed at least one of Inpatient, Outpatient, or Accident and Emergency services in
2012/13 (HSCIC 2014). The median age of patients admitted with a hip fracture is 84, of whom one in three
have dementia; one in three suffers delirium and one in three never return to their former residence (British
Orthopaedic Association and British Geriatrics Society 2007).
The majority of people cared for in their own homes and who receive help with activities of daily living such as
washing, dressing and eating are aged 75 or older. Older patients account for more than half the caseload of
district nurses: in 2004, district nurses looked after 470,000 patients aged between 75 and 84, and 383,000
aged 84 and older (Department of Health 2004). Another half a million (around 453,000) people receive home
care from social services; 84 per cent of them are over 75 (The Information Centre 2010). Around 2.5 million
people over 75 also have some kind of informal care at home from close family members, neighbours and
friends. A quarter of carers are themselves 65 or older (The Information Centre 2010).
Assisting older people to recover their independence after illness or injury is a key recommendation within the
current NHS Mandate (DoH 2013) and a named clinician - either a nurse or doctor responsible for older
people with complex health needs is a recommendation within the refreshed mandate. The importance of
matching care to the patient’s current level of need has been set out this year in the publication of a document
seeking to promote the delivery of safe, compassionate care for frail older people through an integrated care
pathway (NHS England 2014).
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Therefore, the majority of nurses today working across all adult care settings will work with older people, but
may not have the knowledge and skills to effectively care for this client group.
Nursing older people
Despite over a decade of effort to improve the care of older people in the UK (Davies et al., 2007; HAS, 2000,
1998; DoH, 2001, 2006; Nolan et al., 2001), including a National Service Framework for older people (DoH
2001), there has been a great deal of public concern recently about both hospital nursing and the care of older
adults at home (Abraham 2011; Care Quality Commission 2011; Equality and Human Rights Commission 2011;
Francis Inquiry 2009; Nicholson and Oliver, 2012; Tadd et al., 2011). Reports have highlighted that the care of
older people is often suboptimal and unacceptable (Francis 2013; Cavendish 2013; Cornwell 2012). Since the
publication of these reports, there has been a plethora of responses from key organisations, all making
recommendations for improving the care of older patients (Nursing and Midwifery Council 2013; Royal
College of Nursing 2013; General Medical Council 2013).
Over several years authors have reported that many nurses (including students) are reluctant to pursue a
career in older people’s nursing (Duggan et al., 2013, Jeffers, 2014, Chan and Chan, 2009, Koh, 2012, McKenzie
and Brown, 2013, Kydd and Wild, 2013, Avers, 2014). A number of reasons for this reluctance are identified
in the literature and appear to persist. The work is often regarded as basic (Duggan et al., 2013, Kydd and
Wild, 2013, King et al., 2012) and in practice placements students working with older people often focus on
task-oriented goals, for example keeping patients clean, pain management and physical assessment (Jeffers,
2014). Nursing older people is seen by students as lacking in professional kudos in comparison to other types
of nursing such as acute or emergency care (Kydd et al., 2013). Working conditions are often reported as
poor with restricted budgets (Chan and Chan, 2009, Koh, 2012, Kydd and Wild, 2013). Older students are
more likely to be put off by poor working conditions (McKenzie and Brown, 2013). Students often feel unable
to challenge poor practice (Duggan et al., 2013, Dewar and Cook, 2014, Watts and Davies, 2014).
Some have called for the creation of a status of registered older person’s nurse (Francis 2013), while many key
groups identify the need for all staff working with older people to be equipped with the right education,
knowledge and skills (Age UK 2013, RCN 2013). The RCN (2013) argued that rather than a specific part of
the register for nurses working with older people, there should be a nationally recognised career pathway for
those who wish to develop their skills in older people’s nursing at the post-registration stage, and that all those
seeking to be a nurse should understand how to deliver excellent care for older people. Halstead (2012)
similarly argues that a workforce is needed that is generally knowledgeable in care of older people as well as
specialists in gerontological nursing. The recent review of the NHS Mandate (2013) identified that providing
excellent care for older people and their carers is a national priority.
This project is intended to provide evidence regarding the potential components of such a continuing
development framework, and what areas might form a curriculum for nurses in mainstream and more
specialist care for older people.
Pre-registration education for nursing older people
Continuing education builds on skills and knowledge learned at pre-registration level and the literature
describes a number of curriculum developments at undergraduate level. Potter and colleagues (2013)
introduced second and third year students to two assessment tools SPICES (Sleep disorders, Problems with
feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown) and BPI-SF (Brief Pain Inventory – short
form). It is reported that using the tools resulted in longer and more meaningful interaction with patients, as
well as the family and thus students’ geriatric knowledge and attitudes evolved and took on personal meaning
in their intermediate practice experiences. More in-depth assessment was of benefit to both older adults and
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student nurses, and the tools helped students explore underlying complexities. Students also gained in
confidence and critically reflected on attitudes that stereotype older adults as automatically unhealthy and
dependent. Waugh et al (2014) used action learning sets in a pre-registration mental health nursing programme
and reported that students increased listening skills and had enhanced self-awareness. It was also reported
that the students felt better able to connect with clients’ families and staff, and felt safe to develop their
questioning skills to challenge others. Turnbull and Weeley, (2013) describe an initiative which used patient
stories and asked students to make a pledge to make their care compassionate. Whilst students expressed a
desire to make pledges and indeed reported making pledges, they also indicated an inability to fulfil these due
to limited resources and a lack of time or support from their mentors.
Although some curriculum changes and educational initiatives report positive outcomes, the literature also
highlights areas of importance and concern for educators. There is often an emphasis on courses in basic care
skills for older people and a biomedical approach to ageing (Duggan et al., 2013, Koh, 2012, Potter et al.,
2013). Such an approach seems to often leave students anxious as they feel unable to deal with the complexity
that nursing older people presents (Brynildsen et al., Ironside et al., 2010, Watts and Davies, 2014, Clendon,
2011). Students also occasionally report a lack of support, particularly when they have observed, or wish to
query, poor practice (Duggan et al., 2013). What seems to improve the student experience in relation to
older people’s nursing are placements in specialist units for nursing older people (e.g. nursing homes, or EMI
units), rather than in general acute settings. Such experiences raise awareness of the complexity of older
people’s nursing, which could also be improved by teaching from specialist older people’s nurses (Duggan et
al., 2013, Brynildsen et al., Jeffers, 2014, Watts and Davies, 2014, Bruton et al., 2012).
Thus a range of pre-qualification initiatives have been described in the literature highlighting the need for a
mixed approach including direct experience with older people, and the importance of a supportive
environment in which students feel able to make a difference.
Continuing professional development
There have been attempts in recent years to change curricula or introduce courses to address some of the
issues highlighted above. A short development programme for nurses in bands 6 and 7 was commissioned by
the Department of Health and focused on the compassion in practice strategy. It is reported that nurses
were invigorated by the study and felt better able to make the 6Cs real to their teams (Hayes, 2014). A series
of privacy and dignity workshops to healthcare practitioners encouraged them to explore what privacy,
respect and dignity meant to individuals and to recognize best practice (Chadwick, 2012). Feedback was
positive with practitioners reporting improved communication and listening skills. However, some participants
did not feel the workshops had added to what they knew or how they already behaved. A dementia education
scheme (Wesson and Chapman, 2010) introduced across an acute trust ward by ward included; an overview
of common conditions in older patients, local and national guidelines, pain assessment, palliative care, and
general communication tips. The healthcare professionals who participated appreciated the education and
found components such as; palliative care information, behaviour and pain charts useful. A subsequent audit
reported that the scheme had improved awareness, documentation and care of those with memory and
communication difficulties.
In Wales one Health Board developed a graduate foundation programme focussing on the dignity of older
patients which was based around the core values of caring, compassion, competence, confidence, commitment,
comportment and communication (Bruton et al 2012). The programme included a rotational pathway which
incorporated a placement on an elderly mentally infirm specialist unit. This experience was highly valued by
staff and graduates, although a six months rotation, rather than three months, was preferred. However not all
continuing education programmes have worked well with Dewar and Cook (2014) describing a leadership
programme that explored relationships with patients, families and teams. The programme did report
increasing self-awareness and stimulating better relationships and greater reflection on practice. However,
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professionals still felt unable to influence the ward or unit where they worked, and still felt undervalued for
their contribution.
These issues are echoed in literature from a range of nursing specialties and other professions.
Schostak et al (2010) undertook a mixed method study for the Academy of Medical Royal Colleges to identify
what promotes and what inhibits the effectiveness of CPD for doctors. The literature reviewed for the study
suggests that there is no single, correct way of providing CPD. The study proposes that flexibility is critical in
the provision of CPD, together with justifiability and transparency. Active modes of learning, clear links to
analysis of learning needs and planned integration of knowledge into day to day practice, all appear to enhance
the effectiveness of initiatives. One senior clinician interviewed stated that:
‘Learner-led CPD is the most successful because that encourages engagement and acknowledges
professionalism’ (Schostak et al 2010: page10).
The importance of relevance to day to day practice was also noted by Ross (2007) reporting on the
implementation of an EBP educational programme that focused on patient outcome rather than a task to be
performed, which was suggested improved the quality of oral care delivered by the nursing staff ( Ross, 2007).
However Schostak et al (2010) assert that some professionals may be reluctant to move outside of their
“comfort zones” when choosing CPD options to engage in and strategies for addressing this were suggested
including altering scoring systems used in medicine.
Schostak et al (2010) found a wide range of operating models of CPD which offered flexibility and were thus
identified as potentially fitting with models of adult and active learning (for example those of Kolb (1984),
Lewin (1946)etc.). However, much of what was reviewed suggested that CPD provision in practice might not
fit with this aspiration. The authors highlight how those in different organisational roles may have contrasting
notions, stating that ‘CPD was understood differently by those with organisational responsibilities to those who see it
through the filter of their own personal professional development’ ( Schostak et al 2010: page 53).
Respondents in this study, which combined a literature review with individual stakeholder interviews,
questioned whether the purpose of CPD was to raise everyone to an agreed minimum standard or for people
to pursue learning interests more generally. Few felt that CPD was connected to quality of practice. Schostak
et al (2010) conclude that CPD is valued and is seen as effective when it addresses the needs of individual
clinicians, the populations they serve and the organisations within which they work.
Echoing Schostak et al (2010) others have identified organizational support as essential for continuing
education programs to be effective ( Govranos, 2013; Stolee, 2005) and highlighted the need for ongoing
expert support to enable and reinforce learning (Stolee, 2005). For example, a study to improve palliative care
practice through the development of workplace hospice palliative care resources (PCRs) and examine its
impact on knowledge transfer and longer-term changes to clinical practice concluded that “Management
support, particularly the prioritization of palliative care and staff development, were factors facilitating
sustained implementation. These findings highlight the importance of multimodal learning strategies and
supportive work environments in the development of PCRs to enhance palliative care practice.” (Harris, 2007).
Indeed an integrative literature review (Bluestone, 2013) which included 37 systematic reviews and 32 RCTs
found that CPE can lead to improved learning outcomes if the techniques and approaches adopted are
effective. The authors state the evidence reviewed suggests the use of multiple techniques which promote
interaction and enable learners to process and apply information are most effective and show moderate to
high impact. These approaches include; Case-based learning, clinical simulations, practice and feedback .
Furthermore, targeted, repetitive interventions can result in better learning outcomes. While didactic
techniques involving passive instruction, such as provision of reading materials or attending lectures, appear to
have little or no effect or impact on learning outcomes. Thus it is suggested, based on what little evidence
exists it seems that the most commonly used approaches may have the least effect. Bluestone et al (2013)
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additionally propose that the development of, and increased access to, new mobile technology offers
opportunities to develop and deliver in-service education in new ways.
Although not specifically dealing with health care or nursing, Goodall et al (2005) in a study of the impact of
CPD in school based teaching highlighted some important areas for consideration in healthcare. They noted a
trend towards ‘in-house’ provision of CPD for reasons including perceptions of cost-effectiveness, local
expertise and applicability in practice. There was a desire to find methods of delivery that did not take people
away from the ‘coalface’ – ‘non-disruptive’ models. Development needs were most often identified through
performance review / appraisal. Leadership of CPD was often unclear and operational rather than strategic.
The impact of CPD on student experience was rarely considered or evaluated.
