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

Annex K Distinguishing Between Levels 6 and 7: Case Studies of the roles of Clinical Nurse Specialist/Advanced Clinical Nurse Specialist and Senior Nurse Practitioner/Advanced Nurse Practitioner within MDTs

CNS and ACNS roles in the Tissue Viability Service in NHS Lanarkshire^[32]

The Tissue Viability Service offers specialist advice to health care practitioners and provides education on pressure ulcer prevention and wound management. The service has Level 6 and Level 7 practitioners.

Level 6 Tissue Viability Specialist Nurse (TVNS)

The TVNS will independently receive referrals and work with a range of practitioners – medical staff, nursing staff, care home managers and AHPs. This may include the provision of specialist, evidence based advice to staff for moderate to complex wounds, and advising on the use of specialist equipment. The TVNS will review data from a number of sources to identify areas of concern and improvement. They will work collaboratively with key stakeholders in the development and implementation of best practice. The TVNS also works in collaboration with the Patient Information Team to promote self-care. The TVNS will implement programmes of education for staff, from support workers to junior medical staff. Educated to degree level, Nurse Specialists undertake educational preparation – from accredited modules to academic level 10 (Hons) modules on Tissue Viability practice. They have specialist knowledge and skills which enable them to work autonomously and exercise professional judgement.

Level 7 Lead/Senior Tissue Viability Nurse Specialist (LTVNS)

The Level 7 role leads the service and has managerial and professional leadership responsibility for Tissue Viability Nurses Specialists and provides professional support to the Clinical Nurse Advisor. Nurse Specialists will seek support, clinical advice and expert clinical practice from the LTVNS for the highly complex wound care of patients or on issues relating to wound management and adult support and protection. The LTVNS acts as a specialist advisor to the wound formulary group, reviewing best evidence and practice and providing advice. The LTVNS will lead quality improvement programmes in line with local improvement action plans. They assist in determining best outcomes and work collaboratively with teams in the development and delivery of tests of change. This in turn informs the design, delivery and service specification of the overarching service. The LTVNS seeks innovative models of service delivery – such as the use of digital solutions. Educated to SCQF level 11 (master's level) with specialist modules on their clinical areas of expertise, the LTVNS designs and delivers programmes of education to staff across the MDT and in Higher education institutions.

ENP and ANP roles in the Emergency Department^[33]

Within Emergency Departments (EDs) and Minor Injury Units (MIUs) there are nurses who independently manage patients at Level 6 Senior Practitioner (Emergency Nurse Practitioners - ENPs) and at Level 7 Advanced Practitioner (Advanced Nurse Practitioners - ANPs).

Level 6 Emergency Nurse Practitioners

ENPs train by undertaking academically accredited 'ENP' education at Scottish Credit and Qualifications Framework (SCQF) level 10 (i.e. honours level). ENPs have a detailed practical knowledge and critical understanding of a broad range of minor injuries which allows them to assess, manage and deliver care to a large number of patients attending EDs. In practice, patients are triaged by ED staff and minor injuries streamed to ENPs for assessment, diagnosis and treatment. Medications are often supplied from a small collection of Patient Group Directions and the ENP will manage patients from the minor injuries stream autonomously. Should the ENP encounter any difficulty with assessment and diagnosis then senior staff (medical or ANPs) are available to assist.

Level 7 Advanced Nurse Practitioners

In contrast, within nurse-led MIUs, ANPs are required rather than ENPs. The workload should in theory also be patients with minor injuries; however, there is no alternative stream. All patients attending the MIU are assessed and initially managed by an ANP regardless of the presenting complaint, including illness and as yet unidentified medical emergencies. There is often no onsite medical cover and in many centres the MIU ANP has responsibility to respond to deteriorating patients elsewhere in the hospital. Consequently their scope of practice is significantly wider and more complex. MIU ANPs complete a master's level (SCQF level 11) qualification in advanced practice to broaden and deepen their knowledge. All ANPs are prescribers. MIU ANPs therefore offer an advanced generalist approach at Level 7, as well as a higher level of specialist skills compared with the Level 6 ENP. Their practice is characterised by a higher level of decision making and responsibility based on extensive, detailed and critical knowledge of their broader field of practice.