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The Advanced Nurse Practitioner

The journal for members of ACAP

Produced in association with Skills4Nurses

CAPAcute Care Advanced Practitioners

Issue 1December 2010

Scotland Leading the way for Acute Care Practitioners

ACAP Scotland is a new and exciting network that will enable all acute care practitioners to register asmembers allowing provision for bi annual forum events. These events will host guest speakers, workshops, master classes and the opportunity for discussion on topical subjects. Most importantly the forumwill facilitate educational and professional development.

Members will also be entitled to quarterly newsletters and unlimited ACAP web site access

Acute care practitioners in Scotland have never had until now:

✑ The privilege of having an arena to showcase areas of good practice, ✑ The opportunity to bench mark other practices throughout Scotland, ✑ A national opportunity for education ✑ And most importantly have their voice heard.

Now with the onset of ACAP forum Scotland all this will be possible.

Mission StatementThe purpose of the forum is to promote and develop the professional role of the acute care advancednurse practitioner in partnership with stakeholders, in order to advance the quality of care delivered topatients and clients.

ACAP Scotland Leading the way

Support given by:AANPECS MEN

Executive committee members:Elaine HeadleyJulie SmithEdnamay SinclairAnne ScottHazel BeveridgeAgnes AllanDavid WatsonLilian RedmanFiona BuchanPeter ThomsomStephen MorrisonLynne Demeries

Non executive committee Members:Mr. Eddie DochertyDr. Mark CooperMr. Douglas AllanMs .Janet Corcoran

2 ACAP


• www.acapscotland.org •

NEWS....NEWS....NEWS....

Word of MouthAlthough still in the very early stagesACAP is already linking advanced practitioners from Aberdeen to Dumfriesand Galloway. The interest has beenincredible and is continuing to growdaily. ACAP is also reaching to advancepractitioners in primary care and mental health. We are continuing to look for avenues to access practitionersfurther a field. You can help in this area. Let all your colleagues know about ACAP and tell both Julie andElaine of anyone you think would beinterested in becoming members.

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A collaborationACAP is now working more closely with the HEI’s to provide a collaborativeventure between the practitioners, leadsand educationalists. This is all extremelyimportant to keep all links open toensure success in the development in advance practice.

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ProfessionalDevelopmentACAP Scotland will host bi annualforum events. As a delegate you will be able to participate in pre– arrangedmaster classes combining a clinical and seminar component as well as the

opportunity to participate in clinicalOSCE’S, and as part of your professional development you will beissued with a certificate of attendance.These certificates can help build yourprofessional portfolio.

You can either choose to have a paper copy issued or have an electronicversion sent by e-mail– which can theneasily be uploaded onto your eksfsite.—The choice is yours.

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Sharing of BestPracticeACAP Scotland promotes sharing ofbest practice, we recognise that there is a wealth of information and servicedevelopments going on throughoutScotland. Take this opportunity to sharewith fellow ACAPs. We would love tohear about anything that is going on inyour area; any interesting case studies,research or any developments.

At ACAP we welcome both novice andexperienced writers. We are proud topromote and encourage publicationsfrom Advanced Practitioners. All articlesare peer reviewed.

If you would like any of your articles or information considered for publicationin the ACAP journal please contact:

[email protected] [email protected]

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We would like to thank Felicity Garvie,University of Dundee for proof readingthis journal and also Jackie BeastonResuscitation Officer, Victoria HospitalKirkcaldy who was the author of theResus Guidelines article.

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ACAP 3



Copyright Statement : Subject to all articles submitted to and agreed for publication in The Advanced Nurse Practitioner: The author assignsto The Advanced Nurse Practitioner all copyright in and to the article and all rights therein. This will include but notlimited to the right to publish, re-publish, transmit, sell, distribute and otherwise use the article in whole or in part, inelectronic and print editions of the journal and in authorized works throughout the world, in all languages and in allmedia of expression now known or later developed, and to authorize or permit others to do so.

To receive a copy of future ACAP publications please email [email protected] or [email protected]

Elaine HeadleyRGN, DipN, Ba, PGD (Acutely Unwell Adult)Co-lead of ACAPSenior charge nurse with the HECTservice in NHS Lanarkshire since 2004. ALERT instructor. Lecturer throughoutUK & Ireland Background of A&E, ITU,Orthopaedics, Renal/medical, Emergency Receivingand initiated bed management and discharge planningservices in Monklands Hospital. Currently studying amaster PGcert in clinical leadership

Julie SmithRGN, BSc Specialist Nursing – Cardiac. Co Lead of ACAP.Background: Advanced NursePractitioner with the Hospital at NightTeam/ Cardiology in NHS Ayrshire & Arran. ALS instructor. Background of cardiology, Cardiothoracic ITU/HDU, with the latter 5years in cardiothoracic as the HDU ward manager. I am currently studying for MSc in Advanced PracticeThis is an exciting time for Advanced Practitioners and Iam delighted to welcome you to the forum, we hope youget a lot from it

Peter ThomsonHigher Diploma of Adult Nursing, Clinical Decision Making in Critical Care (BSc Hons level) Current position: Training as anAdvanced Nurse Practitioner in Critical Care within NHS LothianBackground: Predominantly IntensiveCare and High Dependency areas where he has worked the most over the past ten years. Pete has also worked within Neurosciences and theEmergency Department and has experience of retrievalservices and remote area nursing in Australia and New Zealand.Current studies: MSc in Advanced Nursing Practice (Critical Care)ACAP role/link: Committee member

David McDermottQualifications:MCP, MCSA, MCTS MSSQLBackground: IT Engineer, working fulltime with local authority FreelanceWebsite and Database designer using.NET, PHP, MY SQL and Microsoft SQL ACAP role: Website design

Lynn DeremiensQualifications: RGN, RN, BSc inadvanced Practice, IndependentPrescriberCurrent position: ANP in primarycare in Lanark, focus on minor illnessesACAP committee memberBackground: ICU, Burns, plastics and oromaxillaryfacial, Cardio thoracic in Los Angeles USA, Cardiac NS & Cardiac rehab NS in the emergency dept, inAlberta Canada. NHS 24 (UK), and primary careDelighted to be invited to join ACAP as the primary care link, I think this is a very worthwhile and necessaryventure. About me - I enjoy good wine, good fun andgood company.

