Transforming Nursing, Midwifery And Health Profession (NMaHP) roles: review of Clinical Nurse Specialist and Nurse Practitioner roles within Scotland

Annex D Outcomes from Review: Core Clinical Competencies

The core role and function of the Specialist at Level 6 and Advanced Specialist at Level 7 can be defined according to four pillars of practice:

• clinical practice;
• leadership;
• facilitation of learning;
• evidence, research and development.

The competencies set out here focus on clinical practice and relate to all Clinical Nurse Specialists and specialist Nurse Practitioners. The other key knowledge, skills and behaviours relating to generic clinical skills and the other three pillars of practice for all Level 6 Senior Practitioners are articulated in the NES NMaHP Development Framework.^[19] Competence in practice provides assurance of safe, effective and person-centred care and remains embedded within the NMC code and in nursing governance structures.

2.1 Core Clinical Competencies

Level 6 Clinical Nurse Specialist:

History Taking

• Undertake a comprehensive assessment of a person's physical, psychological and social needs
• Actively involve the person, their family and carers, and wider partners, in assessments

Focused Clinical Assessment

Carry out a focused clinical assessment of a patient, which may include:

• physical examination
• symptom and treatment assessment
• use of assessment or monitoring tools

The assessment may be face-to-face, or by phone or video conference.

Investigations

Using the appropriate guidelines and/or protocols:

• Request an agreed range of investigations appropriate to scope of practice
• Interpret the findings of investigations and/or act on investigation reports
• Discuss findings and implications with the patient to enable them to make informed decisions about their treatment plans
• Where appropriate, present findings to a Multidisciplinary Team (MDT) forum and/or with other health and social care professionals

Differential Diagnosis/Diagnosis

Analyse clinical information based on the patient's presentation, history, physical and psychological examinations, and findings from relevant investigations to:

• make a differential diagnosis
• make or confirm a diagnosis

Treatment and Care

Make decisions following analysis of a range of clinical findings, by:

• formulating a person-centred treatment and care plan (normally based on local and/or national guidelines) with the patient, family and carers as appropriate. This may include the prescription of medicines and implementation of non-pharmacological-related interventions or therapies
• supporting people to self-manage their condition
• providing episodic care, or care for an extended period of time, depending on the patient and/or area of practice
• determining the frequency of review in order to manage symptoms and assess therapeutic intervention response

The following list is not exhaustive, however a Specialist Practitioner should be cognisant of:

• Common symptoms associated with the disease/condition/disability or any co-morbidities
• Treatment and care to prevent/minimise secondary complications
• Identification and management of deterioration, including supporting advanced care planning and end-of-life care where required
• Medical emergencies commonly seen within the speciality
• Psychological distress, anxiety and depression
• Health promotion including lifestyle choices
• The wider network of support for patients and their families
• Broader public health issues relevant to the area of practice

Co-ordination of Care, Referral, Admission and Discharge

• Plan and/or co-ordinate care
• Authority to admit and discharge from their speciality, depending on patient need and relevant legislation. This may include referral to a range of appropriate health and social care professionals and agencies. The Specialist Practitioner may receive referrals directly or via the MDT team
• Provide advice to other health and social care professionals to inform admission/discharge, planning or referral

Expert Specialist Resource

• Provide specialist advice and support
• Act as an expert link for colleagues across a range of settings
• Act as a clinical advisor, resource or educator to others
• Is a key member of the wider MDT, contributing to case management presentations and clinical management decisions

2.2 Level 7 Advanced Clinical Nurse Specialist

The competencies set out below focus on clinical practice. Practice relating to the non-clinical aspects of the Advanced Clinical Nurse Specialist role is presented in the NES NMaHP Development Framework.^[20] Competence in practice assures safe, effective and person-centred care and remains embedded within the Nursing and Midwifery Council (NMC) Code and in nursing governance structures.

Focused History Taking

• Undertake a comprehensive assessment of a person's physical, psychological and social needs
• Actively involve the person, their family and carers, and wider partners in assessments
• Assessment should include a full analysis and interpretation of their history

Focused Clinical Assessment

Carry out a focused clinical assessment of the patient, which may include:

• physical examination
• symptom and treatment assessment;
• use of assessment or monitoring tools where indicated
• analysing and synthesising findings from any relevant assessments (including those carried out by other members of the MDT), tests and investigations

The assessment may be face-to-face, or over the phone or by video conference.

Investigations

• Authority to request a range of investigations
• Apply knowledge and understanding of pathophysiology and investigations to:
  • Request investigations appropriate to their scope of practice
  • Interpret specific investigations and will act on investigation reports
• Use appropriate guidelines and/or protocols where they exist
• Where appropriate, present findings to an MDT forum and/or with other health and social care professionals

Differential Diagnosis/Diagnosis

• Analyse and synthesise clinical information based on the patient's presentation, history, physical and psychological examination and findings from relevant investigations and may be able to:
  • Make a differential diagnosis
  • Make or confirm a diagnosis
• Make informed judgements in situations in the absence of complete or consistent data/information.

Treatment and Care

• Formulate a person-centred treatment and care plan based on synthesis and analysis of assessment and investigations. This may include the prescription of medicines
• Use guidelines and protocols to inform care and treatment planning where they exist
• Determine frequency of review to assess the therapeutic response

The following list is not exhaustive, however an Advanced Clinical Nurse Specialist should be cognisant of:

• Common symptoms associated with the disease/condition/disability or any comorbidities
• Treatment and care to prevent/minimise secondary complications
• Identification and management of deterioration, including supporting advanced care planning and end-of-life care where required
• Medical emergencies commonly seen within the speciality
• Psychological distress, anxiety and depression
• Health promotion including lifestyle choices
• The wider network support for patients and their families
• Broader public health issues relevant to their area of practice

The Advanced Clinical Nurse Specialist will teach, advise and coach patient/client/carers about their condition, treatment options and health/lifestyle activities.

Co-ordination of Care, Referral, Admission and Discharge

• Plan, deliver and/or co-ordinate care utilising highly specialist knowledge
• Authority to admit and discharge from speciality area, depending on patient need and relevant legislation. This includes referral to a range of appropriate health and social care professionals and agencies. The Advanced Clinical Nurse Specialist may receive referrals directly or via the MDT team
• Provide advice to other health and social care professionals which may inform admission/discharge, planning or referral

Expert Specialist Resource

• Provides specialist advice and support for patients throughout the care pathway
• Acts as an expert clinical advisor for colleagues across a range of settings
• Acts as a resource or educator to others
• Is a key member of the wider MDT, contributing to case management presentations and clinical management decisions

Facilitation of Learning

• In addition to the competencies for Facilitation of Learning for Level 7 Advanced Practitioners set out in the NES NMaHP Development Framework,^[21] the Advanced Clinical Nurse Specialist will lead and/or contribute to the development and delivery of specialist education programmes

Evidence, Research and Development

In addition to the competencies for Evidence, Research and Development for Level 7 Advanced Practitioners set out in the NES NMaHP Development Framework,^[22] the Advanced Clinical Nurse Specialist:

• Will participate and collaborate in research and audit programmes related to the speciality
• May contribute to and collaborate in specific health service research

Leadership

In addition to the competencies for Leadership for Level 7 Advanced Practitioners set out in the NES NMaHP Development Framework,^[23] the Advanced Clinical Nurse Specialist:

• Will act as an advocate for patients
• Will act as a role model for junior staff and other members of the MDT
• May lead a clinical nursing team