Still in the context of CPD for school teachers Kennedy (2005) usefully identifies nine models of CPD, which
are classified in relation to their support for professional autonomy and for transformative practice as follows:
•
The training model (which she argues has been dominant in recent years for teachers but is limited
because usually decontextualized)
•
The award-bearing model (which is often seen as academicised, and thus not ‘practical’ or
‘professional’)
•
The deficit model (tends to assume individual deficits are the whole picture, and ignores structural
issues)
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The cascade model (usually used where resources are short, but can result in limited understanding at
lower levels)
•
The standards-based model (this is behaviourally based, and individual rather than collegial)
•
The coaching/mentoring model (this covers a spectrum from hierarchical mentoring to clinical
supervision, relying on a one to one relationship and focused reflection on practice)
•
The community of practice model (a mutually supportive and challenging network or community
which Kennedy suggests generates rich learning)
•
The action research model (a model allowing people to ask critical questions about their practice, and
empowering them to gather evidence for change)
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The transformative model (which combines and balances features of several others, and which
Kennedy advocates)
Thus a range of literature exists which identifies some of the models of CPD, explores impact and highlights
the following issues for consideration:
 There is some evidence of the impact of interactive, practice based and practice related approaches
 Individual learning needs are important
 The need for organisational support and feeling able to make changes is also important for learning to
transfer to practice
 Flexibility together with justifiability and transparency are important in CPD provision
 Passive didactic approaches appear to have little or no impact
 The potential of new mobile technology requires exploration
12
Data gathering and analysis:
The Delphi process
WP1 involved a postal Delphi survey to 218 people sampled from key stakeholders. A ‘Delphi’ is a structured
facilitation technique used to gain consensus from a number of ‘experts’ across sectors or disciplines (Hasson
et al 2000, Keeney et al., 2011). It does this through a multistage process involving a number of structured
questionnaires (usually referred to as rounds) designed to combine expert opinion into group consensus
(McKenna 1994, Lynn et al. 1998). Through each round the issues under scrutiny are ranked and reduced until
consensus is obtained or the law of diminishing returns sets in. Delphi methods have been used successfully in
many areas of nursing and health professions education (for example Lock (2011), Lakanmaa et al (2012),
Hasson et al (2000)) The sample was drawn from each of 13 Local Education and Training Boards, NHS
Trusts, professional organisations, national and local user and carer organisations, and universities providing
nursing education. It was felt that involvement of user and carer organisations in the Delphi was important in
view of the overall emphasis in policy to put patients at the centre of developing care. Out of a total of 218 we
have had an overall response rate of 31% (67/218), although not all responses were complete.
HEE LETB area
East Midlands
East of England
Kent Surrey Sussex
North East
North West
South West
Thames Valley
Wessex
West Midlands
Yorkshire and Humber
North West London
South London
North Central and East London
Scotland
National
Unknown
Number of respondents
2
9
7
5
7
4
3
3
4
4
6
4
0
2
2
5
Table 1 Respondents by LETB Area
Role
Academic/researcher
Education commissioner
Clinical commissioner
Educator (not HEI)
Independent consultant
Practitioner1
Service Provider
Other (Voluntary sector,
Policy maker, PHC
development, Patient
Experience, Sector Skills
1
Number responding
31
2
2
5
2
16
3
5
One Nurse Consultant
13
Council)
Table 2 Roles of respondents
2
In the initial iteration, questions sought to understand what participants saw as core knowledge and skills at
each level of practice. Participants were asked to rate the importance of areas outlined by the national working
group, and any additional suggestions, between 0 = low priority for inclusion and 10 = high priority for
inclusion in the final framework (half points were permitted) then to take their top 3 and describe clinical
situations reflecting the importance of these. Round 1 data were analysed and sent out to participants for a
second set of rankings of the importance of different issues. Though a third iteration was originally planned for,
the level of decay in the sample response (only 25/218 responses were returned in Round 2) and the high
levels of agreement from second stage respondents on priorities selected meant that the third iteration was
abandoned.
The tables which follow show the topic areas which were scored at or above the median3 by more than 60%
of respondents. In other words, topic areas where there was a high level of agreement as to importance.
Median scores were generally above 5, in other words tending to (6-8) or at (9-10) the high priority for
inclusion level. Where agreement was below 60%, there was little agreement amongst respondents about the
importance of the topic. The shaded column gives responses for Foundation level, and the plain column for
Specialist level.
A Attitudes and Behaviours
Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Median
score
Care
Compassion
Communication
Courage
Commitment
Coaching
Empowering
Enthusiasm
Pride
Resilience
Respect
Dignity
Person-centred care
Family-centred care
Passion
Challenge
Enabler
Motivation
Advocacy
Champion
Diversity, Stigma and
10
10
10
8
10
6
8
9
9
8
10
10
10
8.5
8
8
7.5
8.5
8.5
8
9
Percentage
agreement
over 60%
81
83
74
81
81
78
-
Median score
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
Percentage
agreement
over 60%
86
87
88
60
76
64
86
88
79
64
60
61
64
70
63
2
Two people also self-identified as carers; one represented the Council Of Deans of Healthcare, and one the Royal College
of Nursing
3
The median is the middle value of a list. If the list has an even number of entries, the median is equal to the sum of the two middle (after
sorting) numbers divided by two. Medians are often used when data are skewed, meaning that the distribution is uneven. In that case, a
few very high numbers could, for instance, change the mean, but they would not change the median.
14
prejudice
22. Interpersonal skills
B Clinical Skills
Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
10
64
Median score
Recognising and responding
to the deteriorating patient
Pathophysiology and
prognostication of long
term conditions
Indicators of frailty
Recognising and responding
to Dementia
Recognising and responding
to Depression
Recognising and responding
to Delirium
Assessing nutritional status
Assessment of pain
History taking
Physical assessment
Holistic assessment
Assessing for pressure
ulcers / skin integrity
Recognition of co-morbidity
Rehabilitation
Pharmacology
Nurse Prescribing
Non-pharmacological
treatment
Complex problem solving
Risk assessment
Assessment of falls
Assessment of sensory
impairment
Comprehensive elderly
assessment
Cognitive assessment
Mood assessment
Managing challenging
behaviour
Dual diagnosis
Symptom control
10
83
Median score
10
Percentage
agreement
over 60%
-
10
Percentage
agreement over
60%
82
7.5
-
10
-
9
9.5
-
10
10
62
74
9
-
10
69
9
-
10
69
9
9.7
8
8
9
9
-
10
10
10
10
10
10
69
66
68
-
8
8.5
8
4
7.7
-
10
10
10
9.5
10
66
60
67
5
8
8
8
73
-
10
10
10
10
77
75
-
8
-
10
72
8
8
9
-
10
10
10
71
69
6
8
-
9.5
10
65
15
C Knowledge and Understanding
Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Median
score
Awareness of clinical
research
Factors leading to frailty
Evidence based practice
Outcome focussed care
Health and well-being issues
of older people
The biology of ageing
Psychology of ageing
Polypharmacy
Pharmacology
Understanding complex
conditions
Mental Capacity Act
Mental Health Act
Understanding policy and
guidance for older people
Managing challenging
behaviour
Complex problem solving
Decision making
Practice development
Service improvement
Memory loss
Caring for carers
Protecting the vulnerable
Communication
Community resources and
support networks
Self-advocacy
Impact of lifestyle choices
Knowledge and
understanding of physical,
behavioural, emotional and
psychological indications of
mental health needs
Median score
7
Percentage
agreement over
60%
-
10
Percentage
agreement over
60%
-
8
9
8
9
-
10
10
9.5
10
75
60
8.5
8.5
10
7.5
8
-
10
9.7
7.5
10
10
62
67
9
8
8
-
10
10
10
63
64
9
-
10
63
8
8
7.5
7
8.5
9
10
10
8
-
10
10
10
10
10
10
10
10
9.5
67
74
64
76
72
-
7.5
7.7
8
-
9
9
10
-
16
D Coordination of care and the Multi-Disciplinary Team
Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Median
score
Advanced care planning
Communication
Patient stories
Caring for carers
Inter-professional
learning
Person-centred care
Person centred planning
Referrals
Risk assessment
Safeguarding
Safe patient outcomes
Inter-professional
working
Reablement
Signposting
Cross-agency
coordination
Collaborative
Patient experience
Conflict and dispute
management skills
Median score
7
10
8.5
8.5
8
Percentage
agreement
over 60%
65
-
10
10
9.5
10
10
Percentage
agreement
over 60%
67
76
-
10
9
8
9
10
9.2
8.7
65
-
10
10
10
10
10
10
10
74
69
69
74
61
65
8.5
8
7.5
-
10
9.5
10
63
8.5
10
8
-
10
10
10
64
67
-
17
E Public Health
Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Median score
Ageing well
Prevention
Early detection and
intervention
Nutrition
Making every contact
count
Promoting and
empowering selfmanagement
Living well
Stigma and prejudice
Recovery action plans
Health and well-being in
old age
Health and well-being in
complex conditions
Caring for carers
Understanding of diversity,
discrimination and
stigmatisation
Understanding of cultural
diversity
Ability to analyse public
health data
Understanding of social
constructs of health and
illness
Median score
8.5
8.5
8.5
Percentage
agreement
over 60%
-
9.7
10
10
Percentage
agreement
over 60%
-
9.5
9
-
10
10
66
8
-
10
62
8.5
8.5
8
8.5
-
9.5
10
10
10
-
8.5
-
10
75
9
9
-
10
10
65
8.7
-
10
-
6.5
-
9
-
7
-
9
-
18
F Leadership and Professional Practice
Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Median
score
Culture of caring
Compassion
Autonomy
Professional
accountability
Challenging
Teaching, learning and
coaching skills
Empowering
Communication
Delegation
Influencing and
negotiation
Quality
Patient safety
Risk management
Role model
Team working
Practice development
Understanding service
transformation
Reflection and reflective
practice
Supervision
Ethical issues
Legal issues
Decision making
Research and audit
Knowledge of
organisation
development and
change management
Median score
10
10
8
10
Percentage
agreement
over 60%
74
-
10
10
10
10
Percentage
agreement
over 60%
78
75
71
73
8
8
-
10
10
60
65
8
10
7.5
7.5
71
-
10
10
9.5
10
65
80
67
9.5
10
9
9
9.2
8
7
-
10
10
10
10
10
10
9.7
71
76
73
76
63
60
-
9.5
-
10
63
8
8.5
8.5
8
7.5
7
-
10
10
10
10
10
10
60
64
61
63
-
19
G Advancing Disease and End of Life Care
Topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Median
score
The surprise question
Advanced care planning
Prognostication
Pain Assessment
Pain management
Quality of Care at End of
Life
Spirituality
Communication
Symptom Control
Understanding and
responding to distress
Understanding and
responding to loss
Caring for Carers
Choice at End of Life
Patient Stories
Dying with dignity
Multi professional working
Bereavement
NHS continuing healthcare
Median score
7
8
7
9.5
9
10
Percentage
agreement
over 60%
67
9.2
10
9.7
10
10
10
Percentage
agreement
over 60%
69
68
70
74
8.5
10
9
10
68
-
9.2
10
10
10
76
70
74
9.2
66
10
66
9
9
8
10
8.5
8.5
7.7
60
69
64
-
10
10
9
10
10
10
9.7
60
69
75
-
20
In the first round, no additional areas were suggested for Foundation level nurses.
However, the following additional areas were suggested as priorities for continuing professional
development for nurses working at Specialist level, to improve the level of care received by older
people with complex needs. These are the results from those who participated in the second
round.
Suggested additional areas
Median
score
Acting as agents for change
Ageism and older people
Clinical Leadership
Complex decision making
Continuous quality improvement
Creating positive cultures in care settings
Evaluating care
Innovation and Service Improvement
Leading Practice development
Learning Disability
Mental health needs
Motivating carers
Politics and resources
Polypharmacy
Practice development
Quality improvement methodology
Recognising and reporting
Reflection and Shared Learning
Senses framework
Social needs
Sphere of influence
Supervision for specialists
Transitions between care environments
Value based practice
10
10
10
10
10
10
10
10
10
9
9.5
10
9.5
9.75
9
8
9.75
9
9
9.5
10
10
10
9.75
21
Percentage
agreement
over 60%
(n=25)
68
83
100
74
61
79
63
61
74
-
First draft of proposed Framework of requirements for Foundation and Specialist level
Curricula
Curriculum Frameworks were developed using the data presented above as a starting point. They set out the
knowledge, skills, values and attitudes that nurses working at each proposed level (Foundation and Specialist)
would be expected to acquire or refresh over a period of time through continuing professional
development. These are described as a series of learning outcomes. The outcomes are overarching outcomes
and there may be more specific outcomes or emphases for particular groups or settings – for example
community practitioners or nurses working in care homes.
Foundation level is defined as the base level for registered nurses to master during preceptorship when caring for older
people with complex needs. It is concerned with core knowledge, skills and expertise for all nurses who work with adults
whatever the setting.
Specialist level is the level of knowledge skills and expertise needed for nurses who work predominantly with older
people or for nurses who specialise
It is important to note the Standards for Pre-registration Nurse Education currently in force (NMC 2010) –
see Appendix 2 - to understand the levels that newly qualified registrants should have achieved at the point of
registration, and are responsible for maintaining.