Steven MorrisonRN, Dip (HE), BN, NIP, ALS (I), MSc Advanced Practice (pending).Current position: Acute Care ANP(H@N) - NHS Forth Valley. Lecturer inAdvanced Practice – GlasgowCaledonian University Background: Much of clinical career spent in CCU andMICU. ALS Instructor and spent some time working asan RTO. Proactive in the development & implementation of ACS management programmes.Involved in education of nurses, paramedics, AHPs and doctors in various settings. Free lance lecturerthroughout the UK. 2 year part time secondment to GCU involved in a range of activities and AP modules.H@N ANP for 3 - 4 years.

Current studies: Due to complete MSc in AdvancedPractice at the end of 2010. Recent research “An exploration of the experiences of H@N ANPsFuture Plans: Consolidate knowledge gained throughMSc and Uni secondment before undertaking a clinical doctorateACAP role/link: Steering Group / Committee Member & Peer reviewer

Hazel BeveridgeCurrent position: Senior Nurse Practitioner, Hospital at Night,LothianBackground: Critical CareCurrent studies: Advanced Patient History Taking and Clinical Examination (Masters Level)ACAP role/link: Assistant Treasurer


Staff Profiles

4 ACAP

Ednamay SinclairRGN, RM Senior Charge Nurse HECT in NHS LanarkshireACAP committee memberALS & ALERT instructor, completedRAM, NMP, 1st line middle managementBackground: General surgical,General medicine, night sister in Edinburgh Royal, Day sister in neurological surgery, Ward manager Acute receiving, Edinburgh Western,

Mr Eddie Docherty RN, DipN(Lond), BA, PGD(Critical Care), MScNurse Consultant Acutely Unwell AdultsNHS Ayrshire and Arran. Eddie Dochertyis Nurse Consultant for Acutely UnwellAdults at NHS Ayrshire and Arran. Part of his remit includes responsibility for thedevelopment of advanced nurse practitioners throughout the acute areas, including Hospital at Night and Emergency Response Teams. He is a jointappointee with the University of the West of Scotland.Previous posts include Intensive Care Unit ChargeNurse, Critical Care Unit ward manager and SeniorNurse with NHS Lanarkshire, as well as HECT (Hospitalat Night) charge nurse and clinical co-ordinator.

Lilian RedmanCurrently work as nurse practitioner for H@N in Borders general since Feb 2007. ACAP Scotland - SecretaryQualifications: RGN, BSc. With applied health studies. Independentnurse prescriberBackground: Orthopaedic, Gynaecology, Endoscopy,Haematology,Medicine, Urology. Night Sister and Bed managerPlanned Studies: Masters In Advanced Practice. I have been appointed the secretary for ACAP this year and I am looking forward to fulfilling this role. I think ACAP is a name that I hope will be well known to Advanced Practitioners throughout Scotland, supporting, teaching, educating and enabling otherpractitioners like myself to meet friends, network and discuss hot topics.Currently studying: Masters in Advanced Practice.

David WatsonRGN, Ba, SPQ ( critical care), MScBackground: Renal, EmergencyReceiving, Critical Care ResuscitationOfficer - ALS & EPLS instructorALERT instructorFreelance lecturerACAP committee memberDue to commence professional doctrine Glasgow Caledonian University.

Dr Mark CooperPhD, FHEA, RNCurrent position: Lecturer-Practitioner(Advanced Practice), NHS GreaterGlasgow & ClydeBackground: Mark has a clinical background in Emergency Nursingand in particular Minor Injuries. He teaches and is a module leader on a number of courses aimed at Senior and AdvancedPractitioners. Mark has also been involved with developing the Scottish Government’s AdvancedPractice Toolkit and he chairs the West of ScotlandAdvanced Practice Working Group and the NHSGG&CAdvanced Practice Group. He is involved in researcharound Advanced Practice and also practices as anEmergency Nurse Practitioner each week. He is also anHonorary Lecturer at the University of Glasgow, anAssociate Lecturer at Glasgow Caledonian Universityand is on the Editorial Board Member for InternationalEmergency Nursing.

Current studies: The Evolution of the Role of theEmergency Nurse Practitioner: a longitudinal studyMeasuring the performance of ENP services - the development of a performance dashboardACAP role/link: Non-executive member

Agnes Allan Current Position: Advanced NursePractitioner for the Hospital @ NightTeam in Ayr and Crosshouse Hospitals,Ayrshire and Arran Acute HealthcareTrust. ACAP Committee memberQualifications: Dip HE Adult Nursing,BSc Prof Development, PG CertAdvanced Clinical Practice, Nurse IndependentPrescriber.Background: Worked within the Health Service for a total of 27yrs, Accident & Emergency, Surgical, Care of Elderly.

Fiona Buchan Treasurer at ACAPNurse practitioner within the H@Nteam at the Borders General HospitalBackground of HDU, Surgical and toxicology assessment, Acute Admissions

Excited about being involved with ACAP Scotland. I think this is an extremely important direction for ANP’sthroughout Scotland to network, share best practice,develop educational skills and ultimately progress theadvance practice role Currently studying: Masters in Advanced Practice.


