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Advanced nurse training needed to carry NHS reforms, says expert


Nurses will require more advanced specialist training under a reformed NHS in which patients are increasingly treated outside of hospital, according to two key expert bodies.

Both the Centre for Workforce Intelligence - tasked with helping the NHS to plan its workforce – and the advisory National Quality Board have made the recommendation.

A Centre for Workforce Intelligence report last week found caring for patients across organisational boundaries required “upskilling” nurses, particularly those in the community.

The report, Integrated Care for Older People, said this would “allow a shift in the delivery of care from acute and nursing homes to the community, also reducing admissions”.

It endorsed training in advanced prescribing and intravenous therapies. Parts of the country that were already successfully caring for patients in an integrated setting had required additional nurses with specialist skills in geriatrics, dementia, COPD and falls, the report said.

The need for extra training was identified in seven of the eight integrated care models the researchers looked at in detail.  

The report also found that two of the nurse-led models demonstrated only “weak/ambiguous evidence of economic benefit”. However, there were benefits to patients of having a more seamless NHS service.

Integrated care was supported last week by prime minister David Cameron, who said regulator Monitor would have “a new duty to support the integration of services”.

Meanwhile, the national quality board - whose members include NHS chief executive Sir David Nicholson and chief nursing officer Christine Beasley – has called for better specialist training in specific long term conditions for nurses.

It has published a list of 11 recommendations for “aligning” the NHS to improve quality.

One of the recommendations was that all nurses and other staff “whose work routinely brings them into contact with patients with a particular long term condition, such as dementia, should have received basic education and training in that condition”. It also said the Care Quality Commission should “consider” whether such training has taken place.

Jan Procter-King, a primary care cardiovascular nurse lead in Leeds and formerly Department of Health cardiovascular adviser, said long-term conditions training in primary and community care was often insufficient.

She said: “I have personally seen standards falling because of structured education not being seen as a priority and not being offered. There are differences around the country, often reflecting how well the primary care trust has commissioned and organised education.”

Ms Procter-King also warned the problem was being exacerbated because PCTs were losing staff in advance of their planned abolition.

You can discuss this further on our Nursing Times forum, connect with your peers!


Readers' comments (20)

  • Absolutely agree with this, to an extent. I think that if we are to have the advanced training and advanced qualifications, which I agree will always be a good thing, then we MUST have the standardised career paths, roles and job titles that go with it, not to mention the actual job availability and the pay level to recognise the advanced role.

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  • In my locality we had a team of advanced practitioners who were doing a great job of keeping people out of hospital, UNTIL it was decided to disband them. How many times will THEY make these seemingly arbitrary decisions before they listen to US, the workforce, who know what is actually needed?

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  • michael stone

    I see you have taken my 'titles' point on board, mike. These training debates, all come down to a single thing: anyone who is tasked to do something, should be competent to do it.
    But, there is also a related issue - do nurses get carpeted, if they admit to doubts about their own clinical competence ? Are nurses typically willing to ask other people 'How should this be done ?', etc, or does that raise the spectre of being accused of incompetence ? The relevance, is that sometimes nobody is doing something as well as it could be done, but nobody is willing to be the first person to raise any doubts.

    Looking at this:
    'Parts of the country that were already successfully caring for patients in an integrated setting had required additional nurses with specialist skills in geriatrics, dementia, COPD and falls, the report said'.
    and going back to a discussion of 'titles' I had with mike, elsewhere (and I think 'Coroner' is relevant - a Coroner can have either a medical or legal background, which is not reflected in that operational job title) perhaps a nurse with more specialist training in dementia than a Practice's GPs, might have a title of 'Dementia Practitioner' ? Where the Nursing and Medical (doctors') paradigms overlap, perhaps there should be short(ish) specialist courses which anybody (nurse or doctor) could take, and which led to a relevant 'label' (Geriatric Practitioner, etc) ?

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  • michael stone

    This is somewhat ‘off message’ (so it will probably annoy mike), but I am interested in a certain aspect of ‘evidence-based behaviour’, and I want to try and fit it in somewhere. And, as my concern is EoLC, I’ll use something connected to older people as my example. I would be interested to know, how many of our modern highly-trained nurses, are aware of this ‘analytical technique’ ?

    Suppose a person has written an Advance Decision, and it is witnessed, etc, correctly, but has not been discussed with the clinician who is reading it. The ‘instruction section’ reads as follows:

    ‘I am refusing cardiopulmonary resuscitation, and I am aware that refusing this treatment will probably result in my death if I am in CPA’

    If the clinician is aware of that Advance Decision, and the person is in cardiopulmonary arrest, and the clinician knows no other background detail, should the clinician attempt CPR, or not attempt CPR (assuming resuscitation still appears clinically possible) ?

    As the only evidence is the ADRT, and the law regarding ADRTs, what are the implications for ‘evidence-based behaviour’ here ? I’ll tell you – unless ALL similarly-qualified clinicians do the same thing (either let him die in peace, or attempt CPR) then you CANNOT BE applying the principle of ‘evidence-based behaviour’.

    The theory behind evidence-based behaviour is this. You work out the best treatment for any particular presentation, and then uniformly provide that treatment, for all identical presentations. In the ‘real world’, you cannot have a set of exactly identical presentations. But in the world of written questions, all of the evidence is within the written words: there can be no more, or less, ‘evidence’ than what you can read. So, you can apply the test of evidence-based behaviour IN REVERSE: unless every equally-qualified clinician, gives the same answer to a written question, then either the best treatment (behaviour) is unknown, or else some of you are getting it wrong !