Foundation
At this level, nurses should be able:
VALUES and BEHAVIOURS To review and build on the fundamental values and behaviours expected of
every nurse, in particular to demonstrate effective interpersonal skills and communication with frail or
complex older patients and their families and friends, and to provide effective, compassionate, evidence based
care, delivered through relationships drawing on empathy, respect and dignity, and underpinned by personcentred care. (maps to Domain 1)
END OF LIFE To promote quality of care at the end of life and choice at the end of life. To help people
approaching the end of their life to die with dignity. To understand and respond to loss. (maps to Domain 3)
CARING FOR CARERS To recognise the physical, psychological and social needs of informal carers in
supporting older people living with complex needs and long term conditions. (maps to Domain 4)
4
CLINICAL SKILLS To be able to identify indicators of frailty , and recognise delirium, dementia, depression,
and the deteriorating patient
4
See British Geriatrics Society, ‘Fit for Frailty’ Consensus best practice guidelines, June 2014 – suggest the use of gait speed, timed-upand-go test or PRISMA 7 questions
22
Specialist
At this level, nurses should be able:
VALUES and BEHAVIOURS To build on the fundamental values and behaviours expected of every nurse,
to demonstrate commitment to frail or complex older patients and their families and friends, effective
interpersonal skills and communication (listening with care and attention as well as the ability to articulate
needs clearly and to argue a case persuasively), and provide effective, compassionate, evidence based care,
delivered through relationships drawing on empathy, respect and dignity.
END OF LIFE To promote quality of care at the end of life and choice at the end of life, including the use of
advanced care planning: helping people approaching the end of their life to describe and clarify what they want
to happen, what they don’t want to happen, and who will speak for them, so that people die with dignity
CARING FOR CARERS To recognise the physical, psychological and social needs of informal carers in
supporting older people living with complex needs and long term conditions, at all stages and in all settings, to
address these and to deliver effective family centred care.
CLINICAL SKILLS To understand complex conditions, to be able to take a systematic history and
undertake a comprehensive and holistic elderly assessment, including cognition, and to assess and manage pain.
To be able to identify and respond to indicators of frailty, recognise and respond to delirium, dementia,
depression, the deteriorating patient and a range of co-morbidities. To understand effective symptom control
and the challenges of polypharmacy as well as non-pharmacological treatment options. To understand the
importance of health and wellbeing in complex and long term conditions and for older people, and to
understand and respond to distress and to loss. To deliver high quality evidence based care.
CULTURES OF CARE To create positive cultures of care in care settings which serve older people with
complex needs, and deal with diversity, and address stigma and prejudice – including ageism. To understand
diversity, discrimination and stigmatisation. To promote autonomy, empowering patients to self-manage, and
work to provide a positive, safe patient experience, in which every contact counts, underpinned by personcentred care and person-centred planning. To strive for continuous quality improvement and safe high quality
patient outcomes.
CLINICAL LEADERSHIP To build effective clinical leadership, supported by courage and enthusiasm,
encompassing advocacy, willingness to challenge and champion, and to act as an enabler or an agent for change,
undertaking complex problem solving and complex decision making.
INTERPROFESSIONAL WORKING To build from basic skills in interprofessional and team working, and
to develop skills in effective collaboration, influencing and negotiation, and cross-agency coordination in order
to deliver effective care for older people with complex needs. To support older people in transitions between
care agencies and environments. To work with colleagues and lead innovation, practice development and
service improvement for this group.
23
SAFEGUARDING To protect vulnerable older people with complex needs by confident use of effective
safeguarding processes and understanding of the implications of the Mental Capacity Act. To understand and
be able to address ethical issues arising for this group and their families and carers, to deliver robust risk
assessment and management, and where necessary to manage challenging behaviour.
NURSING PRACTICE To have a robust understanding of policy and guidance in relation to older people
with complex needs and to appreciate and assume appropriate levels of professional accountability for the care
of this group. To reflect on and in practice, and to act as a role model for colleagues. To develop and use skills
in teaching, learning and coaching colleagues, receiving and providing supervision, and undertaking research and
audit in relation to older people with complex needs.
24
Interviews
WP2 involved face to face and telephone interviews following the analysis of WP1 data. Interviews were held
with a purposive sample covering key groups and especially those emerging from the Delphi survey as having
divergent views. They explored issues in more depth and considered how these might be reflected in a draft
national curriculum framework at each level. Of 27 individuals approached, 12 responded and were
interviewed. These included nurse consultants, community and hospital based experts, and service users and
carers. The production of the draft framework was iterative, as the earliest version (see section above) was
developed after initial interviews and refined in dialogue with later interviewees.
Interviews highlighted some of the difficulties in the terminology used, when both ‘Foundation’ and ‘Specialist’
are widely used to mean a range of things outwith the definitions given above. It was suggested that (in
contrast to Delphi responses) ‘all nurses should be able to recognize physical, psychological and social markers of
frailty’, and that ‘a recovery based model of care’ should be adopted by all nurses working with older people. One
respondent suggested that:
Mostly it’s about attitude actually. I think it’s about working with student nurses and early qualified nurses to enable
them to embrace, if you like, the fact that this is their core population group, wherever they happen to work. It’s, unless
they choose to work in child health, or in some branches of mental health, they are going to work with older people
whatever. … That’s the fundamental, I think; to make nurses accept and embrace that this is what you do, so
therefore, you need to develop the skill set in order to do it. (1403066)
Specialist level practitioners in all settings need to be able to identify and ‘develop bespoke programmes to
respond to the needs identified’(1403062). ‘it would be taking those assessments to the next step, which would then be
able to identify erm, programmes of care that would begin to address some of the needs identified through that
assessment’ (1403063).
At the foundation level respondents have stated that nurses must embrace the fundamental importance of
their own attitudes to older people with complex needs, and must be able ‘to recognise deterioration’ and a need
for action. At the specialist level nurses need ‘a sound working knowledge of acute and chronic conditions and the
ways in which they may interface or present’ (1403061) in combination. Nursing ‘can really be showcased’ in
relation to normal ageing, nutrition, hydration, polypharmacy, pain management, and ‘the investigation of
functional change’. Another respondent highlighted more specific priorities. They felt that there was more need
at the specialist level ‘to look at polypharmacy and the implications of that and to have an awareness of falls and the
risks associated with falling and again, a better working knowledge of cognitive impairment and dementia’ (1403066)
Frailty was noted as key, with some discussion of how far complexity and frailty might be similar, and how they
might be addressed:
‘There are so many different pathways of care that the problem that older adults and people with frailty have is that
they may well have many comorbidities and which pathway should they follow? Erm, so if you have more of a complex
needs-based assessment and then a bespoke programme of care developed, it’s more likely to be successful, rather
than pushing people down a diabetes and a dementia and a COPD pathway, you know, so they end up needing a road
map, rather than just a pathway.’ (1403063)
It was also noted that some of the aspirations of those commissioning services for older people were not in
every case sufficiently informed by the realities of the care of older people, and that the skills required by staff,
and indeed the skill mix available needed careful tailoring to need. This reflects aspects of the literature which
discussed organisational issues.
‘There’s a real thought that you can keep people out of hospital, but I don’t think commissioners always have an
understanding of the level of complexity and frailty that we… that older person’s nurses and therapists deal with and
one of our very senior commissioners, when I showed her round the ward, er, ended up in tears. She had no idea our
patients were so sick, so you kind of think… I was very sad that she was that emotional, but in a way, it made the point
that when you’re talking about redesigning services, you know, these are not elderly people who are sitting in their
25
nighties, by their beds, waiting to go home, you know, they are the most frail; the most complex and need a high level of
skill and a very carefully crafted skill mix to manage’. (1403064)
Asked whether there were any particular priorities if people work in hospital; if people work in primary care;
or if people work in care homes or similar settings, respondents identified some areas which all nurses in a
particular setting should achieve. For example nurses in the community deal with considerable complexity:
‘The level of complexity that’s managed within the community and the level of complexity managed by informal carers,
you know, family members, is astounding as well. So in terms of risk assessment and management, there are huge skills
that all nurses and community staff need.’ (1403064)
Service user and carer perspectives
For service users, and carers, they expressed general approval and confirmation of the themes identified.
However, one said: ‘it should cover the bulk of it irrespective of whether you are a specialist nurse or not’ (1403068).
The main priority for this person was the values underpinning care, relating to dignity, compassion and a
culture of care. An anecdote was used to explain the shortcomings of care for older people observed when
she herself had been a patient in a surgical ward, both in terms of attitudes to individual need and the
management of care. Another key area commented on was caring for carers – a service user commented that
nurses ‘don’t always listen to them’ (1403069). He attributed this to the pace of life and the demands on staff.
Safeguarding was identified as important at all levels and something that in many situations ‘Joe public’ is
expected to engage with.
In relation to caring for carers and also end of life care, strong views were expressed by another carer
(1409025) about the need for all nurses to be able to help relatives to understand what is going on with an ill
relative, dealing with guilt about decisions they may be asked to make, and for nurses to provide resources to
support them after their loved one dies. Another (1409026), talking about the culture of care, emphasised the
importance of the atmosphere generated by nurses in a ward to make it welcoming.
Student perspectives
The draft themes were also discussed with a group of 20 final year adult nursing students (September 2012
GT13). Their strong feeling was that at qualification, all adult nurses should be able to demonstrate all of the
themes listed across both groups. However, they acknowledged that for some areas – for example end of life
care and safeguarding - although they gained theoretical understanding in university and undertook limited
simulations, they were sometimes not exposed to these areas in practice because they were dealt with there
by more experienced staff. It was suggested that mentors might be actively encouraged and supported to
facilitate final year students in undertaking the management of more complex cases. There was recognition
that it would be helpful to focus on these during their preceptorship work to consolidate prior learning whilst
supported. They also recognised the importance of support to enhance and build on prior learning at points of
transition.
Several in the group were keen to emphasise that every nurse should cover the whole framework: One said
‘you might have one ‘specialist’ nurse – what happens if she’s not in?’ Another said ‘All nurses should do all of that:
Carers should do some of that, and they should be trained to do some of that.. Health care assistants, people in the
community who go and see people in their own homes.’ Asked if there might be some areas of practice where
particular themes might be less relevant – for example end of life care in A&E or outpatients – students were
keen to suggest that in those settings they might need these skills to deal with a distressed family effectively –
and that for example in an outpatient setting dealing with renal care – ‘the conservative management clinic was
done by the same nurses and doctors…people who decided they no longer wanted dialysis… and their options were
discussed with them in an outpatient setting.. Nurses had to have the same knowledge and skills..’ The group
suggested that in fact the first group of themes should be those to be focused on during preceptorship, and the
remainder become the expectation for all qualified adult nurses to review and maintain. The students also
suggested that there might be some nurses who if there were any degree of option might not take all aspects
seriously. If it were some or most, some thought, some nurses might say it was nothing to do with them.
26
Students commented that it was easier for them to raise questions or ‘whistleblow’ about poor quality care as
students, where they would not return to a unit, than it would be once they were qualified staff. This
perspective is reflected in the literature presented above. Students felt that whistleblowing should be explored
within the clinical leadership theme. Continuity of care was emphasised as important as underpinning care
provision. There was some debate about the ways in which different wards and units took account (or not) of
carers needs, with a consensus that they should. All nurses should be able to assume appropriate levels of
professional accountability for older people with complex needs.
27
LETB discussions
WP3 followed analysis of WP2 data to develop a draft national curriculum at each level. Meetings using Skype,
telephone or face to face were arranged with key staff and/or their teams at the 13 Local Education and
Training Boards (see Table 3) to review existing provision locally, how it mapped to the specifications agreed
through WP 1 and 2, and to identify what action may be needed to fill any gaps in provision identified. It was
envisaged that a series of meetings would also take place with key stakeholders (for example colleagues
involved in development of Care Certificates, and those engaged in developing Higher Specialist content) to
scope the compatibility of the specifications agreed for a draft national curriculum through WP 1 and 2 with
developments in Bands 1-4 and for Higher Specialist nurses, and developments in areas such as dementia care.
The questions explored were:







What are respondents’ views of the framework priorities (drawn from Delphi material and
interviews)[a draft copy was provided]
How do the respondents view the interfaces between this work and Bands 1-4 provision (notably
Care Certificates) and also the Higher Specialist provision being developed
Are qualifications or accreditation important and why? What might be the disadvantages?
How does the draft framework map to this LETB’s currently commissioned provision
What do respondents feel about the need for future provision across any of these areas. What modes
of delivery (for example work based, blended, on-line, mixed or classroom taught) would they feel
most suitable for each?
Are any important / specific topics omitted?
Do respondents have any other comments?
Table 3 LETBs Consulted
LETB area
East Midlands
East of England
Kent Surrey Sussex
North East
North West
South West
Thames Valley
Wessex
West Midlands
Yorkshire and Humber
North West London
South London
North Central and East London
√
√
√
√
√
√
√
√
√
√
Framework priorities for Foundation level
It was noted that the confident delivery of high quality evidence based care, and a basic understanding of
safeguarding, legal and ethical issues and pathways for whistleblowing should be included at foundation level.
Nurses at this level should also have consolidated their knowledge of long term conditions and be beginning to
learn about the management of multiple pathologies. They should be developing an understanding of services
available and ways of signposting people appropriately. It was noted that the framework as presented tended
to focus on particular topics, but should make room to reflect on for example consolidating and developing
skills in critical analysis and review of evidence. Some respondents explicitly emphasised the need to
demonstrate progression, so that by the end of the foundation level nurses should be expected to have
28
consolidated and gained confidence putting into practice areas of which they had a theoretical understanding
and for which they had met standards for registration. Some more advanced areas which were listed as
specialist could be initially introduced at foundation level. Cultural diversity (to include different cultural groups,
as well as people with disabilities including learning disabilities) and basic competence in cultures of care should
be included at this level, given the cultural diversity of many parts of UK.