ACAP 5

6 ACAP

Recognition ofAcutely UnwellAdults IMPACT-GlasgowCaledonianUniversitySince 2006 Glasgow Caledonian University has offereda double module specifically for advanced care nursepractitioners. The RAM module (recognition andManagement of Acutely Unwell Adults is now offered at masters level and can be undertaken as stand aloneor as part of an MSc in advanced nursing. This moduleis delivered in the NHS by a team of senior nursing andmedical staff. The module makes use of a variety ofteaching methods including tutorials, problem basedlearning and simulation. As part of the module the students undertake the Federation of Royal MedicalColleges and the Royal College of Anaesthetics IllMedical Patients Acute Care and Treatment ( IMPACT)course. This was a course which was only opened tomedical staff until the first cohort of RAM studentsundertook it in 2006. Students are also taught at theScottish Clinical Simulation Centre at the new ForthValley Royal Hospital. This course is also still offered at honours level

For more information contact:www.nhsggc.org.ukadvancedpractice

HECT & CCNP’sThe Hospital Emergency Care Team (HECT) inLanarkshire is now in it's 6th year. This pioneeringservice, which has been mirrored by many NHSTrusts now provides a robust H@N service with asupportive H@D service. The HECT nurses are nowindependent nurse prescribers, continuing to delivera high standard of care to their patients.

September this year sees the first critical careadvanced nurse practitioners qualifying inLanarkshire. These highly trained nurses gaining aMSc .with a competency based learning approach,will now undertake many roles that were once pertinent to the anaesthetic staff. ACAP wishes them the very best in their future careers

The legal side of nursing

ACAP Scotland are all too aware that as more andmore nurses work autonomously, they are more likelyto fall victim to the increased risk of litigation shouldthings go wrong.

Although we are all highly trained and highly skilledpractitioners where do we stand should we have a lapse of concentration or miss something that perhaps we shouldn’t have. There are increasingpressures on the modern nurse and this combinedwith an ever increasing sick society leaves manyANP’s feeling very vulnerable. Getting both the RCN and the NMC point of view on how we are protected may be something worth looking into.

Do we need more support, more education, is theeducation available the right for us?

Should we have a different approach to make ourpatient care as safe as it possibly can be?

All these questions and more should be up for discussion.

ACAP Scotland is the place to air your concerns and get answers.

ACAP 7

The following discusses the implementationand operational factors of the EmergencyResponse Team (ERT).

This team will act as a ‘rescue’ service, in the absenceof the patient’s own team, or at that teams request. It isnot tasked to take over the general management of thepatient. Any ERT interventions will be fed back to theparent team, including the out of hours period. The ERTshould liaise with the specialist doctor for any patient inthe out of hours period, prior to escalation to consultant.This team would work Monday to Sunday 08:30- 21:00and follow the operation factors of the ERT. Additionallythe team will liaise directly with the H@N team, handingover their role and function to H@N at 21:00 hr. andagain at 08:30 thus allowing a 24 hour /7 days a weekresponse to the acutely unwell adult.

Team Composition:The team will consist of an advanced nurse practitioner and a member of the medical staff. It hasbeen discussed that resuscitation officers, as well asstaff from ITU, CCU, MHDU and SHDU will also beincluded as able. A training package has been out into place to support additional members.

Anaesthetic call- out; the ERT criteria will not include anasethetic response initially. On arrival of theemergency response team the anaesthetist will bepaged at the discretion of the team members.

Team Activation:There will be a tiered level of response for all standardward patients and all high dependency patients. Withslightly altered emergency response call-out criteriaaccording to high dependency areas. This team will be activated in the absence, unavailability or request of the patient’s own team.

During Monday to Friday 9amto 5pm, following emergency response intervention a handover back to the patient’s own team will always take place. For the out of hours period, escalation to the on-call consultantwill be made by the specialist doctor. For example, if asurgical patient requires an intervention, the member willdeal with the appropriate on site surgical doctor, prior tocontacting the consultant. Discussion about consultantinvolvement should include failure to stabilize the patient,

need for transfer to higher level of care, i.e. HDU, andmajor alteration to the patient’s current managementplan, including discontinuation of own consultant’s treatment plan.

The Emergency Response Teams will respond to cardiac arrest calls.Identification and ‘Tagging’ of unwell patients:Three times per day the team will be tasked with a roving mandate, to walk round all clinical areas to identify and tag any patients who are considered at risk, Once identified and reviewed the team will ‘tag’ thepatient onto the virtual ward used within the electronicdata base system. During these ‘rounds’ patients identified previously will be reviewed and their progress logged on the virtual ward.

Once during the day and once during the night the team should liaise with ITU staff to flag any potentialpatients that may become acutely unwell or requireanaesthetic support. As well as actively identifyingpatients the team should respond to any patients immediately at risk of deterioration.

The team would be directly responsible to a tripartitemanagement group of:-

Consultant anaesthetist—Paul WilsonConsultant Physician- Vincent McAuley/ Neil Mara.Consultant Nurse- Acutely Unwell Adult- Eddie Docherty.

Implementation of ERT-Aryshire & ArranEddie Docherty- Nurse Consultant- Acutely Unwell Adult.

8 ACAP

H@N and Nurse Prescribing Hospital at Night Advanced Nurse Practitioners (ANP)emerged in Ayrshire & Arran in 2006, following the implementation of the European Working Time Directive(EWTD) and subsequent reduction in junior doctors’ hours.ANPs act as first responders to acutely unwell adults withMEWS scores less than 6, inherent in this role is the ability todiagnose and prescribe treatment that includes medication.Initially, several Patient Group Directives were in place i.e.oxygen therapy, paracetamol and intravenous fluids, allowingANPs the power to safely administer first line treatment tounwell adults, within agreed parameters.

All ANPs are required to undertake a 6 month IndependentNurse Prescribing course at university, authorising the nurseprescriber to make a clinical examination, diagnosis and subsequently prescribe as appropriate.

For a number of reasons it was 18 months between the firstprescribers qualifying to being permitted to utilise this skill,which led to some trepidation. These fears were taken intoaccount and a traffic light system was devised by the NurseConsultant for Acutely Unwell Adults, (as shown opposite). The reasons for a traffic light system were twofold, firstly tosafeguard patients, and secondly to safeguard ANPs andallow them to adjust to prescribing practice.