    Evidence-based behaviour, is an excellent analytical tool when it is ‘run backwards’, and applied to test the behaviour of clinicians; or, indeed, to test for coherent behaviour sets across different groups of professionals (such as between nurses and paramedics).

    I am not sure how many people, understand this – it does not seem to be used very often, in that way, as an analytical tool during the discussion of the correctness of behaviour sets.

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  • Anonymous | 13-Jun-2011 12:01 pm I totally agree, and that goes back to my point about there needing to be a strong career path where these advanced roles are an accepted and recognised part of the MDT, and cannot be just disbanded, and we as a profession and the unions have to play a stronger role in ensuring these conditions are put into place and enforced. Otherwise, why will people bother to gain Masters and Doctorates? Or for those that do, why will they bother to stay and work in this country when other countries can offer them better roles, pay and conditions? To coin a phrase often used by the banks to justify their bloated salaries not so long back, we need to pay top dollar to attract and keep the best people. Why is our profession not deserving of that?

    Michael, I have taken it on board, but in fact (if you look through previous posts) it has been discussed a fair bit before. The excellent series on the image of Nursing was the last one (if memory serves). I absolutely agree that these titles and roles are absolutely fundamental not only to our professional image, but in ensuring we can give the highest quality care that the qualifications we can get reflect.

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  • I disagree with standardisation for a couple of reasons in advanced nursing at the present time.

    I do agree with standardisation is basic training as the core elements to what a nurse should know.

    However, at present we have a range of older highly competent nurses already in practice in advanced areas, those who have pushed the boundaries and pioneered many various specialities and I just think making this group conform to a new core ideal and jumping through hoops is a backward step. Also, standardisation reduces the desire to innovate and goes back to the certification when there is not always a certificate to be had. So many times I have heard nurses not that keen on advancing their skills, almost wetting themselves because they just don't like to take "risks", and that is not working riskily, just having the confidence to take more responsibility.

    I am a practice nurse and they tried to "standardise" me back in 2003 with the Specialist Practitioner degree in Practice Nursing, but when I looked at the modules, I already had them from various institutions at a higher level. It would cost as much to accredit them, even they would. The answer I was given was that they all had to be from one institution, and even more insulting, my then Level 3 (60 CATS) in Research would not "count" and I would have had to repeat it at Level 2 (30 CATS)! How stupid is that??
    Instead, I spent several years acquiring various clinical modules just because I needed to know, but they don't make up a nice neat degree.

    At the end of the day, I have been practising for 11 years as a PN, trusted by various consultants in not just one area and enjoy autonomy in my role with the exception of prescribing, because my employer for some reason sees that as too much nurse competition. However, he relies on me to diagnose various things and refer to secondary care if necessary for things I have just learned to do in the absence of someone doing it!

    I am 57, love my job, but have no intention of starting more Masters level "core" modules by way of cost or time. Much of mine has been self-funding.

    I think as nurses and boundary pushers in diverse areas we should accept more diversity ourselves.

    Yes, we could be assessed to a standard, but at this stage I think it is too much, as for example many senior nurses at this level maybe coming up to retirmement (mine might be age 70??), and forcing more core modules on those already practising could actually force us out and leave no one to fill the gaps quickly enough.

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  • it would be helpful to have references to these reports please as all the ones on google are several years old.

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  • michael stone

    mike | 13-Jun-2011 3:26 pm

    'Michael, I have taken it on board, but in fact (if you look through previous posts) it has been discussed a fair bit before. The excellent series on the image of Nursing was the last one (if memory serves).'

    I only joined this site quite recently, to try and get some answers from nurses to my concerns about their understanding of the MCA, Advance Decisions, the role of welfare attorneys, etc - I have no knowledge of 'legacy discussions'. But, if other people have made similar comments, then I happen to agree with them: if your title includes 'nurse', but you object to being seen as junior to doctors, you need to soemhow get 'operational titles' which do not include nurse or doctor, to cover equivalent operational roles (where these can be either nurse- or doctor-led).

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  • Anonymous | 13-Jun-2011 6:02 pm I see what you are saying and agree to an extent, but I think the standardisation can focus more on the roles or career pathways created by gaining such quals, rather than the quals themselves.

    Michael, I know you did, thats why I suggested the image of Nursing series of articles, very interesting. And I still agree with you about the titles, but a specific career pathway in our profession is just as important as it is very fragmented at the moment.

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  • Anonymous | 13-Jun-2011 6:02 pm

    There are so many of us in a similar situation to you, with such a swell of knowledge, having undergone modules to improve our practice, but haven't been put 'into a nice degree'. We should not be put under pressure to have that piece of paper, there is no contest or comparison between what knowledge and experience we have, to a newly qualified degree nurse.

    However, if advanced nurse training becomes part of career progression for the next generation of nurses, then I am all for it. It will negate the somewhat struggle of 'goalpost chasing' we have been subjected to.

    I approached a senior tutor a few years ago about undertaking a degree, to be told to go for a Masters instead, as a deree would be wasting my time. I ended up with a Post Grauate Diploma, not through my inability to achieve an MSc, but due to having to dedicate my time to the failing health of parents....and then the MSc I was undertaking has changed, so I couldn't complete it. I am in a deparment that respects individual skills, not just the letters after your name, which is a breath of fresh air.

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