Framework priorities for Specialist level
In general there was broad agreement with the items listed at this level: ‘appropriate without being descriptive’,
though questions were raised about how such a framework might be used, issues of progression for example
across pay bands, and how the achievement of these areas might be refreshed. It was thought that undertaking
audit and collaborating on research might be appropriate at specialist level but that undertaking or leading
research would more appropriately be located at the higher specialist level.
The interface between this work and Bands 1-4 provision
It was noted that bands 1-4 staff may be more experienced than newly qualified Band 5 staff nurses: it was
argued that there should be a seamless transition for example for staff in Bands 1-4 with considerable
experience now undertaking OU or similar courses to become registered nurses. Band 4 staff should be close
to the Foundation level here. Having a large gap would not be sensible.
The interface between this work and the Higher Specialist provision
There was little information available to respondents about the Fellowship provision. Those interviewing were
often more knowledgeable about what was proposed than the people they were speaking to.
Mapping the draft frameworks to LETB currently commissioned provision
Commissions vary by LETB (see Appendix 1) However, to some extent mode of delivery is determined by
topic or theme. For example, end of life care in one area is a priority, largely delivered as workshops, with
some e-learning. One respondent noted that work is ongoing to look at ‘One HEE’ – seeking to commission 95%
of provision the same nationally (‘like Sainsbury’s!’), with some local flexibility. A national TEL workgroup has
found ‘there are 40 e-learning handwashing modules available: what a waste of time!’. A huge focus on qualifications
for some people was said to be ‘a complete turn off’ but accreditation of learning as up to a universally accepted
standard (and thus transferrable between trusts) was viewed as very important by most respondents.
29
Discussion and Implications
The premise which lay beneath the commission of this work was that frameworks were needed to underpin a
required set of knowledge, skills and attitudes for all nurses, and particularly for nurses working mainly with
older people. The knowledge, skills, experience and attitudes were to be identified by consensus among
experts in the field, and reviewed by key people in the field, as well as by commissioners.
In the commission, ‘all nurses’ were labelled as ‘Foundation level’ and interpreted in terms of nurses working
with adults in any setting at the end of preceptorship. Of course there are also many staff in these areas who
have already completed their preceptorship period. ‘Nurses working with older people’ were labelled as
‘Specialist level’ and interpreted as nurses who work predominantly with older people and nurses who
specialised in relevant areas such as stroke care or continence.
Figure 1 suggests that the notion of two levels only is not without its difficulties. Whereas education preregistration has to achieve set levels, continuing
professional development works more in terms of
ensuring that practitioners are continually topping up to
required levels and renewing their knowledge – a cross
between filling the petrol tank and changing the oil.
“Continuing professional development is the
process by which health professionals keep updated
to meet the needs of patients, the health service,
and their own professional development. It includes
the continuous acquisition of new knowledge, skills,
and attitudes to enable competent practice.” Peck
et al (2000)
Figure one
In addition the boundaries between generalists and
specialists are permeable, with, many argued, all nurses needing to act as specialists at some points.
A model which assumes a one-off educational input – the achievement once for all of clinical skills, safeguarding
or interprofessional working for example, takes no account of:





the rapidly changing context of health and social care:
new techniques and equipment developing which require new skills;
how the legal basis of safeguarding and understanding of frailty and vulnerability alter as new thinking
and research emerge, affecting the assumptions of safeguarding;
continuous changes to the skill mix and agencies engaged in care, affecting patterns of contact
between individuals and agencies.
Increases in the percentages of older people being managed across the spectrum of healthcare
provision.
The model adopted must incorporate a system of regular review, driven by a focus on both feedback from
practice and professional reflection on the requirements of the role being undertaken at that time, in order to
improve the quality of care – for which different aspects of the overall framework may have different levels of
importance (see Figure 2). The current work on revalidation by NMC should align closely with this.
30
Figure two
The notion of a clear boundary between nurses working with adults in any setting and nurses who work
predominantly with older people or nurses who specialise in areas particularly relevant to older people with
complex needs is debatable. Demographic trends mean that most nurses working with adults will be working
with an increasing population of older people, of whom at least some may be exhibiting frailty or have complex
needs.
A metaphor which might help the reader in thinking about this is that of the
nurse as a swimmer… The overall category of adult nurse might be likened to
the overall category of swimmer. Swimmers may be more or less experienced,
and able to swim just one or perhaps several strokes. Nurses may be newly
qualified band 5 staff with limited confidence or experience in leading care for
older people with complex needs, or experienced band 6 staff with many years’
involvement in leading and managing their care.
Swimmers may also swim in a variety of contexts – ranging from the child completing a width of a school pool
under supervision, and experienced swimmer in a leisure pool navigating between playing children, through the
competition pool to open water swimming whether in a lake or the sea. Some nurses working with adults –
for example in A&E – will be working with a broad spectrum of age groups, of whom several may be older and
some will have complex needs. Others – for example in a general medical ward - will have a greater population
of older people, with a proportion, probably greater, of people with complex needs. Even in outpatient
departments and in the community, there will be large proportions of patients with multiple and complex
needs. To some extent the proportion of complex needs aligns with age, but by no means absolutely.
31
As the complexity or specialisation of the situation increases, swimmers – for example crossing the Channel look to coaches or advisers with more experience to facilitate them in using the skills they have as appropriate.
Nurses in each setting will need supervision or mentoring in their workplaces to enable them to identify and
enhance the skills and expertise they have as required in that setting, and in the role they currently have.
An alternative way of considering the interaction between what people do (their functions) their levels of
knowledge and skill, and the contexts in which they work is offered by Skills for Health (2012). They define
functional analysis as ‘a methodology for competence-based workforce design and associated education, based on the
direct relationship between functions (what needs to be done), the context in which it is done (e.g. high risk, or very
predictable) and the skill level required to provide a quality service’. They represent this as shown below in Figure 3:
Figure three
Functional Analysis
=
Functions /
Competences
x
Level of Skill
x
Context
At the same time, in many contexts, the workforce balance incorporates many healthcare assistants. At
present a ‘Certificate of Fundamental Care’ is being developed (see Appendix 3), which will allow these staff to
recognise and be valued for their existing skills. However, Cavendish (2013) noted that ‘the airline industry has
demonstrated that common goals and a common language, training junior and senior staff together, are a
cornerstone of safety’ (page 36).
The model framework proposed therefore offers a degree of flexibility but can be used to facilitate a
conversation with every adult nurse, and possibly also with healthcare assistants about the characteristics of
patients managed in that setting and their learning needs related to older people with complex needs, out of
which a clear, justifiable and transparent plan, located alongside specifics of context and role can be produced.
Planned CPD will then facilitate the integration of new knowledge into practice.
Exemplars
A series of ‘exemplars’ are set out below to illustrate some of the potential contexts in which the team
envisages the model being applied.
Joy (band 5 staff nurse in A & E)
Joy has worked in an Accident and Emergency (A& E) unit for 6 months and has completed courses in Trauma
Care, ECG interpretation and Advanced Life Support which were considered core requisites for this role.
32
Whilst Joy considers that she has gained some knowledge of caring for acutely ill adults and children and also
minor injuries in these groups of patients, there are many challenges encountered in practice.
Many older people are brought to the department following a fall or minor injury at home. The Health and
Social Care Information Centre (HSCIC) (2014) identify that the number of older people presenting at
accident and emergency has doubled in 5 years and discussion around this considers lack of responsive
community services and also changes to GP contract and out of hours provision may be contributory factors.
The HSCIC report in January (2014) also shows that over the past year 1.16 million people in their eighties
attended A& E and with a 75% increase in the number sent by Ambulance. The number of people over 90
arriving at A& E has risen by 93% over the past 5 years.
Joy can competently deal with wound care and provide advice re home safety. However she feels it can be
difficult when people have been treated and they live alone at home and often appear frail and say they have no
support at home. She also sees many people who have recurring admissions to the department.
An increasing number of acute admissions via A & E are older people from home and care home settings. The
reasons for admission range from falls, fractures, stroke, exacerbation of long term conditions, acute infection
and end of life care.
Whilst Joy has the knowledge to manage the medical aspects of care, many of these individuals present with
various degrees of cognitive impairment, sometimes as a consequence of their condition eg infection or
hypoxia, but in many cases the people being admitted have a known diagnosis of dementia and in conjunction
with illness or injury can be very confused and distressed.
Joy considers this a challenging part of her role and is concerned about holistic assessment and management of
older people. She also has concerns about safety and supervision of confused patients in the department. She
also lacks confidence in looking after people at the end of life and talking to families and sees many people who
are experience pain or distress and also anxious relatives. Within a busy department there is pressure to treat
and forward or discharge patients but there is increased workload demand in dealing with wider issues relating
to the care needs of frail older people.
Mike a band 3 support worker in stroke discharge team
Mike was a healthcare assistant on a busy stroke ward for 3 years and has been involved with care and
rehabilitation of patients following CVA as part of a wider ward based team. He has Level 3 NVQ study in
healthcare and 12 months ago was successful in getting a band 3 post working with a community based stroke
discharge team. He works under the supervision of a band 6 nurse facilitator and works closely with
Physiotherapists and occupational therapists to follow a plan of care. Most of his clients are over 65 years of
age but recently there have been a few patients in their forties and fifties.
Mike visits patients in their own home following discharge for a 12 week period. Some people need assistance
or prompting with personal care tasks or getting dressed as part of their rehabilitation and reablement plan. It
is recognised that providing this approach to care can reduce the need for assistance with personal care in the
longer term (Francis and Fisher 2011). ‘Reablement improves outcomes, restores people's ability to perform
usual activities and improves their perceived quality of life’ (SCIE 2013)
Mike also prompts rehabilitation activities prescribed by the Physiotherapist and Occupational Therapist. Some
patients have a range of equipment such as walking aids and bathing aids and Mike has to reinforce how these
can be used safely. He also advises on other hazards at home such as rugs, loose carpets and obstructions in
walkways. These interventions can reduce possible recurring admissions to hospital.
Many of the patients are still unsteady and at risk of falling. Falls are a significant and growing public health issue
in an ageing population. (ROSPA 2014) Some of them have assistive technology and community alarm systems
to alert family or services if there has been a fall.
33
Mike recognises that every patient is different and some make more progress than others depending on the
severity of their stroke and existing health problems. Mike observes that some individuals lack motivation
whereas others work hard in their rehabilitation tasks. He worries that some of the patients get upset with
lack of progress and observes a range of emotional and mood responses. At least a third of stroke survivors
remain disabled, about 75% of survivors need ongoing assistance to undertake personal, domestic, and
community-based activities of daily living (Hankey 2013).
Mike also sees that carers and family members are greatly affected when someone has a stroke and finds they
need ongoing information about communication, nutrition, positioning, pressure area care, moving and
handling and continence.
Anne (Experienced Staff Nurse who works in an Ophthalmic Out Patient Department)
Anne has worked in Ophthalmology outpatients for 15 years. The most common conditions that people
present with are cataract, glaucoma and AMD and these are mainly recognised as diseases of the ageing eye
(The Royal College of Ophthalmologists 2012). Anne considers that most of her time is spent with older
people attending the department, during and after the appointment. More than 60% of attendances of
ophthalmology outpatients and over 80% of ophthalmology inpatients are aged 60 years and over. (NHS
Hospital Episode Statistics) In England ophthalmology has the second highest number of outpatient
attendances in the UK and accounts for 10% of all outpatient visits (NHS Hospital Episode Statistics)
Many people need appointments and transport arranged for them and Anne has to accompany patients to the
desk, she often has to deal with issues relating to transport delays. Anne also sees many older people who
complain of falls and bumps at home due to their poor vision and has to arrange for treatment of minor
wounds sustained as a consequence of this.
At diagnosis of sight related diseases there is often a lot of information about eye care and even at follow up
appointments people need ongoing support and advice in compliance with treatment. There is a link between
sight loss and reduced psychological wellbeing in older people, and around 35% of older people are known to
have some form of depression (Hodge, Barr and Knox 2010). The provision of emotional and practical
support at diagnosis can help people with sight loss to retain their independence and signpost them to support
services. (RNIB (2012)
The preparation for examinations can require administration of eye drops which can further impair sight and
cause disorientation. Anne is also required to assist people have injections into the eye and other minor
treatments. Some people have difficulty with dexterity and are unable to apply their regular eye drops and
Anne has to make arrangements with primary care services to assist with this.
There are an increasing amount of people who present with cognitive problems and are unable to comply with
advice and information about eye care. Some of these people have a range of other conditions such as
diabetes and vascular dementia associated with circulatory problems.
Anne is also involved in arranging planned admissions and doing pre-assessment for people who require
surgery or day case procedures. This can also be time consuming and Anne is concerned that even with the
large print written information, some people have difficulty retaining the information. Anne also sees that
informed consent is obtained in clinic prior to admissions.