“Despite still having some anxieties, using a trafficlight system has helped immensely , in allowing usto slowly become more adjusted to prescribing..”

Prescribing is usually the domain of the medical staff, and as such we as nurses were initially concerned that we maywrongly or inappropriately prescribe, however using the traffic light system allowed ANPs to gain confidence in bothprescribing and carrying out clinical examinations, includingmaking diagnosis and differential diagnosis.

Four months after the traffic light system was employed it was determined that we as ANPs could act as independentprescribers, utilising the BNF.

It has always been explicitly pointed out to us that if we arenot yet comfortable in doing so, we could continue to use the initial traffic light system. Currently the H@N team prescribe within their scope of experience and to agreed hospital policies, in line with clinical governance. ANP nurseprescribers are currently required to produce 10 case notereviews including prescribing rationale for nurse consultantreview.

In conclusion, we as a team would all agree that prescribingfor patients has had many advantages, the first and mostimportant advantage is that patients no longer need to waiton busy medical staff for treatment, analgesia, anti-emetics,IV fluids are all prescribed when requested. The secondadvantage is that prescribing has allowed us to deliver holistic care when assessing patients. Prescribing is carriedout in a logical, deductive manner, taking into account thediagnosis, the characteristics of the patient, and a considered balance of the benefits and risks involved.

Despite still having some anxieties when prescribing, the traffic light system has helped immensely, in allowing us toslowly become accustomed to prescribing, creating a saferenvironment for both patients and nurse prescribers.

A team would all agree that prescribing for patients has hadmany advantages, the first and most important advantage isthat patients no longer need to wait on busy medical staff fortreatment, analgesia, anti-emetics, IV fluids are all prescribedwhen requested. The second advantage is that prescribinghas allowed us to deliver holistic care when assessingpatients. Prescribing is carried out in a logical, deductivemanner, taking into account the diagnosis, the characteristicsof the patient, and a considered balance of the benefits andrisks involved.

Despite still having some anxieties when prescribing, the traffic light system has helped immensely, in allowing us toslowly become accustomed to prescribing, creating a saferenvironment for both patients and nurse prescribers.

Independent Nurse Prescribing - Ayrshire and Arran by Julie Smith

TRAFFIC LIGHT SYSTEM - devised by Mr. Eddie Docherty - Consultant Nurse, Ayrshire & Arran

GREEN Must take e.g of drugsclinical history – lactulose, senna,

IV fluids, loperamide

AMBER History and e.g salbutamol,clinical examination atrovent, GTN,

DF118,cyclizine

RED Full examination e.g cardiac arrestand must refer to drugs, lorazepam,medical staff. For narcan, morphine,one off use only prednisilone

ACAP 9

What you can expect to see in future editions of the ACAP journalThe ACAP journal will be produced quarterly. We aim to cater to ACAP members needs and requirements, so we would like to hear what you would like published in the journal. Please send your requests via the web site:www.acapscotland.org

EDITION ARTICLES

March 2011 Mental Health PractitionersInfection ControlLegal IssuesHead Injury Guidelines

June 2011 Legal issuesPrimary Care IssuesCardiovascular ExaminationSepsis

Sept 2011 Legal IssuesNeuro ExaminationENT Stroke thrombolysis

Dec 2011 Legal IssuesRespiratory ExaminationBiPaP/ CPAPABG Interpretation

ACAP Conference :June 24th 2011ACAP are delighted to have secured a booking for their first forum conference at the new MedicalEducation Centre (METC) at Kirklands in Bothwell,Lanarkshire. This venue, which opened in May 2010, will provide ACAP with all the facilities required for ourfirst Scotland-wide event. Hosting state-of-the-art simulation and training facilities coupled with well-appointed lecture theatre and syndicate rooms, it isexactly what ACAP was looking for.

The lecture theatre is equipped with a 4-metre projectionscreen, so regardless of your seating area you will not miss anything. There are radio and hand-held microphones to accommodate audience interaction.Touch-screen panels offer effortless access to operatethe multimedia equipment. The syndicate rooms areequipped with Smartboard projection facilities; in addition, the main conference room has a large drop-down projection screen and multi-media projector.

The centre is a collaboratively funded venture by NHS Lanarkshire and the University of Glasgow, in association with NHS Education for Scotland (NES). It isdesigned to enable competency-based learning for awide range of users including medics, medical students,nurses and allied health professionals. This provision will enable ACAP to showcase master classes, facilitatenetworking and benchmarking from regions throughout

Scotland, as well as enhance educational development,which ultimately will smooth the progress of improvement in patient care through growth inadvanced practice.

These sentiments were endorsed at the opening ofMETC, when Ken Corsar, Chair of NHS Lanarkshire, said “Thanks to these facilities, we can offer our clinicalstaff excellent educational and development opportuni-ties which will be of great benefit to patients.”

Tim Davies, Chief Executive, NHS Lanarkshire

Hazel Scott, Director of Dept. of Medical Education,NHS Lanarkshire

Nicola Sturgeon MSP, Cabinet Secretary for Health and Wellbeing

Ken Corsar, Chair, NHS Lanarkshire.

The centre is easily accessible from all areas within central Scotland. Situated just off the M8, it is ideallylocated on the route from Glasgow to Edinburgh.

See more of the venue at - www.metc.scot.nhs.uk

Bothwell village houses one ofthe area’s most prestigioushotels, which is only a short drive from the venue. This would make the ideal stopoverfor those who need to travel.


10 ACAP

IntroductionAs nursing practices continue toexpand, develop and become moreadvanced, practitioners need to keepabreast of their professional and legalobligations to the patients under theircare. An expression of these roles hasfound some nurses undertaking theresponsibility of verification of death. This article will discuss and hopefullyclarify some of the issues that surroundnurses who hold the authority to verifythe expected death of their patients.Additionally this article will open for discussion some of the ambiguity thatsurrounds nurses who, while not verifying death do issue Do Not AttemptResuscitation (DNAR) orders on theirpatients.

