The Challenges of providing The Challenges of providing an acute CCN service in an acute CCN service in Northern IrelandNorthern Ireland

Peter Johnston Bsc, RGN, RSCN, CCNPeter Johnston Bsc, RGN, RSCN, CCN

Community Paediatric NurseCommunity Paediatric Nurse

Causeway Health & Social Services TrustCauseway Health & Social Services Trust

Northern IrelandNorthern Ireland

85 MILES

110 MILES

The Mourne Mountains The Fermanagh Lakes

The Giant’s Causeway

StatisticsStatistics

Population under 19 years of age=500,153Population under 19 years of age=500,153

Population Population 20012001

% total % total UK UK populatiopopulationn

EnglandEngland 49,000,0049,000,0000

83.6%83.6%

ScotlandScotland 5,000,0005,000,000 8.6%8.6%

WalesWales 3,000,0003,000,000 4.9%4.9%

Northern Northern IrelandIreland

1,700,0001,700,000 2.9%2.9%

Total Area :5,456 square miles

Current CCN provision in Current CCN provision in N.IrelandN.Ireland

CCN teams are now available in every CCN teams are now available in every Community and combined Trust in NICommunity and combined Trust in NI

Each team has a unique skill mix and Each team has a unique skill mix and ethos but underlying is the dedication ethos but underlying is the dedication of care for sick children in their own of care for sick children in their own homehome

Generic teams covering all referralsGeneric teams covering all referrals Specific complex needs and acute Specific complex needs and acute

teams within Trust areasteams within Trust areas Limited provision of respite care in Limited provision of respite care in

some but not all Trustssome but not all Trusts

What are the What are the challenges ?challenges ? Organisational Organisational Regional Regional LocalLocal ProfessionalProfessional GeographicalGeographical FinancialFinancial Changing population profile of Changing population profile of

N.Ireland N.Ireland

Organisational Organisational Review of Public Administration Review of Public Administration Challenges in integrating teams from Challenges in integrating teams from

previously separate trusts with previously separate trusts with differing priorities differing priorities

Further integration of health and Further integration of health and social services MDT working social services MDT working

Regional Regional Inequalities of health Inequalities of health Inequalities of accessInequalities of access Differences in priority across trustsDifferences in priority across trusts Lack of regional strategy and visionLack of regional strategy and vision

Local Local

Remaining small sizes of teamsRemaining small sizes of teams Dominance of Chronic and Complex Dominance of Chronic and Complex

needsneeds Poor knowledge amongst GP’s and Poor knowledge amongst GP’s and

other health care professionalsother health care professionals

Professional Professional Changing and evolving roles in Changing and evolving roles in

community paediatrics specialisms, community paediatrics specialisms, palliative , acutepalliative , acute

Lack of representation at higher Lack of representation at higher levels within trusts and board/ levels within trusts and board/ department leveldepartment level

Recruitment and trainingRecruitment and training

Geographical Geographical Largely rural population Largely rural population Inequality of access to regional Inequality of access to regional

servicesservices Closing of local hospitals / Closing of local hospitals /

Reconfiguration of services Reconfiguration of services Emphasis on increased community Emphasis on increased community

care and specialismscare and specialisms

FinancialFinancial Focus on estates and revenue Focus on estates and revenue

promotionpromotion Reduction in service developmentReduction in service development Trust prioritiesTrust priorities Competing service needsCompeting service needs Direct ruleDirect rule

Population profile Population profile

Ethnicity -new language and cultural Ethnicity -new language and cultural challengeschallenges