Anne often feels overwhelmed at the amount support and care required for people attending this clinic and
that there is often not enough time and staff to meet the wider needs of people attending
Joe a specialist Nurse in Cardiac Rehabilitation
Joe works in a community cardiology rehabilitation service serving a rural community. The majority of
attendees at his clinic are people in 50- 60 years of age often following diagnosis of cardiovascular disease or
after a cardiac event such as Myocardial Infarction. Joe provides education and advice on health and lifestyle
and provides a targeted exercise programme for participants. “It felt a bit strange at first, but after a few
34
sessions I really began to enjoy it. They don’t make you do 100 press-ups or anything. You work to your own
limits,” (BHF Case Study)
Coronary Artery disease is acknowledged to be the leading cause of morbidity and mortality in the developed
world. Cardiac rehabilitation (CR) successfully addresses cardiac risk and has been shown to reduce mortality
by 25%. Participating in Cardiac rehabilitation can improve confidence and help people to return to usual
activities more quickly. It also provides an opportunity for people to discuss worries and concerns and alleviate
anxiety. Peer support is an added advantage (BHF 2014).
Age is a recognised risk factor in people developing cardiovascular problems as well as family history and
lifestyle. (British Heart Foundation 2014).
Despite higher incidence of cardiovascular disease in older people, Joe sees that referral rates for older people
do not match known incidence. It would appear that older people are less likely to be invited to participate in
cardiac rehab even though there are proven benefits (Mosley et al 2009). Also of those invited many do not
attend. Joe has to consider whether there is a lack of understanding on the part of health professionals or
negative perceptions about rehabilitation from patients. Also practical issues around travel and transport may
be a factor. There is a suggestion that to overcome some lack of uptake services should be redesigned to meet
the needs of individuals and also more effort needs to be made to explain the benefits of this when invitations
are sent.
Sarah Charge Nurse in Continuing Care / Dementia Unit
Sarah is a registered Mental Health Nurse has worked in older peoples’ Mental Health Services since qualifying
10 years ago. She is now the senior charge nurse in an NHS acute dementia unit. Many people are admitted
from home or transferred from other hospital wards following any acute event such as increasing confusion or
delirium.
There is significant evidence and pressure on GP’s and Clinical Commissioning Groups to reduce the
prescribing of antipsychotic medication particularly in older people with dementia. Sarah is aware that many
people were taking a lot of this medication on admission and following a period of assessment it was
sometimes found that the person was restless and distressed due to pain and sometimes responded well to
the use of regular painkillers instead of antipsychotic medication.
Objective 13 of 'Living Well with Dementia - A National Strategy for England' states that there should be: 'An
informed and effective workforce for people with dementia. All health and social care staff involved in the care
of people who may have dementia to have the necessary skills to provide the best quality of care in the roles
and settings where they work. To be achieved by effective basic training and continuous professional and
vocational development in dementia.'
Sarah is confident in managing many aspects of care in people with dementia. Increasing the involvement of
carers to get some information about the person in the form of a life story and the use of This is Me
document produced by the Alzheimer’s Society http://alzheimers.org.uk/thisisme has assisted staff in looking
after people who become increasingly confused and distressed.
Sarah also sees many people admitted with acute onset delirium and this is often due to underlying infection.
The unit uses the Nice Guidelines on Assessing and managing delirium and this has improved practice.
https://www.nice.org.uk/guidance/cg103/.../cg103-delirium-full-guideline3
Sarah also sees many people who have very progressive Dementia and are very frail. She is concerned about
lack of knowledge and support when managing people approaching the end of life. There are also frequent
questions from staff and relatives about swallowing difficulties and the use of tube feeding and PEG feeding.
The issue of nutrition for older people raises concerns about dignity in care (CQC 2012)
35
She considers there are many ethical issues faced in caring for these individuals and also in relation to other
end of life care decisions. There is a palliative care team who serve the main hospital unit but they do not
currently have any input into her unit.
Sarah feels that even with her experience in older peoples mental health services she still lacks confidence in
dealing with palliative and end of life care issues.
The Joint Commissioning Framework for Dementia suggests that ‘An informed and effective workforce should
be present in specialist as well as universal services. The level of skill and expertise should be proportionate to
the level of contact staff have with people with dementia’.
Lynn a District Nursing Sister in Community
As part of her community caseload, Lynn visits Mr T a 78 year old man with prostate cancer. Prostate cancer
mainly affects men over the age of 50 and risk increases with age. The average age for men to be diagnosed
with prostate cancer is between 70 and 74 years (Prostate Cancer UK).
Lynn has been administering hormone injections to Mr T for over 4 years. On the most recent visit she is
concerned that Mr T appears very gaunt in appearance and he is a bit unkempt compared with usual. As he
lives alone she is concerned about his care needs and also when he explains that he cannot manage to go out
due to pain and limited mobility. She noticed that he struggles to get up from the chair and grimaces with pain
when walking around.
Pain is a common problem for some men with advanced prostate cancer if the cancer has spread to other
areas such as the bones, lymph nodes or other areas of the body. The most common cause is cancer that has
spread to the bones.
Lynn arranges to visit more regularly and do a holistic assessment of his health and social needs. She is unsure
about managing symptoms and concerned about the impact of strong pain killers if these are prescribed. She
will speak to the GP in the first instance.
A major part of the District Nursing role is to care for people right up to the end of life, but Lynn is
concerned that Mr T is deteriorating quite rapidly and there is lack of support available to meet his needs over
24 hours, even though he is keen to stay at home.
36
Final proposed Framework of requirements:
At qualification, all nurses should be able to demonstrate and during their preceptorship work to
consolidate:
VALUES and BEHAVIOURS To review and build on the fundamental values and behaviours expected of
every nurse, to demonstrate commitment to frail or complex older patients and their families and friends,
effective interpersonal skills and communication (listening with care and attention as well as the ability to
articulate needs clearly and to argue a case persuasively), and provide effective, compassionate, evidence based
care, delivered through relationships drawing on empathy, respect and dignity and underpinned by personcentred care. (maps to Domain 1).
END OF LIFE To promote quality of care at the end of life and choice at the end of life, including the use of
advance care planning: helping people approaching the end of their life to describe and clarify what they want
to happen, what they don’t want to happen, and who will speak for them, so that people die with dignity. To
understand and respond to loss. (maps to Domain 3)
CARING FOR CARERS To recognise the physical, psychological and social needs of informal carers in
supporting older people living with complex needs and long term conditions, at all stages and in all settings, to
address these and to deliver effective family centred care. (maps to Domain 4)
5
CLINICAL SKILLS To be able to identify indicators of frailty , and recognise delirium, dementia, depression,
and the deteriorating patient
SAFEGUARDING To protect vulnerable older people with complex needs by confident use of effective
safeguarding processes and understanding of the implications of the Mental Capacity Act. To understand and
be able to address ethical issues arising for this group and their families and carers, to deliver robust risk
assessment and management, and where necessary to manage challenging behaviour.
Nurses after preceptorship in any adult nursing setting, bearing in mind data on the density of older
people with complex needs, should be able to demonstrate in addition:
CLINICAL SKILLS To understand complex conditions, to be able to take a systematic history and
undertake a comprehensive and holistic elderly assessment, including cognition, and to assess and manage pain.
To be able to identify and respond to indicators of frailty, recognise and respond to delirium, dementia,
depression, the deteriorating patient and a range of co-morbidities. To understand effective symptom control
and the challenges of polypharmacy as well as non-pharmacological treatment options. To understand the
importance of health and wellbeing in complex and long term conditions and for older people, and to
understand and respond to distress and to loss. To deliver high quality evidence based care.
CULTURES OF CARE To create positive cultures of care in care settings which serve older people with
complex needs, and deal with diversity, and address stigma and prejudice – including ageism. To understand
diversity, discrimination and stigmatisation. To promote autonomy, empowering patients to self-manage, and
work to provide a positive, safe patient experience, in which every contact counts, underpinned by person5
See British Geriatrics Society, ‘Fit for Frailty’ Consensus best practice guidelines, June 2014 – suggest the use of gait speed, timed-upand-go test or PRISMA 7 questions
37
centred care and person-centred planning. To strive for continuous quality improvement and safe high quality
patient outcomes.
CLINICAL LEADERSHIP To build effective clinical leadership, supported by courage and enthusiasm,
encompassing advocacy, willingness to challenge and champion, and to act as an enabler or an agent for change,
undertaking complex problem solving and complex decision making.
INTERPROFESSIONAL WORKING To build from basic skills in interprofessional and team working, and
to develop skills in effective collaboration, influencing and negotiation, and cross-agency coordination in order
to deliver effective care for older people with complex needs. To support older people in transitions between
care agencies and environments. To work with colleagues and lead innovation, practice development and
service improvement for this group.
NURSING PRACTICE To have a robust understanding of policy and guidance in relation to older people
with complex needs and to appreciate and assume appropriate levels of professional accountability for the care
of this group. To reflect on and in practice, and to act as a role model for colleagues. To develop and use skills
in teaching, learning and coaching colleagues, receiving and providing supervision, and undertaking research and
audit in relation to older people with complex needs.
Each of these areas should be regularly reviewed alongside the characteristics of the setting and the individual’s
role and responsibility, as well as feedback from practice, probably at the point of revalidation, to ensure that
skills and knowledge are topped up to required levels and knowledge appropriately renewed. Diagrams below
indicate how the framework above might be applied to the selected exemplars.
Educational provision should be commissioned with a view to the total framework and the balance of need
within the local workforce. Whilst the achievement of qualifications offers individuals and organisations a clear
benchmark, the most important consideration apart from identifying key areas of content is attending to the
characteristics of CPD which lead to impact. Commissioners should seek delivery modes which favour
interactive, practice based and practice related approaches, which address individuals’ combined learning
needs, but should also interrogate service provider organisations to ensure that staff are provided with
organisational support and feel able to make changes, as this is also important for learning to transfer to
practice. Further diagrams (figures 3 & 4 below) indicate how the framework above might be applied in
commissioning.
38
Applying the framework:
On the following pages are shown a check list suitable for staff to use in reviewing their development needs, in
collaboration with a supervisor or manager, and profiles for each of the exemplar cases.
At qualification, all nurses should be able to demonstrate and during their preceptorship work to consolidate:
Domain
Achieved
Partly
achieved
Not
achieved
Not
applicable
(explain6)
Date
reviewed
VALUES and
BEHAVIOURS To
review and build on the
fundamental values and
behaviours expected of
every nurse, to
demonstrate
commitment to frail or
complex older patients
and their families and
friends, effective
interpersonal skills and
communication (listening
with care and attention
as well as the ability to
articulate needs clearly
and to argue a case
persuasively), and provide
effective, compassionate,
evidence based care,
delivered through
relationships drawing on
empathy, respect and
dignity and underpinned
by person-centred care.
(maps to Domain 1).
Comments
END OF LIFE To
promote quality of care
at the end of life and
choice at the end of life,
including the use of
advance care planning:
helping people
approaching the end of
their life to describe and
clarify what they want to
happen, what they don’t
want to happen, and who
6
It is envisaged that the areas listed should apply to some extent at least to most adult nurses, unless they
work in a very restricted context.
39
will speak for them, so
that people die with
dignity. To understand
and respond to loss.
(maps to Domain 3)
Comments
CARING FOR
CARERS To recognise
the physical,
psychological and social
needs of informal carers
in supporting older
people living with
complex needs and long
term conditions, at all
stages and in all settings,
to address these and to
deliver effective family
centred care. (maps to
Domain 4)
Comments
CLINICAL SKILLS To
be able to identify
indicators of frailty7, and
recognise delirium,
dementia, depression,
and the deteriorating
patient
Comments
SAFEGUARDING To
protect vulnerable older
people with complex
needs by confident use
of effective safeguarding
processes and
understanding of the
implications of the Mental
Capacity Act. To
understand and be able
7
See British Geriatrics Society, ‘Fit for Frailty’ Consensus best practice guidelines, June 2014 – suggest the use of gait speed, timed-upand-go test or PRISMA 7 questions
40
to address ethical issues
arising for this group and
their families and carers,
to deliver robust risk
assessment and
management, and where
necessary to manage
challenging behaviour.
Key aspects of context: Please note the age profile of patients in your unit; the proportion of people with multiple
morbidity that present, the workforce profile and any key clinical or organisational factors which may affect older people
differentially
41
Nurses after preceptorship in any adult nursing setting, bearing in mind data on the density of older
people with complex needs, should be able to demonstrate in addition:
Domain
Achieved
Partly
achieved
CLINICAL SKILLS To
understand complex conditions,
to be able to take a systematic
history and undertake a
comprehensive and holistic
elderly assessment, including
cognition, and to assess and
manage pain. To be able to
identify and respond to
indicators of frailty, recognise
and respond to delirium,
dementia, depression, the
deteriorating patient and a range
of co-morbidities. To understand
effective symptom control and
the challenges of polypharmacy
as well as non-pharmacological
treatment options. To
understand the importance of
health and wellbeing in complex
and long term conditions and for
older people, and to understand
and respond to distress and to
loss. To deliver high quality
evidence based care.