This article will not discuss in detail therole of the doctor or the legislation thatsurrounds certification of death, otherthan when it impacts on the nursing profession.

LegislationLike so many of the role changes ofmodern nursing and developments by Modernising Medical Careers (MMC 2003) many of the traditionallymedical roles are now undertaken by experienced or advanced nursepractitioners. Verifying the expecteddeath of a patient is one of those roles.Dimond (2004) identified the need toallow nurses to provide a continuum ofcare for the dying patient and their families when death finally occurred.This service to the dying patient wasparticularly problematic when thepatient died at home or when Out OfHour’s general practitioner (GP) servicewent live. There could very often beseveral hours that would pass until theGP could free up the time to verify andcertify the death, issuing the medicalcertificate of cause of death(MCCD/death certificate). The conceptof verifying expected death is not a new one. The RCN (1996) providedguidance stating registered nurses will have the authority to:

• Verify death• Notify relatives• Arrange last offices•Arrange for the removal of the

deceased to the mortuary

In 2008, the RCN again recognised theneed that nurses should be trained in

verifying expected deaths when theyoccur, to lessen the strain on familiesand staff and improve quality of care.

So what is the legislation that surroundsnurses verifying the expected death of a patient? The BMA (1999) stipulatedthat ‘there is no legal requirement formedical practitioners to attend to verifythat death has occurred, only to issuethe death certificate stating the cause of death’. However, it is a legal requirement that only doctors can complete and issue certificates ofdeath. The aforesaid doctor must alsohave attended the patient during theirillness stating to the best of his/herknowledge and belief the cause ofdeath (Birth and Death RegistrationAct 1953, section 22).

For clarity a definition of expected death is ‘…. Where a patient’s demise is anticipated in the near future and thedoctor has seen the patient within thelast 14 days before death’ (the HomeOffice 1971). Although this definition isdated it is still currently used in practiceand is relevant. Nurses in this respectmust be very aware that they are onlygoing to verify the death of patients whoare expected to die. In contrast , wherethe death of patients is unexpected, i.e.they die without a DNAR order in placeand they die without prior discussionand agreement with the medical staff, all need to have active resuscitationattempts carried out. If these efforts are unsuccessful, verification must becarried out by the medical practitionerresponsible for the patient’s care.

There has been much media publicitysurrounding expected and unexpecteddeath. Following the Shipman Inquiry(2004) the Parliamentary SelectCommittee Affairs investigated the failings that surrounded certification of death and agreed to action reforms of the process to necessitate adequatesafeguards for this. However the legislation did not alter nurses beingable to verify expected deaths.

Many health boards and NHS Trustshave their own policies of good practicein place which I have compiled to reflectrecommendations of patients who wouldbe unsuitable for nurses to verify deathon. Some of these are included in Box 1.

A point for nurses to consider is that ofpaediatrics. Many policies recommendthat nurses do not do this on patientsunder the age of 18-years old. Howeverit should be remembered that this is just a recommendation. So long as thedeath is expected, then nurse canagree to verify it. Many nurses who work in children’s hospice care will findthemselves in this situation. While thelegislation does not stipulate an agelimit, many local policies and employers may.

Clinical AssessmentIt has to be remembered that the dying process can be long and slow.Nurses verifying death must beabsolutely sure and competent in theirown clinical skills to ascertain that deathhas actually occurred. Dr. Greenvillestipulated at the Shipman Inquiry (2005)that ‘you need to be very certain that theheart has really stopped, that it is notbeating very, very slowly and very, veryslightly. That respiration really hasstopped, that you are not missing veryslow, very shallow respirations’

I have compiled a clinical assessmentstoolbox that could be used to carry outthe necessary assessment to facilitatenurses verifying expected deaths: seeBox 2.

BOX 1

• Sudden or unexpected death

• Where there is an allegation/suspicion of medical or nursing mishap

• A death within 24hrs of discharge from hospital UNLESS it is documented in patients notes that death is expected

• Death due to an accident or occupational risk

• Within 7 days of surgical intervention UNLESS it is documented in patients notes that death is expected

• In cases of expected death but where the death occurs in an unexpected manner or unexpected circumstances

• In cases of expected death but where there is no documentation entered in the patients notes

• If the deceased had not been seen by a GP for more than 14 days prior to thedeath

• Paediatric deaths

• Death due to personal neglect or neglect by others

• Suicide (Where the deceased may have contributed to his or her own death)

• An unidentified person

• Death that has followed an untoward incident, fall or drug error. (No time limit from the event to the death)

• Any unclear reason for death

Verification of Expected DeathElaine Headley - Senior Charge Nurse Hospital Emergency Care Team, NHS Lanarkshire

ACAP 11

Confirmation of the absence of thesesigns should be clearly documented,dated and signed in the patient’s medical notes. The time of death should also be recorded at this point(NMC 2009). If there is any doubt or discrepancy over the clinical findingsthen the nurse should repeat them again after a few minutes, or seekadvice from another competent practitioner.

Nurses deciding on resuscitationOver recent years there has been development in who can issue Do NotAttempt Resuscitation (DNAR) orders on patients. The NMC, British MedicalAssociation (BMA), Royal College ofNursing (RCN) and ResuscitationCouncil, in a joint statement (2007),have all issued guidance on decisionsabout attempting to resuscitate patients.This guidance stipulates that theresponsibility for decision –making andCPR must always rest with the mostsenior clinician in charge of a patient/client’s care. It recognises that in themajority of cases this will be the registered medical practitioner. However changes in this area nowenable nurses, such as nurses whowork in palliative care and run a nurse-led service, to issue DNARorders. It is recommended that it is a senior nurse who has undertaken the appropriate training. Furthermore,whoever takes this responsibility wouldalso be subject to discussion andagreement. Recommendations requirethat robust policies and protocols are in place with no conflict to the NMCcode of professional conduct (NMC 2008). However, clarity should be sought on what is meant by appropriate training and what level of seniority the nurse has to hold?.These questions should be answered by the NMC, BMA, RCN and theResuscitation Council.

