INTENSIVE AND CRITICAL CARE NURSING 305

gration of art, science, intuition, personal knowledge and the interpretation of perceptual cues. I believe that nursing practice is at this end of the continuum; that it is context dependent and complex.

Tools that attempt to measure competency from the more simplistic perspective tend to be reductionist in approach and are almost insulting to the critical care nurse’s knowledge and skill, through their view of what competency is. If nursing practice is a complex phe- nomena then appropriate processes need to be used to access, understand and improve it.

Clinical supervision using Chris John’s model of guided reflection is presented as one such approach to understanding the nature of competency and how to improve it. This approach is used within the context of both group and individual supervision. Through using this model the realities of practice are acknowledged, the factors influencing practice are identified and the frustrations evident to the practitioner dismantled.

remain at the ‘bedside’ in order to promote and enhance innovations in care is increasingly being iden- tified and acknowledged (UKCC 1990, ENB 1992). This paper explores the history of and the likely implications fo; critical care nursing practice of the ENB framework and the Higher Award. It will argue that the nursing care of people with life threatening problems and their families is an extremely complex activity, requiring advanced knowledge and expert practice skills, and that consequently the creation of educational and practice development opportunities, such as those that the ENB framework and Higher Award potentially offer, are vital for high quality patient care.

The paper will open with an exploration of the key concepts and values enshrined in the framework and Higher Award. A brief resum6 of the history of these developments and the rationale for their adoption will follow. Drawing extensively from the recent British, North American and Australian literature, searching

Such a model recognises all four ways of knowing cen- questions will be posed regarding the universality of tral to nursing, and empowers nurses to become more access, academic recognition, other alternatives to effective in their practice. meeting the same ends, the implications for managers

and marketability of these developments to nurses and others. Finally some attempt will be made to evaluate he

APL/APELi are we achieving equity? ENB framework and the higher Award in the light of

Carol Haigh APL Co-ordinator, Lancashire College empowering critical care nurses and nursing.

of Nursing and Health Studies, UK References In order to discuss how well we are achieving equity via APL/APEL processes it is necessary to consider the

ENB 1992 Framework for continuing professional education. London. ENB

various myths that have sprung up around the AF’L concept.

Myth 1: APL is un easy o,btion - it is my contention that APL is not an easy way out of study as examination of an Cost benefit adysis in intensive care outline portfolio will show. Mike Proctor Nurse Manager, Intensive Care, York,

Myth 2: how much credit you get depad.s upon who you talk UK to- for an APL system to be academically credible as rig- orous system must be in place for the assessment of

The financial limits imposed on health care have been

portfolios. brought increasingly in to focus during the past few

Myth 3: ?&sing APL is a ks credible option than completing years. Intensive therapy is an expensive resource and it

study-APL can be shown to be as credible (if not more is anticipated that in the future the benefit of this

so) than traditional study. therapy will have to be proved in relation to particular

Myth 4: credit exemption is something fm nothing - this patient groups rather than assumed. This paper

will concentrate upon the notion of ‘tariffing’ and will describes how an intensive care unit in York has begun

examine the processes behind the tariffing of courses. to assess the cost/benefit of the service they offer. This will be presented in two sections:

It is hoped that by consideration and discussion of these factors the question of APL and equity will be resolved.

Evaluating the ENB framework and the higher

Fw,, erson Lecturer in Nursing, IANE Royal College of Nursing, London, UK

1. Assessing the cost. The elements of the total cost of intensive care will be identified and the move towards using a modified Therapeutic Inter- vention Scoring System to identify cost per case will be described.

2. Assessing the benefits. The protocol and initial results of an ‘outcome of intensive care’ study will be summarised. The system in operation in York for assessine cost/benefit is in its infancv and is far

Historically, nurses wishing to advance their careers from perfect, however, it does represent a first step have had to choose between education and manage- towards an acknowledgement of the reality of ment, however, a need for advanced practitioners to health care finances in 1994 and beyond and has