Comment
CULTURES OF CARE To
create positive cultures of care in
care settings which serve older
people with complex needs, and
deal with diversity, and address
stigma and prejudice – including
ageism. To understand diversity,
discrimination and stigmatisation.
To promote autonomy,
empowering patients to selfmanage, and work to provide a
positive, safe patient experience,
in which every contact counts,
underpinned by person-centred
care and person-centred
planning. To strive for
continuous quality improvement
and safe high quality patient
outcomes.
42
Not
achieved
Not
applicable
(explain)
Date
reviewed
Comment
CLINICAL LEADERSHIP To
build effective clinical leadership,
supported by courage and
enthusiasm, encompassing
advocacy, willingness to challenge
and champion, and to act as an
enabler or an agent for change,
undertaking complex problem
solving and complex decision
making.
Comment
INTERPROFESSIONAL
WORKING To build from basic
skills in interprofessional and
team working, and to develop
skills in effective collaboration,
influencing and negotiation, and
cross-agency coordination in
order to deliver effective care
for older people with complex
needs. To support older people
in transitions between care
agencies and environments. To
work with colleagues and lead
innovation, practice development
and service improvement for this
group.
Comment
NURSING PRACTICE To
have a robust understanding of
policy and guidance in relation to
older people with complex needs
and to appreciate and assume
appropriate levels of professional
accountability for the care of this
group. To reflect on and in
practice, and to act as a role
model for colleagues. To develop
and use skills in teaching, learning
and coaching colleagues,
receiving and providing
supervision, and undertaking
43
research and audit in relation to
older people with complex
needs.
Key aspects of context: Please note the age profile of patients in your unit; the proportion of people with multiple
morbidity that present, the workforce profile and any key clinical or organisational factors which may affect older people
differentially
44
Joy (band 5 staff nurse in A & E)
45
Mike a band 3 support worker in stroke discharge team
46
Anne (Experienced Staff Nurse who works in an Ophthalmic Out Patient Department)
47
Joe a specialist Nurse in Cardiac Rehabilitation
48
Sarah Charge Nurse in Continuing Care / Dementia Unit
49
Lynn a District Nursing Sister in Community
50
Framework use in commissioning
The diagrams below (Figures three and four) indicate how the framework above might be applied in
commissioning. In figure three each box should indicate the number of staff for this area for whom this domain
is a current priority (top three areas rated at personal development review) /total staff, and indicating the
levels of need
Trust A
A&E
Outpatients
Acute
medical
Acute
surgical
High
dependency
Elder
care
Community
values and
behaviours
end of life care
caring for carers
clinical skills
safeguarding
cultures of care
clinical skills
clinical leadership
interprofessional
working
nursing practice
Percentage
people over 80
Percentage
complex needs
or frailty among
people over 65
TOTAL
Figure three
In figure four, the totals from all trusts for figure three for staff for this area for whom this domain is a current
priority /total staff, and for people over 80 and people with complex needs would be combined.
Area X all
trusts
values and
behaviours
end of life care
caring for carers
clinical skills
safeguarding
A&E
Outpatients
Acute
medical
Acute
surgical
High
dependency
cultures of care
clinical skills
clinical leadership
interprofessional
working
nursing practice
Percentage
people over 80
Percentage
complex needs
or frailty among
people over 65
TOTAL
Figure four
51
Elder
care
Community
Implementation and Evaluation
The translation of new initiatives into practice is not simple or linear (Rushmer, Steven & Hunter 2014, May et
al 2010) and requires a planned process of implementation coupled with concurrent evaluation and feedback.
In the first instance the framework requires piloting perhaps in two LETB areas with differing characteristics.
This would allow exploration of its use as a framework for reviewing staff development needs and for
commissioning. However given the multitude of variables which could account for variations in practice,
education, commissioning and service, traditional quantitative methods are not enough to discern and
understand the impact of complex interventions and new initiatives such as the framework described (Mathers
et al 2013, Wong et al 2010, Pawson and Tilley 1997, Usher et al 1997). This difficulty is viewed as analogous
to that encountered in the evaluation of complex interventions (Wong et al 2010), as outlined by the Medical
Research Council (Craig et al 2008, Anderson 2008, MRC 2000).
Thus it is suggested that an evaluation could draw on the Principles of Realistic Evaluation (Pawson and Tilley
1997) Normalisation process theory (Amy and Finch 2009) and potentially also participatory approaches.
This approach views social reality as complex and multi layered but proposes that by comparing what works,
for whom, and under what circumstances, commonalities and variations across mechanisms and outcomes can
be identified, described and explored (Pawson and Tilley 1997). Realistic evaluation emphasises the role of
context taking into account for example the different organisational settings, workforce, teams and sociopolitical issues and holds similarities with illuminative evaluation (Parlett and Hamilton 1977) and Normalisation
Process theory (May et al 2010).
Normalisation Process theory ‘is concerned with the social organization of the work (implementation), of making
practices routine elements of everyday life (embedding), and of sustaining embedded practices in their social contexts
(integration)’ (May and Finch 2009) and would offer an additional theoretical and analytical lens from which to
explore the embedding and ‘normalising’ of the framework as both: a mechanism for reviewing staff
development needs and a guide for commissioning of educational and training provision.
The evaluation team could also consider the use of a modified participatory action approach (ie done with
them, not done to them) working with pertinent stakeholder groups (e.g. providers, trusts, commissioners) as
the implementation proceeds. This would facilitate joint ownership and enable timely changes to be made as
implementation of the framework unfolds (Argyris and Schon 1989).
We suggest that pilot work should be evaluated through a range of data collection methods possibly including:
interviews, focus groups, routine data and documents. Furthermore, rather than a traditional input-output
model of evaluation which assumes any changes are due to the initiative (in this case use of the framework)
data collection should track the implementation and use of the framework and feed back into an ongoing cycle
of enhancement. This pilot evaluation should inform the framework’s subsequent rollout, and provide guidance
for indicative data collection to identify on-going impact and effectiveness.
52
Conclusions and recommendations
This report has examined the continuing professional development needs of nurses engaged in the care of
older people who may be described as frail (BGS 2014) or have complex needs, across acute, community and
independent settings. This work was commissioned to address the needs of nurses. However, much of the
thinking within it could apply equally to other groups engaged in work with this group of people. Effective
delivery of healthcare involves collaboration- which requires communication and trust between team members
and across professional groups.
Stakeholders from across England, including experts from NHS Trusts, professional organisations, HEIs and
LETBs, together with service users, carers and students have been involved in a process to agree overarching
specifications which will form the basis of CPD content at Foundation and Specialist level. Consultations have
been undertaken with a majority of LETB areas to review their existing local provision and consider how it fits
with the specifications agreed.
This project has developed what we believe to be a robust framework which has potential for use across
wider staff groups, and to interface with work at other levels. It should, we believe, also fit with the national
priority for enhanced dementia care. Initial contact has been made with colleagues developing the Higher
Specialist level work, but further engagement will enable us to confirm that this Framework forms part of a
coherent learning pathway. One possible route for roll out of this Framework might be to work with the
Higher Specialist Fellows in a particular area and ask them to support communities of practice among those
undertaking the components of the Framework.
We have also sought to understand the current work on Care Certificates for the bands 1-4 workforce and
believe that, in line with discussions above, there may be benefits in drawing on domains within this
Framework for this staff group also, and encouraging shared opportunities for learning.
The team have submitted abstracts to relevant conferences (Royal College of Nursing and British Geriatric
Society) but also intend to disseminate this report to all LETBs and to HEIs through the Council of Deans of
Healthcare, as well as offering workshops when requested and publishing in peer reviewed academic journals.
The model framework proposed offers a degree of flexibility but has the potential to facilitate a conversation
with every adult nurse, and possibly also other staff groups about the patients managed by them and their
learning needs in relation to the care of older people with complex needs. It is further suggested that these
can then be combined into a commissioning template, out of which a clear, justifiable plan for CPD which takes
account of context and patient need can be produced, and ultimately patient care for this group enhanced.
53
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58
Appendices
1.Summary of provision by LETB
LETB
Providers
Delivery modes
Qualification?
Academic
levels if
stated
Academic
credits if
stated
Kent, Surrey &
Sussex
Universities
(3)
Lectures and discussion, seminar
presentation, small group work, experiential
learning
Optional, top up
and BSc
5,6,7
15,20,30
North Central
and East
London
Universities
(5)
not known
not known
4,5,6
not known
North Central
and East
London
Independent
providers
not known
n/a
n/a
n/a
North East
Universities
(2)
Lectures , seminars, workshops,
masterclasses
BSc, PgC/D, MSc
6,7
20,40,120
North West
Universities
(6)
classroom, mixed
BSc, PgC/D, MSc
6,7
20
North West
Foundation
Trusts (6)
classroom, mixed,
e-learning
none
none
none
Thames Valley
Universities
(5)
short courses, mixed, lectures, seminars,
blended
Clinical upskilling,
BSc, PgC/D, MSc
6,7
nonaccredited,
15,20,30 180
Wessex
Universities
(4)
workshops, blended, online
BSc, PgC/D, M
6,7
nonaccredited,
15,20,30,60
NW London
Universities
(6)
Lectures, blended, unknown
not known
4,5,6
not known
NW London
Independent
providers
Unknown
not known
none
not known
59
LETB
Providers
Delivery modes
Qualification?
Academic
levels if
stated
Academic
credits if
stated
South London
Universities
(6)
Lectures, unknown
not known
5,6,7
nonaccredited,
15,20,30
South West
Universities
(2)
Lectures, mixed, workshops, simulation
none, PgC, PgD
5,6,7
nonaccredited,
10,15,20,30,40
South West
Independent
providers
e learning
none
none
none
East Midlands
No information
East of England
No information
West Midlands
No information
Yorkshire and
Humber
No information
60
2. NMC Standards for preregistration nursing
Competencies for entry to the register - Adult nursing
Domain 1: Professional values
Generic standard for competence
All nurses must act first and foremost to care for and safeguard the public. They must practise autonomously and be responsible and
accountable for safe, compassionate, person-centred, evidence-based nursing that respects and maintains dignity and human rights. They
must show professionalism and integrity and work within recognised professional, ethical and legal frameworks. They must work in
partnership with other health and social care professionals and agencies, service users, their carers and families in all settings, including the
community, ensuring that decisions about care are shared.
Field standard for competence
Adult nurses must also be able at all times to promote the rights, choices and wishes of all adults and, where appropriate, children and
young people, paying particular attention to equality, diversity and the needs of an ageing population. They must be able to work in
partnership to address people’s needs in all healthcare settings.
Competencies
1
All nurses must practise with confidence according to The code: Standards of conduct, performance and ethics for
nurses and midwives (NMC 2008), and within other recognised ethical and legal frameworks. They must be able to
recognise and address ethical challenges relating to people’s choices and decision-making about their care, and act within
the law to help them and their families and carers find acceptable solutions.
1.1
2
3
Adult nurses must understand and apply current legislation to all service users, paying special attention to the
protection of vulnerable people, including those with complex needs arising from ageing, cognitive impairment,
long-term conditions and those approaching the end of life.
All nurses must practise in a holistic, non-judgmental, caring and sensitive manner that avoids assumptions, supports
social inclusion; recognises and respects individual choice; and acknowledges diversity. Where necessary, they must
challenge inequality, discrimination and exclusion from access to care.
All nurses must support and promote the health, wellbeing, rights and dignity of people, groups, communities and
populations. These include people whose lives are affected by ill health, disability, ageing, death and dying. Nurses must
understand how these activities influence public health.
4
All nurses must work in partnership with service users, carers, families, groups, communities and organisations. They
must manage risk, and promote health and wellbeing while aiming to empower choices that promote self-care and safety.
5
All nurses must fully understand the nurse’s various roles, responsibilities and functions, and adapt their practice to meet
the changing needs of people, groups, communities and populations.
6
7
All nurses must understand the roles and responsibilities of other health and social care professionals, and seek to work
with them collaboratively for the benefit of all who need care.
All nurses must be responsible and accountable for keeping their knowledge and skills up to date through continuing
professional development. They must aim to improve their performance and enhance the safety and quality of care
through evaluation, supervision and appraisal.
8
All nurses must practise independently, recognising the limits of their competence and knowledge. They must reflect on
these limits and seek advice from, or refer to, other professionals where necessary.
9
All nurses must appreciate the value of evidence in practice, be able to understand and appraise research, apply relevant
theory and research findings to their work, and identify areas for further investigation.
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Domain 2: Communication and interpersonal skills
Generic standard for competence
All nurses must use excellent communication and interpersonal skills. Their communications must always be safe, effective, compassionate
and respectful. They must communicate effectively using a wide range of strategies and interventions including the effective use of
communication technologies. Where people have a disability, nurses must be able to work with service users and others to obtain the
information needed to make reasonable adjustments that promote optimum health and enable equal access to services.