Ideally one would imagine that these elements would effectively beincorporated into a robust policy toensure a secure safety net for patient,families and nurses. I can personallyreflect the countless times that members of the medical profession are reluctant to place patients on DNAR, even although they are awarethat resuscitation would be futile. Thisreluctance, from my own experience, is evident from junior doctors to consultant level. Family members andfamily dynamics can carry a great dealof persuasive power for doctors to carryout pointless resuscitation on patients.As advocates for the patient, is this theright decision, are we acting in the bestinterest for those under our care, or arewe influenced by our emotions and thefeelings and wishes of others?

It is clear from the ambiguity that surrounds this advancement or change in nursing practice that moreclarity should be sought to avoid making the wrong decision on such a delicate matter.

Conclusion Verification of expected death is now becoming common practice formany experienced or advanced nursepractitioners. There is no legislation tostate that these nurses cannot carry-outthis procedure for their patient. It willprovide continuity of care at the end oflife and provide support for the familiesof the person who has just died. Thenurse is often best placed to carry outthis procedure, which can reduce thestrain by avoiding delays that can occurin waiting for medical staff to free uptime to verify the death. This in turn willimprove quality of care.

Ideally, allowing senior or advancednurse practitioners to place DNARorders on their dying patient would alsoprovide quality end of life care. However

there does appear to be a lack of clarity with regard to the level of seniority and appropriate trainingrequired to achieve this. This is clearly one area that should be up for consideration by all the governingprofessional bodies. Identify clearlywhat is required; make clearer the distinction between withdrawing treatment and withholding treatment,and when each of these elements wouldbe best placed in the care of the dyingpatient and their families.

References:

British Medical Association (1999)Confirmation and Certification of Death

The United Kingdom Parliament: SelectCommittee on Constitutional Affairs 8threport on Death Certification (2004).http://www.publications.parliament,uk

Dimond, B. (2004). The law and the certification, verification and registrationof death- British Journal of Nursing 13:8 480-481

Home Office (1971). Report of theCommittee on Death Certification andCoroners, Nov: CMND 4810

House of Commons Health Committee:Modernising Medical Career (2003)http://www.publication.parliament.uk[online] available [accessed] 3/11/10

Nursing and Midwifery Council (2008)Standards of conduct performance andethics for nurses and midwives,-http://nmc-uk.org [online] accessed[available] 3/11/2010

Nursing and Midwifery Council (2009).Record keeping guidance for nursesand midwives. http://www.nmc-uk.org[online] accessed [available] 3/11/2010

Resuscitation Council (2007). A JointStatement from the British MedicalAssociation, the Resuscitation Council(UK), and the Royal College of Nursinghttp://resuscouncil.org [online]accessed [available] 3/11/2010

Resuscitation (2008) Nursing andMidwifery Council (NMC) www.nmc-uk.org [online] available[accessed] 15/9/2010

The Shipman Inquiry (2005)http://www.the-shipman-inquiry.org.uk[online] available [accessed] 3/11/10

The UK Statute Law Database: Office ofPublic Sector Information (OPSI): Birthsand Deaths Registration (1953) c-22.http://www.statutelaw.gov.uk [online]available [accessed] 3/11/2010

BOX 2

• Absence of respiratory effort Look at the chest wall for movementListen to each lung area for 1 minute using stethoscope

• Absence of heart sounds Listen to the apex of the heart for 1 minute, using stethoscope

• Absence of carotid pulses Check for 1 minute

• No response to painful stimuli Sternal rub/pressure for 10 seconds

• Pupils fixed and dilated Check both eyes

• Death verified by: NameStatusDateTime of death

Background:For the last 2 years I have beenemployed in the role of a LecturerPractitioner between GlasgowCaledonian Univversity teachingadvanced practice modules, and theAcute Care Team of Forth Valley NHSworking as a H@N ANP. The role hasbeen extremely challenging but equallyinteresting and enlightening from aneducational perspective. This article isbased on personal experience but isalso a reflection of discussions in somerecent literature and follows on froma poster I presented at the AP

conference held in Ayr in June 2010.

Introduction:The Modernising Nursing Careers(MNC) documents map future careerstructures for nurses (Scottish ExecutiveHealth Department, 2006). It advocatesthe development of parallel careers forpractitioners by encouraging flexibilitywithin institutions, such as NHS boards& Higher Education Institutions (HEI’s),in order to facilitate such opportunitiesfor practitioners. This view wasendorsed by NHS Education Scotland(NES) who aim to inform the progressionof clinical education careers in Scotlandas part of the MNC agenda. They advocate both horizontal & verticalcareer opportunities for nurses & havehighlighted exemplar career pathways & models of employment. It is purportedthat such developments will benefit allstake holders; the practitioners, NHSboards, HEI’s but more importantlypatients (NES 2008).

The Development of LecturerPractitioner Roles:Nursing requires a flexible & responsiveworkforce. The education & develop-ment of this workforce requires learningin both clinical & academic settings.Nevertheless, career opportunities inclinical education have traditionallybeen ad hoc. Progression has oftenmeant leaving clinical practice. Similarly,individuals working within HEI’s havehad limited options in regard to clinicalcareers. The rationale for developinglecturer practitioner roles is that clinicaleducation career opportunities will beenhanced. It is believed that this willhave a positive impact on staff development & retention, the educational experience of practitioners,& ultimately enhance patient experiences (NES 2008).

Successes:Although a very challenging role theLecturer Practitioner role is not without

its successes. Being part of the education of nursing staff while beingclinically active certainly allows thefocuss to be on reducing any percievedtheory practice gap, given practitionerawareness of “coal face” issues.Additionally, practitioners can have a positive impact on how education and training is moved forward, from the inside, by influencing HEI agendasand brining a fresh outlook to HEI’s.