De-urbanisation De-urbanisation

How we are meeting the How we are meeting the challenges ?challenges ?RegionallyRegionally A Healthier Future –Twenty year vision A Healthier Future –Twenty year vision Developing Better ServicesDeveloping Better Services Children’s commissioner / Minister for ChildrenChildren’s commissioner / Minister for Children Children’s strategyChildren’s strategy Strategic framework for children, young people and Strategic framework for children, young people and

familiesfamilies

LocallyLocally Greater integration of services both within health and Greater integration of services both within health and

with social serviceswith social services Proposed establishment of children's directorates in Proposed establishment of children's directorates in

each Trust areaeach Trust area Service initiativesService initiatives

How we are meeting How we are meeting the challenges ?the challenges ? Quarterly CCN forum meetingsQuarterly CCN forum meetings Sharing of best practiceSharing of best practice Development of equipment registerDevelopment of equipment register Guest speaker from specialist nurse Guest speaker from specialist nurse

forum from the regional children's forum from the regional children's hospitalhospital

Biannual conference Biannual conference

The real challenge?The real challenge? Though there are many organisational and Though there are many organisational and

service challenges facing CCN’s in Northern service challenges facing CCN’s in Northern Ireland the only way that we can realistically Ireland the only way that we can realistically affect the future of our service is to actively affect the future of our service is to actively become involved in the higher levels within the become involved in the higher levels within the HPSSHPSS

We now have our first CCN in a senior nurse We now have our first CCN in a senior nurse management rolemanagement role

Representation at Department levelRepresentation at Department level Advancing roles of CCN’s across the region.Advancing roles of CCN’s across the region.

A Scottish Perspective of A Scottish Perspective of Community Children’s Community Children’s

Nursing ServicesNursing Services

Presented by Karen Sinclair on behalf ofPresented by Karen Sinclair on behalf of

the Scottish CCN network groupthe Scottish CCN network group

March 2006March 2006

Scottish DemographicsScottish Demographics

• Scotland has a population of just over 5 million

• 20% of Scotland’s population are children aged 0-19years old

CCN BackgroundCCN Background

• Before Diana funding in 1999 only four health boards had established CCN services

• Today thirteen out of fifteen have a CCN service available

CCN Team ConfigurationsCCN Team Configurations

0

2

4

6

8

10

12

14

16

WT

E

H

G

F

E

D

C

B

A

0

1

2

3

4

5

6

7

8

9

Trained CCN in teams

Qualified Community Children’s NursesQualified Community Children’s Nurses

Setting the SceneSetting the Scene

• Most operate a Mon-Fri 8am-5pm flexibly• Tertiary hospital based teams work limited

hours at weekends• No CCN services offer 24/7 provision• Most teams aim to provide a needs led

service • Acute community services account for

between 5-20% of most CCN teams caseload

Challenges of providing acute Challenges of providing acute community services in Scotlandcommunity services in Scotland

• Team size• Travel• Clinical responsibility• Communication• Funding for equipment and supplies• Accountability

Challenges of providing acute Challenges of providing acute community services in Scotlandcommunity services in Scotland

Challenges of providing acute Challenges of providing acute community services in Scotlandcommunity services in Scotland

• Travel

• Team size

• Clinical responsibility

• Communication

• Funding for equipment and supplies

• Accountability

The FutureThe Future

• Promote CCN services

• Needs assessment and analysis

• Development Plans

• Increase skill mix in teams

• Employ practice development nurses

• Training future CCN

ConclusionConclusion

• CCN teams in Scotland are small and none provide a 24/7 service

• Needs led service

• Between 5% and 20% of caseload is acute

• Challenges

• Future

AcknowledgementAcknowledgement

• I would like to thank my colleagues in the Scottish Community Children’s Nursing Network group for providing me with up to date information on their teams and the services they provide locally

Advanced Practice Skills -What are they and how do

we achieve them?

Dr Fiona SmartDirector of Studies:

Advanced Clinical Practice with responsibility for CPD

The question [s]?

• Not least the meaning of advanced?• And the debate about skills …

– what is a skill and – who should/ could/ might own it?

Advanced Practice Skills -What are they, how do we achieve them and importantly how will we know that they are in place and in use?

But first, the legacy

• With a clean slate …

• With the slate we have …

• Numerous, potentially competing agendas– Not least

• The European WTD• Changes to medical education/ development• Issues re. access – timely and appropriate• User/ carer focused/ centred provision

• The impetus for and reality of role design

Role Redesign???• Is what?• A venture/ an initiative/ a solution ?• To address … what?:

– Staff shortages– Job dissatisfaction via the development of new and emerging

roles– ?