Field standard for competence
Adult nurses must demonstrate the ability to listen with empathy. They must be able to respond warmly and positively to people of all
ages who may be anxious, distressed, or facing problems with their health and wellbeing.
Competencies
1
2
3
All nurses must build partnerships and therapeutic relationships through safe, effective and non-discriminatory
communication. They must take account of individual differences, capabilities and needs.
All nurses must use a range of communication skills and technologies to support person-centred care and enhance
quality and safety. They must ensure people receive all the information they need in a language and manner that allows
them to make informed choices and share decision making. They must recognise when language interpretation or other
communication support is needed and know how to obtain it.
All nurses must use the full range of communication methods, including verbal, non-verbal and written, to acquire,
interpret and record their knowledge and understanding of people’s needs. They must be aware of their own values and
beliefs and the impact this may have on their communication with others. They must take account of the many different
ways in which people communicate and how these may be influenced by ill health, disability and other factors, and be
able to recognise and respond effectively when a person finds it hard to communicate.
3.1
4
Adult nurses must promote the concept, knowledge and practice of self-care with people with acute and longterm conditions, using a range of communication skills and strategies.
All nurses must recognise when people are anxious or in distress and respond effectively, using therapeutic principles, to
promote their wellbeing, manage personal safety and resolve conflict. They must use effective communication strategies
and negotiation techniques to achieve best outcomes, respecting the dignity and human rights of all concerned. They
must know when to consult a third party and how to make referrals for advocacy, mediation or arbitration.
5
All nurses must use therapeutic principles to engage, maintain and, where appropriate, disengage from professional caring
relationships, and must always respect professional boundaries.
6
All nurses must take every opportunity to encourage health-promoting behaviour through education, role modelling and
effective communication.
7
All nurses must maintain accurate, clear and complete records, including the use of electronic formats, using appropriate
and plain language.
8
All nurses must respect individual rights to confidentiality and keep information secure and confidential in accordance
with the law and relevant ethical and regulatory frameworks, taking account of local protocols. They must also actively
share personal information with others when the interests of safety and protection override the need for confidentiality.
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Domain 3: Nursing practice and decision-making
Generic standard for competence
All nurses must practise autonomously, compassionately, skilfully and safely, and must maintain dignity and promote health and wellbeing.
They must assess and meet the full range of essential physical and mental health needs of people of all ages who come into their care.
Where necessary they must be able to provide safe and effective immediate care to all people prior to accessing or referring to specialist
services irrespective of their field of practice. All nurses must also meet more complex and coexisting needs for people in their own
nursing field of practice, in any setting including hospital, community and at home. All practice should be informed by the best available
evidence and comply with local and national guidelines. Decision-making must be shared with service users, carers and families and
informed by critical analysis of a full range of possible interventions, including the use of up-to-date technology. All nurses must also
understand how behaviour, culture, socioeconomic and other factors, in the care environment and its location, can affect health, illness,
health outcomes and public health priorities and take this into account in planning and delivering care.
Field standard for competence
Adult nurses must be able to carry out accurate assessment of people of all ages using appropriate diagnostic and decision-making skills.
They must be able to provide effective care for service users and others in all settings. They must have in-depth understanding of and
competence in medical and surgical nursing to respond to adults’ full range of health and dependency needs. They must be able to deliver
care to meet essential and complex physical and mental health needs.
Competencies
1
All nurses must use up-to-date knowledge and evidence to assess, plan, deliver and evaluate care, communicate findings,
influence change and promote health and best practice. They must make person-centred, evidence-based judgments and
decisions, in partnership with others involved in the care process, to ensure high quality care. They must be able to
recognise when the complexity of clinical decisions requires specialist knowledge and expertise, and consult or refer
accordingly.
1.1
2
3
All nurses must possess a broad knowledge of the structure and functions of the human body, and other relevant
knowledge from the life, behavioural and social sciences as applied to health, ill health, disability, ageing and death. They
must have an in-depth knowledge of common physical and mental health problems and treatments in their own field of
practice, including co-morbidity and physiological and psychological vulnerability.
All nurses must carry out comprehensive, systematic nursing assessments that take account of relevant physical, social,
cultural, psychological, spiritual, genetic and environmental factors, in partnership with service users and others through
interaction, observation and measurement.
3.1
4
Adult nurses must safely use a range of diagnostic skills, employing appropriate technology, to assess the needs of
service users.
All nurses must ascertain and respond to the physical, social and psychological needs of people, groups and communities.
They must then plan, deliver and evaluate safe, competent, person-centred care in partnership with them, paying special
attention to changing health needs during different life stages, including progressive illness and death, loss and
bereavement.
4.1
4.2
5
Adult nurses must be able to recognise and respond to the needs of all people who come into their care
including babies, children and young people, pregnant and postnatal women, people with mental health problems,
people with physical disabilities, people with learning disabilities, older people, and people with long term problems
such as cognitive impairment.
Adult nurses must safely use invasive and non-invasive procedures, medical devices, and current technological
and pharmacological interventions, where relevant, in medical and surgical nursing practice, providing information
and taking account of individual needs and preferences.
Adult nurses must recognise and respond to the changing needs of adults, families and carers during terminal
illness. They must be aware of how treatment goals and service users’ choices may change at different stages of
progressive illness, loss and bereavement.
All nurses must understand public health principles, priorities and practice in order to recognise and respond to the
major causes and social determinants of health, illness and health inequalities. They must use a range of information and
data to assess the needs of people, groups, communities and populations, and work to improve health, wellbeing and
experiences of healthcare; secure equal access to health screening, health promotion and healthcare; and promote social
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inclusion.
6
7
All nurses must practise safely by being aware of the correct use, limitations and hazards of common interventions,
including nursing activities, treatments, and the use of medical devices and equipment. The nurse must be able to evaluate
their use, report any concerns promptly through appropriate channels and modify care where necessary to maintain
safety. They must contribute to the collection of local and national data and formulation of policy on risks, hazards and
adverse outcomes.
All nurses must be able to recognise and interpret signs of normal and deteriorating mental and physical health and
respond promptly to maintain or improve the health and comfort of the service user, acting to keep them and others
safe.
7.1
7.2
8
Adult nurses must recognise the early signs of illness in people of all ages. They must make accurate assessments
and start appropriate and timely management of those who are acutely ill, at risk of clinical deterioration, or
require emergency care.
Adult nurses must understand the normal physiological and psychological processes of pregnancy and childbirth.
They must work with the midwife and other professionals and agencies to provide basic nursing care to pregnant
women and families during pregnancy and after childbirth. They must be able to respond safely and effectively in an
emergency to safeguard the health of mother and baby.
All nurses must provide educational support, facilitation skills and therapeutic nursing interventions to optimise health
and wellbeing. They must promote self-care and management whenever possible, helping people to make choices about
their healthcare needs, involving families and carers where appropriate, to maximise their ability to care for themselves.
8.1
Adult nurses must work in partnership with people who have long-term conditions that require medical or
surgical nursing, and their families and carers, to provide therapeutic nursing interventions, optimise health and
wellbeing, facilitate choice and maximise self-care and self-management.
9
All nurses must be able to recognise when a person is at risk and in need of extra support and protection and take
reasonable steps to protect them from abuse.
10
All nurses must evaluate their care to improve clinical decision-making, quality and outcomes, using a range of methods,
amending the plan of care, where necessary, and communicating changes to others.
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Domain 4: Leadership, management and team working
Generic standard for competence
All nurses must be professionally accountable and use clinical governance processes to maintain and improve nursing practice and
standards of healthcare. They must be able to respond autonomously and confidently to planned and uncertain situations, managing
themselves and others effectively. They must create and maximise opportunities to improve services. They must also demonstrate the
potential to develop further management and leadership skills during their period of preceptorship and beyond.
Field standard for competence
Adult nurses must be able to provide leadership in managing adult nursing care, understand and coordinate interprofessional care when
needed, and liaise with specialist teams. They must be adaptable and flexible, and able to take the lead in responding to the needs of
people of all ages in a variety of circumstances, including situations where immediate or urgent care is needed. They must recognise their
leadership role in disaster management, major incidents and public health emergencies, and respond appropriately according to their levels
of competence.
Competencies
1
All nurses must act as change agents and provide leadership through quality improvement and service development to
enhance people’s wellbeing and experiences of healthcare.
2
All nurses must systematically evaluate care and ensure that they and others use the findings to help improve people’s
experience and care outcomes and to shape future services.
3
All nurses must be able to identify priorities and manage time and resources effectively to ensure the quality of care is
maintained or enhanced.
4
All nurses must be self-aware and recognise how their own values, principles and assumptions may affect their practice.
They must maintain their own personal and professional development, learning from experience, through supervision,
feedback, reflection and evaluation.
5
All nurses must facilitate nursing students and others to develop their competence, using a range of professional and
personal development skills.
6
All nurses must work independently as well as in teams. They must be able to take the lead in coordinating, delegating
and supervising care safely, managing risk and remaining accountable for the care given.
7
All nurses must work effectively across professional and agency boundaries, actively involving and respecting others’
contributions to integrated person-centred care. They must know when and how to communicate with and refer to
other professionals and agencies in order to respect the choices of service users and others, promoting shared decision
making, to deliver positive outcomes and to coordinate smooth, effective transition within and between services and
agencies.
There are considered to be five essential skills clusters as follows:
• Care, compassion and communication
• Organisational aspects of care
• Infection prevention and control
• Nutrition and fluid management
• Medicines management.
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3. Care certificate
Why is the Care Certificate being developed?
In the wake of the Francis Inquiry, and following the identification of serious challenges in some
other health and social care settings in 2013, Camilla Cavendish was asked by the Secretary of State
to review and make recommendations on: the recruitment, learning and development, management
and support of healthcare assistants and social care support workers, ensuring that this workforce
provides compassionate care.
The resulting report, The Cavendish Review: An Independent Review into Healthcare Assistants and
Support Workers in the NHS and Social Care Settings (July 2013) found that preparation of
healthcare assistants and social care support workers for their roles within care settings was
inconsistent and she recommended development of a Certificate of Fundamental Care – the ‘Care
Certificate’.
When is the Care Certificate being introduced?
It is planned that the Care Certificate will be introduced in March 2015. Initially, draft Care
Certificate documents (available from the partner websites) are being piloted with employers
between April and September 2014.
Who should do the Care Certificate?
Health Care Assistants, Assistant Practitioners, Care Support Workers and those giving support to
clinical roles in the NHS where there is any direct contact with patients. Care Support Workers
denotes Adult Social Care workers giving direct care in residential and nursing homes and hospices,
home care workers and domiciliary care staff. These staff are referred to collectively as Healthcare
Support Workers (HCSW)/ Adult Social Care Workers (ASCW). Other roles in health and social care
such as caring volunteers, porters, cooks or drivers that have direct contact with patients and service
users could also undertake all or some of the Care Certificate, but in order for the Care Certificate to
be awarded the person must achieve success in all of the outcomes and assessment requirements.
What does the Care Certificate cover?
The Care Certificate is the start of the career journey for these staff groups and is only one element
of the training and education that will make them ready to practice within their specific sector. The
Care Certificate builds on the Common Induction Standards (CIS) and National Minimum Training
Standards (NMTS) and sets out explicitly the learning outcomes, competences and standards of
behaviour that must be expected of a HCSW/ASCW in both sectors, ensuring that such a
HCSW/ASCW is caring, compassionate and provides quality care. The Certificate also reflects how
these behaviours are underpinned by the Chief Nursing Officer's 6Cs (care, compassion,
competence, communication, courage and commitment).
The Care Certificate standards
1. Understand Your Role
2. Your Personal Development
3. Duty of Care
4. Equality and Diversity
5. Work in a Person Centred Way
6. Communication
7. Privacy and Dignity
8. Fluids and Nutrition
9. Dementia and Cognitive Issues
10. Safeguarding Adults
11. Safeguarding Children
12. Basic Life Support
13. Health and Safety
14. Handling Information
15. Infection Prevention and Control
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Duty of Care
4. Equality and Diversity
5. Work in a Person Centred Way15. Infection Prevention and Control
Is the Care Certificate knowledge only?
No, the Care Certificate contains both knowledge and competence outcomes.
Assessment of knowledge and understanding is prefixed with verbs such as ‘describe,’ ‘explain,’
‘define,’ ‘list,’ or ‘identify’ and can be undertaken using written or verbal evidence such as the
workbook, written questions, case studies or sound files.
Evidence of performance prefixed with words such as ‘demonstrate,’ ‘take steps to,’ ‘use’ or ‘show’
must be undertaken in the workplace during the learners real work activity and observed by the
assessor unless the use of simulation is expressly allowed. Learners can practice and develop their
new skills in a classroom or similar setting but the assessment evidence must be collected during real
work activity.
Is the Care Certificate a replacement for induction?
The Care Certificate does not replace employer induction specific to the environment in which
practice will take place, nor will it focus on the specific skills and knowledge needed for a specific
setting.
What happens to the Common Induction Standards and the National Minimum
Training Standards?