There are also a great many opportunities that allow individuals togain support to develop academicallyas well as professionally. This bringswith it the idea of career long learningopportunities as the institutions openpractitioners up to new & ongoingdevelopments, as well as researchexperiences & opportunities. Throughsupporting & encouraging staff in thiskind of collaborative practice educationrole, the lecturer practitioner role canenhance career framework goals as wellas helping maintain or improve patientcare.

Challenges:There are of course challenges in the role. It seems the success oftendepends on the self-motivation of individuals in the role. This brings with it the issue of getting the role balanceright as demands from both roles canprovide the feeling of being pulled intwo directions at once. This can alsobring questions of role commitment,potentilly leading to role ambiguity andlack of clarity. Together this can have a profound impact on the individualswork / life balance, which can effect apractitioners persoanl life and how wellthey are ready for the roles they areexpected to take on.

There can also be a percived lack offlexibility towards the practitiners withinthe roles, due to communicationbetween employers being limitied orless than effective; appraisal systemsneed to be combined rather than in isolation otherwise this contributes to the feeling of being pulled in two directions. In turn, such pressures canlead to practitioners feeling that they are showing a lack of flexibility towardsemployers and sometimes colleagues,due to dual role demands; this canpotentially cause conflict.

Being opened up to diverse opportunities and being in a position to maximise such opportunties whilegaining an understanding of HEI

structures and rules, at the same timeas being expected to maintain clinicalcontact and competance is very chal-lenging indeed! If, as has been mentioned, this is not managed effectively then there is clearly potentialfor job satisfaction to be decreased.

The Way Ahead:In order to debate the successes, challenges & indeed opportunities,there needs to be a range of openregional & national stakeholder events.Scoping exercises should be used toensure that practitioners are in the market for such roles in the first placeand where they are, practitioners needto seek ongoing commitment from allstakeholders in regard to providingopportunities such as NES’ exemplars.Further stakeholder collaboration isessential to increase the number ofposts and opportunities for practitioners,while ensuring ongoing and indeedincreased flexibility and support those in such dual roles. Wider use of dualroles and widespread publication of thebenefits to HEIs and practitioners is ofparamount importance. Finally, thereneeds to be more research to ensurethat there is a tripartite evaluation ofthese roles to include practitioners, NHS boards & HEI’s.

Sources of Information / References:

Barrett, D. (2007) “The clinical role of nurselecturers: past, present, and future.” NurseEducation Today. Vol. 27, No. 5, p. 367-374.

Hancock, H., Lloyd, H., Turnock, C., Craig,S., & Campbell, S. (2007) Exploring theChallenges and Successes of the LecturerPractitioner Role Using a StakeholderEvaluation Approach. [online] Available from:http://northumbria.openrepository.com/northumbria [Accessed 16/5/10].

Leigh, J., Howarth, L & Devitt, P. (2005) “The role of the lecturer practitioner: Anexploration of the stakeholders and practitioners perspective.” Nurse Educationin Practice. Vol. 5, p. 258–265.

Nelson, L. & McSherry, R. (2002) “Exploringthe lecturer/ practitioner role: individuals perceptions of the lived experience.” NurseEducation in Practice. Vol. 2, p. 109–118.

NES (2008) Modernising Nursing Careers:Clinical Education Careers. DiscussionPaper. Edinburgh: NES Scottish ExecutiveHealth Department (2006) Modernising nursing careers: Setting the Direction.Edinburgh: Scottish Executive

Steven Morrison, Lecturer Practitioner inAdvanced Practice, NHS Forth Valley &GCU.

The Successes & Challenges of the Lecturer Practitioner Role:An Advanced Practice Lecturer Practitioner’s Perspective

12 ACAP

IntroductionThe following is an informative article on the updated resuscitation guidelines.It briefly highlights the salient pointsexamining the main changes in relationto Adult Advanced Life Support 2010Guidelines which were released onOctober 18th 2010. Details of allchanges can be found by accessing the Resuscitation Council websitewww.resus.org.uk. It will use an ABCDE approach to highlight and clarify the recommendations.

Current healthcare is driven by evidence- based practice; the field of resuscitation is no exception. Everyfive years the European ResuscitationGuidelines are reviewed by theEuropean Resuscitation Council (ERC)at an international level. Subsequentlyany recommended changes are published in the United Kingdom by the Resuscitation Council (RCUK). The new recommendations are thankfully only very subtle;- in fact,recently at the BirminghamResuscitation Council ScientificSymposium, one of the speakers jokedthat the Resuscitation Council couldhave saved money by simply scoringout the numbers 2005 in the ALSGuidelines and simply added 2010!- So the good news is that by and largewe were getting it right in 2005. Thechanges are indeed subtle and willensure an optimistic approach taking,us a step closer to achieving a morepositive outcome for the victims of cardiac arrest.

As with all previous guidelines, cardiopulmonary resuscitation (CPR)should be commenced as soon as possible after confirmation of cardiacarrest whilst help is being summoned.The only significant changes to basiclife support are:

Compress the chest to between 5--6cm, at a rate of 100 – 120 per minute-Minimise interruptions to CPRRescue breaths should be deliveredover one second

So what about the Advanced part of the algorithm? To help us understandthe changes that may affect both theshockable and non- shockable sides of the algorithm, this article uses a specially modified ‘ABCDE’ structure:-Airway, Breathing, Circulation, Drugsand Electricity (Defibrillation).

AirwayAirway management remains a vital partin Advanced Life Support but the role

of intubation has been de-emphasisedunless highly- skilled individuals areable to achieve it with minimal interruptions to chest compressions.This means that ideally, laryngoscopyshould be performed with chest compressions in progress and onlypausing to allow for intubation: see Box 1.

