VOL: 97, ISSUE: 27, PAGE NO: 34
Sheila McKinley, MSc, BEd, RN, project lead, critical care project, London West Sector Consortium, is currently an assistant director of nursing, West Middlesex University HospitalThe government has charged hospitals with huge changes in the care of critically ill patients (Department of Health, 2000; Audit Commission, 1999). This agenda will involve the development of services that focus on the level of care patients need rather than specific specialty beds (Table 1).
The government has charged hospitals with huge changes in the care of critically ill patients (Department of Health, 2000; Audit Commission, 1999). This agenda will involve the development of services that focus on the level of care patients need rather than specific specialty beds (Table 1).
To achieve this, all nurses working in hospitals need to be able to provide effective and timely care for patients up to level 2, that is those who have a single failing organ, are developing a critical illness or need step-down care from more intensive areas (Table 1). They also need to be able to support the flexible use of specific critical care beds so that services can respond quickly to changes in patient demand.
A more structured career path is needed to support the development of consultant nurses in critical care (DoH, 1999), and if the government's directives are to be met there needs to be a radical change in the way nurses, midwives and therapists are educated and supported in acquiring critical care skills.
Senior staff from all 11 hospitals in west London decided that we needed to work with our education consortium and local universities to find a solution. With funding from London West Sector Consortium, a project was recently set up to redesign an integrated spectrum of critical care education.
Working in partnership with each other and local universities it aims to support:
- Effective and timely care for patients in general and specialised areas on levels 1, 2 and 3 (Table 1);
- Tangible improvements in clinical skills and decision-making for nurses, midwives and therapists;
- Flexibility of staffing and the continuing development of services;
- The development of higher levels of practice in critical care services;
- The recruitment and retention of nurses and therapists in west London;
- A continuum of expertise to uniform standards across west London that allows staff to move easily between trusts, with a standardised portfolio of knowledge and skills.
We want to achieve this through the development of competency-based modular programmes that enhance core skills and competencies across professional boundaries. Initially, they will be for nurses (both adult and children's), midwives, physiotherapists and some occupational therapists but the aim is to adopt an approach that will eventually enable other professional groups to access the modules.
The project team includes representatives from all the partnership hospitals and is currently working with Thames Valley University and Buckinghamshire Chilterns University College to develop three levels of integrated competency-based programmes that support different areas of need. The modules will be accredited at diploma and degree level, both first and higher, and will form part of general or critical care diploma/degree pathways.
Basic critical care course
The project team is currently developing a basic critical care course because this is considered the area of most immediate need. It is aimed at nurses, midwives and therapists working in general areas who need to be able to care for critically ill adults and children or those who are at risk of becoming critically ill. Both universities are working with nursing and therapy representatives from all the hospitals involved to develop a programme based on a common curriculum with common assessment tools.
It is envisaged that candidates will undertake a work-based theoretical assignment and achieve competence in a range of clinical skills. These will include a set of core skills and an agreed number of optional skills that will address the needs of different clinical areas (Table 2).
The core specific skills for nurses will include:
- Systematic assessment of haemodynamic stability;
- Management of central lines and monitoring of central venous pressure;
- Recognition of life-threatening cardiac dysrhythmias;
The optional specific skills for nurses will include:
- Management of non-invasive ventilation;
- Management of tracheostomies;
- Management of chest drains.
Assessment and learning
Competence in practical skills and their integration into the proactive management of patient care will be through common assessment tools supported by the module's curriculum and standardised guidelines for assessors.
It is anticipated that candidates will spend 50% of the programme based in the clinical areas as learners rather than part of the workforce. This will give them an insight into the holistic needs of critically ill patients as well as supervision in acquiring proficiency in specific clinical skills.
Critical care practice educators, some of whom will work for the universities and others for the trusts, will support learning in the clinical environment.
They will be the key to ensuring that candidates acquire the skills, knowledge and insight to improve their ability to provide care for patients who are critically ill or those at risk of becoming critically ill. This development will be supported by London West Sector Consortium, at least for the pilot year.
We will put two groups of candidates (about 50) through a pilot programme in October, with at least the same number starting in the next semester.
The plan is to run several groups concurrently by September next year so that the programme can meet the demand throughout West London. Most trusts envisage that all their staff will complete the programme.
Intermediate critical care course
Intermediate courses should start during the next academic year. They will be aimed at junior staff nurses and possibly therapists who work in specialist critical care areas and should replace ENB courses in critical care.
Candidates, whatever their specialty, will take core critical care modules as well as those related to their particular area, so moving specialty will involve taking specific modules only.
The universities have agreed to work in partnership with the trusts to devise a competency-based curriculum that will give junior staff the clinical knowledge and skills they need to provide effective care for patients in specialist areas. The intention is to base modules on current critical care courses, such as ENB 100, but the new courses will be more flexible and have a wider remit.
This approach should support the increasing need for flexibility among specialist critical care staff and be available to staff who have not traditionally had access to critical care courses, such as senior nurses working in general areas that accept patients from specialised critical care areas, increasing the effectiveness of nursing management.
Advanced critical care courses
This range of courses, which should be available by next September, aims to support the development of specialist practitioners and advance the skills of senior nurses in specialised areas. Modules will be at master's level and will support autonomous practice and higher levels of clinical decision-making.
The challenge is to develop a course that is flexible enough to give nurses working in a variety of critical care areas the advanced clinical skills they need while having the rigour to prompt autonomous decision-making and develop practitioners who will be prepared to push the boundaries continually.
The project is an exciting opportunity to change the provision of critical care education across west London. It will be the first time, at least in this area, that all trusts and local universities have worked in partnership to devise programmes that meet the changing needs of patients, both in and outside specialist areas. It is also the first time that nurses, midwives and therapists have worked together to establish modules that reflect a multiprofessional approach to the provision of health care.
The project has begun to link with work recently initiated by London Region to devise a common approach to critical care across the capital.
We hope to inform the pan-London initiative and to learn from the ideas and experience of others.
It is too early to predict the effect of the proposed programmes on enhancing patient care, but the enthusiasm and commitment of 11 hospitals and two universities should be a recipe for success. In the short-term we are looking forward to appointing two H-grade nurses to join two education colleagues as the first practice educators on the basic critical care programme.