• Argued to:– expand the depth and breadth of roles, creating new jobs or

moving tasks up or down a traditional uni-disciplinary ladder

– change traditional and long-standing barriers to change such as professional boundaries, team structures and hierarchies, existing care processes and established divides between organizations

– benefit the entire healthcare team

For nursing …

• Numerous possibilities• Multiple tensions … not least

• The decision to regulate the role of the nurse practitioner

• Subject to the approval of the Privy Council

• The protection of a new title in the family of nursing– Registered Advanced Nurse Practitioner

An unexpected gain?

• The validation of skills …– as opposed to knowledge in

isolation

• A challenge to the division which separates work-based roles and allows the perception that

• Doctors know; nurses do

Perhaps even …

•Approval for ‘dirty work’

•The closer the role of the worker to the body, the less well regarded they are likely to be

The Advanced Nurse Practitioner

“ Advanced nurse practitioners are highly experienced, knowledgeable and educated members of the care team who are able to diagnose and treat your health care needs or refer you to an appropriate specialist if needed ”

NMC 2005

More specifically …• Advanced nurse practitioners are highly skilled nurses who can:• carry out physical examinations;• use their knowledge and clinical judgement to decide whether to

refer patients for investigations and make diagnoses;• decide on and carry out treatment, including the prescribing of

medicines, or refer patients to an appropriate specialist;• use their extensive practice experience to plan and provide skilled

and competent care to meet patients health and social care needs, involving other members of the health care team as appropriate;

• ensure the provision of continuity of care including follow-up visits;• assess and evaluate, with patients, the effectiveness of the

treatment and care provided and make changes as needed;• work independently, although often as part of a health care team

that they will lead; and • as a leader of the team, make sure that each patient’s treatment

and care is based on best practice.

So what was the question[s]?

•Advanced Practice Skills •[1] What are they and•[2] How do we achieve them?

The easy bit … controversy accepted

• The RCN’s 7 domains of practice– Reviewed and Reordered– Minor Amendments

• Mapped to the Knowledge and Skills Framework

• The Benchmark/ Standard has been established

How will the standard be achieved?

– Group A

• Potential registrants who have undertaken a programme based on the competencies that have been approved by the Council. Currently this group would include all those who had obtained an award as a Nurse Practitioner from a Higher Education Institution (HEI) where the programme had been jointly approved by the HEI and the RCN since 2002;

– Group B

• Includes individuals who undertook programmes that were based on programmes similar to those undertaken by nurses in Group A but prior to 2002. Programmes would have included most of the competencies that have now been approved but they may not all have been assessed;

– Group C

• Includes individuals who have completed other programmes approved by HEIs in 'advanced clinical practice’;

– Group D

• Includes individuals who have not completed a conventional programme of preparation, but who wish to have their prior learning and competencies (certificated or not) accredited

– Group D may include individuals who have spearheaded the development of this level of practice.

Catch up addressed [?]Future provision …

• M level thinking

• The next 5 years

• Thereafter• all taught modules/ provision at Level 4

Meanwhile …

• If we know the skills–How are they to be known/ valued?

• If the skills matter–How will they be supported/ enabled/ sanctioned in practice?

Nursing’s Past

• Status ….

• Potential …

• Internal tensions

• And its future ………………..

Today’s Challenge old times; new thinking?

• “Training is to teach a nurse to know her business, that is to observe exactly, to understand, to know exactly, to tell exactly … training has to make her not servile, but loyal to medical orders and authorities … training is to teach the nurse to handle the agencies within our control which restore health and life, in strict obedience to the physician’s or surgeon’s power and knowledge” [Nightingale 1882: 6 in Gamarnikow 1978]

And so the challenge …

Advanced Practice Skills -What are they, how do we achieve them and importantly how will we know that they are in place and in use?

Thank you

Questions?