BreathingThere is an increased emphasis onusing waveform capnography to confirmtracheal tube placement. However itshould be remembered that on its own,this can be unreliable. Auscultation and visualisation of the tube passingthrough the vocal cords remain primaryindications of successful tube place-ment. Detection of exhaled CO2 canalso guide the quality of CPR performedand be an indication of early return ofspontaneous circulation.

During CPR the ventilation ratio for apatient with an unsecured airway is 30compressions to two breaths. Once airway is secured, chest compressionsare continual with a ventilation rate of 10 breaths per minute: see Box 2

CirculationQuality of chest compressions remainsa focus of high priority. Excellence inCPR should remain paramount toensure improvement in cerebral andcoronary perfusion pressures.Interruptions of more than 10 secondscan have a detrimental outcome for thepatient in cardiac arrest. Therefore, anyinterruptions to CPR must be minimaland all interventions planned ahead to ensure this is achieved. The new recommendations advocate ‘minimiseinterruptions’ three times, -a clear indication of the level of - importancethis has for to the care and outcome for the patient.

The compressions depth is now

recommended to be between 5 -6 cm(previously 4 - 5 cm) and the rate isbetween 100 – 120 per minute. Theremust remain time for full chest recoil:see Box 3

DrugsThere are several small changes in therealm of drug administration duringresuscitation attempts.

1. AdrenalineWhen treating Ventricular Fibrillation (VF)/ Pulseless Ventricular Tachycardia (VT).Adrenaline 1mg is now given after chestcompressions are recommenced andafter the 3rd shock,- and then every 3 – 5 minutes. This slight variation intiming is to separate drug delivery fromdefibrillation, in an attempt to reduceany delays in shock delivery and chestcompressions.

2. Amiodarone Amiodarone is now also given after the3rd shock. It is not stated, but it wouldbe prudent to give the Adrenaline first. The improvement in the cardiac con-tractibility effect of adrenaline on thecardiac muscle subsequently increasesthe circulatory volume to other vitalorgans. This in turn increases thechance of the heart returning to a normal sinus rhythm (Gallimore 2006).Once an improvement in the cardiacconduction has been established it isconsidered prudent to administerAmiodarone. The pharmacodynamics of Amiodarone are recognised to becomplex (Gallimore 2006, Nattel et al1986) and is not for discussion at thistime. However, it has the ability to pro-mote a reduction in the heart rate andact in chemical cardioversion. Thereforeit is important for use in arrhythmias asV/F & pulseless V/T (Gallimore 2006).

3. Atropine Atropine is no longer recommended forroutine use in asystole or slow PulselessElectrical Activity (PEA) and has subsequently been removed from theguidelines.

4. Route of administration:-If intravenous (IV) access cannot beachieved within the first two minutes ofcardiac arrest, then intraosseous (I/O)access should be considered. Deliveryof drugs is no longer recommended viathe tracheal tube.

Box 1

No intubation attempt should interruptchest compressions for more than 10seconds

Box 3

Minimise interruptions to ChestCompressions. Compressions continue while Manual Defibrillator ischarging.

Box 2

Synchronous Compression/Ventilation: 30:2

AsynchronousCompression/Ventilation : 10 breathsper minute

What’s new in adult resuscitation?by Jackie Beatson

ACAP 13

14 ACAP

Electricity (Defibrillation)This is probably where the most challenging changes take place as thisis often when the longest periods of ‘nochest compressions’ happen. The 2010guidelines aim to make defibrillationsafe but rapid, to minimise interruptionsto CPR. The single shock strategyremains the strategy of choice.

Firstly the role of the precordial thumphas been de-emphasised and shouldonly be attempted on witnessed, monitored and confirmed (VF/VT) arrest when a defibrillator is not immediately at hand. It must not delaygetting help or obtaining a defibrillator,therefore will only be used when thereare several clinicians available. This will enable these tasks to be undertaken simultaneously.

Manual Defibrillation5. It may be possible to minimise interruption to chest compressions tobelow five seconds when a defibrillatoris used in manual mode.

The team leader must pre- plan all interruptions and give clear instructionsto the team but the aim is to addressany potential safety issues before stopping CPR. The following sequenceis recommended:-

5.1 Pause briefly to assess the heart rhythm.

5.2 With a manual defibrillator, if the rhythm is shockable, then recommence chest compressions.

5.3 The defibrillator is charged and everyone else, apart from the person performing compressions, stands clear.

5.4 When the defibrillator is fully charged the chest compression provider is asked to stand clear.

5.5 A rapid safety check is performed and a shock is delivered.

5.6 High- quality chest compressions are recommenced as quickly as possible.

Automated External Defibrillation (AED) 6. There is no change of practice hereas AED user follows the machineprompts. Chest compressions are notexpected to be delivered through thecharging phase, although chest compressions post- shock should berecommenced as quickly as possible.

7. In some very specialist areas such as cardiac catheterisation laboratory orimmediate post- operative following

cardiac surgery (when cardiac compressions may disrupt sutures) it is recommended that three successive(stacked) shocks should be used for VF or pulseless VT.

Additional changes, pertinent to thepost- resuscitation care phase willnot be discussed within the scope of this article. For a more in- depthunderstanding, it is recommended that you visit the Resuscitation Councilwebsite. Your local resuscitation officer may also be able to help with any queries you may have. A review ofthe new algorithm can be seen inAppendix 1.

APPENDIX 1

REFERENCE

"http://www.erc.edu/" EuropeanResuscitation Council ERC (2010)http://www.erc.edu [online] available [accessed] 10/11/2010

Gallimore, D. (2006) UnderstandingDrugs used during cardiac arrestresponse. Nursing Times 102: 23 24-30

Nattel,S.(1986) Pharmacology andPharmacodynamics of Amiodarone:http://www.medscape.com [online]accessed [available] 11/10/2010

"http://www.resus.org.uk/SiteIndx.htm"Resuscitation Council (UK) (2010)http://www.resus.org.uk [online] available [accessed] 10/11/2010

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