The Care Certificate will replace the National Minimum Training Standards (NMTS) and the Common
Induction Standards (CIS) and provides the framework for these within Health and Social Care. Each
HCSW/ASCW starting within a new role within the scope of this certificate is expected to have
training, education and assessment as part of this certificate, within the first 12 weeks of
employment.
What training sessions must be delivered to meet these needs?
Training sessions which are delivered for the Care Certificate can include using a number of methods
to impart knowledge and skills but they must meet the standards of the learning outcomes.
What is the assessment process?
Assessment will differ dependent upon the element of the Care Certificate. Most assessment should
be within a care setting, in practice, with people who use services/patients, and should be
completed face to face by an occupationally competent assessor. Simulated (simulation is where the
achievement of valid and reliable assessment calls for evidence of performance under workplace
conditions, but where it will be difficult to assess through normal working practice) evidence can
only be used where the evidence could not reasonably be assessed in a real work situation or is
unlikely to occur during the induction period for example basic life support. It is not permissible to
use Skype or other forms of video evidence when assessing performance.
What is the minimum time permitted for providing the training requirements of the
Care Certificate?
Each HCSW/ASCW starting within a new role within the scope of this certificate is expected to have
training, education and assessment as part of this certificate, within the first 12 weeks of
employment.
Will there be a certification process for the Care Certificate?
This should be recorded by the employer and where possible made accessible via a national system.
For example NHS Trusts that use it can do this via the Electronic Staff Record. Where the employer
does not use a national system the record must be maintained locally and made available where
appropriate for inspection purposes.
There is no central certification process for the Care Certificate. We are seeking feedback from
employers during the pilot processes for viability and potential of certificates being made available.
It is likely that award of the Care Certificate will be via the employer using a standard national
template.
How is the Care Certificate quality assured?
The employer is responsible for assuring the quality of the teaching and assessment of the Care
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Certificate. The Registered Manager in Adult Social Care or named person in a health employer will
sign off the HCSW/ ASCW as having successfully met all the standards to achieve the Care Certificate.
The Registered Manager/ named person must assure themselves that the standard of teaching and
assessment is of sufficient quality that they can be confident that the HCSW/ASCW has fully met the
standard.
The outcomes of the Care Certificate will be quality assured via the CQCs existing methodology in
reviewing its essential standards.
Will the Care Certificate be accredited?
It is not the intention or expectation that the Care Certificate will be accredited as a national
qualification. The Care Certificate does not require local accreditation by any awarding body or
Higher Education Institution, and there is no requirement for it to have external quality assurance.
However, employers may wish to seek accreditation of the learning or external quality assurance. It
is however an expectation that the Care Certificate would provide evidence towards QCF
qualifications and Apprenticeships across both Health and Social Care.
Will internal training still be permitted?
It is up to the employer how the Care Certificate is delivered if they have the appropriate
skills/knowledge and competency to deliver that particular element of the Care Certificate then they
may wish to deliver the training themselves.
Will e‐learning be permitted to be used?
The Care Certificate allows the use of e‐learning to provide the knowledge related to the Care
Certificate and recognises technology offers individuals and employers the opportunity to learn
anywhere. However, design and delivery must meet the standards of the outcomes. Where
competency is being assessed it must be face to face.
If I have already completed my CIS do I have to do the Care Certificate?
No, the Care Certificate is for HCSW/ASCW starting within a new role. Those who have completed
their CIS have already completed preparation for their roles and will continue to be recognised.
Those who have completed their CIS have already completed preparation for their roles and will
continue to be recognised. On‐going compliance with required competencies will be picked up as
part of supervision and the yearly appraisal cycle.
Can I be credited with the Certificate even though I have already completed my
Common Induction Standards/ National Minimum Training standards?
The content of the Care Certificate builds on the content of the CIS/NMTS and requires assessment
of competence as well as knowledge. Achievement of the CIS/NMTS does not automatically mean
that you can be awarded the Care Certificate. The initial focus is for new staff to achieve the Care
Certificate although during the pilot work we will be looking at how existing staff can prove that they
are working to the Standards set out in the Care Certificate.
The Care Certificate has additional standards to the current CIS and NMTS do workers
who has completed the CIS/NMTS undertake further learning to meet the new Care
Certificate standards?
For those workers who have completed CIS/NMTS they will have met the requirements of induction.
It is the responsibility of the employer to identify whether the job role requires a need to meet the
additional standards of the Care Certificate. It is envisaged that the framework of the Care
Certificate will form part of supervision and appraisal process.
If a HCSW/ASCW moves in to a new job role or employer do they have to re‐do the
Care Certificate?
No, once the Care Certificate is completed it is portable and therefore does not have to be retaken.
However, as the Care Certificate does not replace employer induction specific to the environment in
which practice will take place, nor does it focus on the specific skills and knowledge needed for a
specific setting; the employer may request additional induction.
What should employers be doing in terms of induction whilst the Care Certificate is
being developed?
Employers should still continue to induct their staff as they have been doing. In social care this
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would be by completion of the Common Induction Standards.
How frequently should the Care Certificate be refreshed?
Once the Care Certificate is completed it is portable and therefore does not have to be retaken.
However, as you remain in or develop in your job role your employer may request you to undertake
other forms of formal or informal learning.
Will there be a national record of who has / has not completed the Care Certificate?
No there is no national record of who has / has not completed the Care Certificate. The employer is
responsible for maintaining a record.
Do Personal Assistants employed by individual employers have to complete the Care
Certificate?
Individual employers are not bound by the same requirements as other employers to complete the
Care Certificate. It is good practice for the individual employer to encourage Personal Assistants to
complete the Care Certificate.
28 April 2014
http://nwl.hee.nhs.uk/files/2014/07/Care-Certificate-briefing-and-Qs-and-As-PDF.pdf
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4. Higher specialist (Fellow) programme
http://www.kcl.ac.uk/nursing/study/Older-Persons-Nurse-Fellowship-Programme.aspx
Older Person's Nurse Fellowship
A message from Health Education England - sponsors of the Older Person's Nurse
Fellowship at King's
HEE recognises the importance of developing and training nurses caring for older people
with complex needs so that they have the expertise and skills required to excel in their role.
The Older Person's Nurse Fellow Programme aims to develop a cadre of nurse leaders who
are recognised experts in the care of older people and who have national influence and
are able to drive change so that the care of older people is compassionate and of the highest
possible quality.
Professor Lisa Bayliss-Pratt
Director of Nursing
Health Education England
Introduction
Have you the drive and vision to champion excellence in care for older people in your
organisation, as well as on a national and international stage?
If the answer is yes, then the inaugural Older Person's Nurse Fellowship, sponsored by
Health Education England (HEE) and hosted by King's College London, will help you realise
your ambition to lead innovation and quality improvement in care for older people.
The Older Person's Nurse Fellowship Programme will run during the 2014/15 and 2015/16
academic years, at the Florence Nightingale School of Nursing and Midwifery, King's College
London.
We are seeking to recruit senior nurses, from across the UK, who currently work in older
person’s services in the community, acute care or mental health. These senior nurses should
already have specialist knowledge and skills in working with older people, as well as
experience of decision making at a senior level in their organisations.
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Why study as part of the Older Person's Fellowship at King's?
The ethos of the Older Person’s Nurse Fellowship is quality, safety, service transformation
and innovation in older person’s care. The Fellowship will deliver confident, competent and
compassionate leaders to act as agents of change, to transform person-centred services.
Fellows will be part of King’s College London and the King’s Health Partners Academic
Health Science Centre (AHSC). The programme will enable Fellows to realise their full
potential across many domains , including becoming:







An expert nurse in the holistic care of older people
An innovator in care delivery and service development
Skilled in the implementation and evaluation of innovation
A recognised leader and role model in older person’s care
A resilient and self-aware individual
An agent of change, shaping the future of healthcare for older people
Confident and committed to disseminating excellence in older person’s care among
national and international communities
Older Person's Nurse Fellowship Skills and Expertise Tree:
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Who should apply
The Older Person’s Nurse Fellowship is a specialist education programme, targeted at
individuals who can demonstrate relevant experience of working in older person’s
healthcare at a senior level (for example Band 7 / 8, clinical nurse specialist or community
matron). However, in exceptional circumstances, candidates at a lower grade, who have
demonstrated exceptional leadership and innovation within their organisation, will also be
considered.
There will be two cohorts of 12 students. The first cohort will commence their studies in
November 2014, and finish in October 2015. The second cohort will commence their
studies in March 2015 and finish in February 2016.
Applications must be received by Friday 5pm, 19th September. If you apply, you
must be free to travel to London for a selection event on 8th October 2014.
How to apply
The recruitment process reflects the HEE Mandate (2014-15) for person-centred care and
will be tailored to ensure the 24 candidates selected embody the core values of the NHS
Constitution, and care, compassion, competence, communication, courage and commitment.
Eligible candidates will be nominated by their Local Education and Training Board (LETB) in
conjunction with their Director of Nursing. HEE and King's College London will jointly
select candidates, from LETB nominations, who have the drive and ambition to achieve the
highest standards of safety, quality and innovation in older person’s care and service design
in the community, mental health and acute services.
Eligible applicants must:






Be a first level registered nurse and operating at a senior / decision-making level in
the care of older people (minimum band 7, e.g. clinical nurse specialist, nurse
consultant, community matron)
Hold a current registration with the Nursing and Midwifery Council
Be nominated by their LETB and Director of Nursing
Have a minimum of a 2:1 honours degree in nursing or higher level award
Be currently active in clinical practice or a significant part of their role involves direct
contact with older people which may include service development
Not be enrolled or engaged in another course or programme of study during the
fellowship.
To apply, you need to submit the following:


A letter of nomination from your LETB (the LETB will require a statement of
support from your Director of Nursing)
An up-to-date CV, highlighting your current experience and knowledge, as well as
any specialist interests or advanced practice qualifications
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
A proposed change management project (see below)
Nominated applicants will also be asked to complete a leadership recruitment assessment
tool.
To receive a letter of nomination from your LETB the potential candidate must first discuss
the Fellowship programme with his/her Director of Nursing (DON). The DON should
submit a letter of support directly to the LETB Lead. The statement should be no more than
200 words. It must endorse the candidate as an aspirant leader and state a commitment to
support the candidate, including releasing them from clinical practice for the required (12)
study days.
Applicants who are nominated by the Director of Nursing and LETB, but who are not
selected at the event on 8th October, will be offered feedback.
The deadline for submissions is Friday 19th September 2014. Further details of
the submission process will be posted here shortly.
Funding support for the Fellowship
The 24 students who make up the first two cohorts on the Fellowship will have:



Their Fellowship Programme fees funded by HEE
Up to a maximum of 15 days salary backfill paid to their employing organisation by
HEE. This time is to cover their attendance at the single study days, the two, twoday residentials, and study trip. This will be funded at mid-point band 8A, plus on
costs.
Their travel for the single study days and residential will be paid by HEE in line with
standard NHS terms and conditions
Briefing event for interested applicants
All interested potential applicants are invited to a briefing event, at King's
College London, on 3rd September 2014.
The event will help answer any questions you might have about the Fellowship, how to apply,
guidance for applicants' proposed change management projects, and anything else you might
want to know. You'll also be joined by the academics teaching the Fellowship.
The briefing event will run from 11am - 3pm and will be held at the King's Strand Campus.
For full details will follow.
If you're interested in applying for the Fellowship, we advise that you attend the briefing
event. However, if you are unable to attend, we will be posting videos of the talks, and the
Q&A sessions, on these pages shortly afterwards.
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Please note, you do not have to be nominated by your LETB to attend the briefing event,
but, following the event, if you wish to apply for a place on the Fellowship, your final
application will need to be accompanied by a letter of nomination from your LETB.
Your commitment to study
The Fellowship utilises the latest web-based technology to enhance your learning
throughout. Fifty per cent of teaching will be delivered through online learning, so moderate
IT literacy is required. The other fifty per cent of teaching will take place at the Faculty's
base in Waterloo, London.
Successful Fellows will be expected to travel to London for two residential
weekends and for one study day per month.
About the Fellowship
The one year, part-time Fellowship will consist of distance and online learning, single study
days, and two residential (two day) events at King's College London, and a study trip, which
may be international. Prospective Fellows will be able to continue working in their current
roles while completing the Fellowship.
The Fellowship consists of two core modules:


Module 1: Advanced Knowledge and Skills in the Care of Older People (15 credits)
Module 2: Leadership in Service Development, Innovation and Quality Improvement
in Older Person's Care (45 credits)
Guidance on submitting an outline of a proposed change management project
As part of your application, you need to submit a 500 - 1,000 word outline for a change
management project, which could be implemented in practice, using the template below.
Your proposal should:







Relate to your organisation’s strategic plans/objectives
Show a clear need for improvement
Show the impact the change will have on older people
Consider the resources and logistical considerations needed to make the changes
(e.g. timings, cost)
Give outcomes (what, by when, by whom)
Be orientated around SMART goals
Be set within a realistic time frame
Download the template for a proposed change management project. The complete
template, with the details of your proposed project, needs to be returned with your
application.
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