A review of in service training identified a need for individual skills induction to guide nurses’ knowledge and provide a format for ongoing career enhancement
Tony Bush, RMN, Cert (Ed), Dip (N), Bsc, is senior nurse, in service training and development; Karen Smith, SEN (M), RMN, PGCE, Msc, is divisional lead for KSF, equality and diversity and training and development; both at St Cadoc’s Hospital, Newport.
Bush T, Smith K (2010) Introducing a programme for post registration induction and knowledge and essential skills development. Nursing Times; 106: early online publication.
Post registration nursing induction can be a neglected area.This paper describes the rationale, processes and methods used to establish a model for post registration nursing induction and knowledge and skills development. This model integrates the personal development review and planning process in the context of the Knowledge and Skills Framework, and provides a format for ongoing career development.
Keywords Education, Development, Skills
- This article has been double-blind peer reviewed
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Nursing practice involves negotiating an ever evolving, and continually changing set of complex initiatives and objectives. Coordinating workloads with personal career development, adapting to technological and clinical advances, and balancing the statutory and mandatory requirements for role and the needs of the organisation are all challenging prospects.
When the Department of Health introduced the Knowledge and Skills Framework (KSF) (DH, 2004) it sought to clarify and put into context the processes of developing individual nurses. Despite defining and describing the range of skills and competencies required, the DH failed to consider just how those skills and competencies could be acquired and maintained in practice. Considering the diversity of nursing practice and specialties, and the distinct capabilities required to carry out different roles, the KSF seems too broad to provide targeted guidance.
There is no single standard system that integrates a personal development portfolio (PDP), the KSF and either a skills based or transitional induction within the profession. This article discusses an initiative in Gwent, South Wales that has resulted in the development of a comprehensive and flexible means of meeting both the needs and expectations of a wide variety of nursing staff and those of the organisation.
Review of in service training
Arthur et al (2003) assessed the effectiveness of training in organisations, and showed that assessing training needs, identifying job requirements, looking at who needs training and what kind should be delivered should result in more effective learning across the board.
In 2008, the training and development department for community, mental health, learning disabilities and therapies in Gwent conducted asystematic review of in service training programmes. The purpose of the review was to establish the extent to which programmes were designed to equip staff with the knowledge and skills they needed to carry out their roles effectively. We also wanted to identify significant gaps or omissions in training provision and any strategic interventions to address these deficits.
Gaps in training provision were identified by linking courses directly to the KSF and the skill sets required; initially in bands 5, 6, and 7.Mapping continuous professional development (CPD) activities against the KSF is vital to help identify ways of meeting challenges (Neville, 2006).All existing training programmes and modules were analysed and mapped to the KSF based on content, target audience, specialty and the level of educational attainment they were attributed. We found that the predominant focus of in service training provision was seen as mainly theoretical and conceptual, rather than clinically practical.
Work by Hicks et al (1996) examining general primary healthcare teams concluded that the ever growing demand for professional updating and training within the health service had created a proliferation of post registration courses, but that many failed to reach the appropriate staff or meet the real training objectives of the participants and their managers. Often this was because courses were designed and delivered in a haphazard way.
In Gwent, we agreed there was a need for more clinical and practical skills based courses and initiatives, which included targeted induction and management training. Training and development was viewed as a largely “ad hoc” department, which did not have a dedicated in service training team or strategic agenda.
Complaints from service users, carers and others, together with the results of formal inquiries into these concerns - some of which related to serious incidents with consequent legal ramifications - almost always resulted in training implications and recommendations. Training and development departments needed to be responsive in light of these issues, and work to address them.
The Knowledge and Skills Framework
The requirements of the KSF - in tandem with National Occupational Standards, clinical governance initiatives and individual personal development reviews (PDRs) - are an integral part of providing guidance for nurses’ training direction and development. Gournay (2000) discussed the grounds for an increase in “skills based nurse training” throughout the profession. Recommendations included more interdisciplinary courses, more robust training in research methods and closer links between university departments and clinical areas. Neville (2006) felt that educational programme development needed to take account of the KSF at an early stage.
A report by the National Institute of Adult Continuing Education (Bowden et al, 2007) examined the operation of the KSF across six NHS trusts in England and Wales. The broad objective was to understand how the framework could most effectively support skills development and progression through learning. It concluded that the core dimensions of the KSF required closer scrutiny and that ways of meeting them through creative learning needed to be clarified. It was felt that organisations needed to provide more “responsive” courses and development opportunities.
Before this initiative staff induction had been more of a broad introduction to the division than a formal induction; it involved disseminating important information on aspects of working for and within the trust. While this was informative, the processes of individual skills induction should be distinct from informing staff about mandatory corporate affairs; induction should offer practical guidance on individual skills and personal development in the workplace.
Post registration framework and career development
Bradshaw (2000) noted that nurse training used to rely on a standardised, explicit syllabus. From the late 1980s onwards the focus shiften away from clinical environments and into the classroom. This resulted in professional boundaries and the competencies needed for new roles becoming far less distinct.
Some newly qualified staff can appear ill prepared for the responsibilities of basic patient care management in their first job after quaslifying, and lack safe clinical and general management skills. Many express their own concerns about their knowledge and skills and feel they lack confidence in taking on the role of a qualified practitioner (Last and Fulbrook, 2003).
A comparative study by Gerrish (2001) highlighted the limitations of pre-registration nurse education and its failure to prepare nurses for their post registration roles. Despite education reforms and changes in policy in the years since Gerrish’s initial study, student nurses still say they are inadequately prepared. Gerrish recommended that pre-registration courses should support students’ development of clinical, organisational and management skills. It also suggested there should be “a bridging period between the latter part of the course and the first six months post qualification, to enable nurses to acclimatise gradually to becoming accountable practitioners”.
Guidance from the Nursing and Midwifery Council (NMC, 2006) sets out good practice in terms of giving newly qualified nurses a period of consolidation. The NMC recommends that new registrants should be given protected learning time in their first year of practice and the support of a preceptor - a qualified first level nurse with at least 12 months’ experience in the specialty in which the registrant is working. The NMC suggested this period of consolidation should become mandatory in future.
The Welsh Assembly Government, in its consultation document Post Registration Career Framework for Nurses in Wales (WAG, 2008), said that induction to the employer organisation and compliance with mandatory training regimes must be encouraged. It is likely the use of rotation schemes will be expanded across Wales, with new registrants being given the opportunity to have “taster” experiences in academic, research, community and inpatient settings.
The DH (2006) stated that wherever nurses work there are four elements to their role:
- Education, training and development;
- Quality and service development;
- Leadership, management and supervision.
These elements link to both the core and specific aspects of the KSF. The proposed career framework engages with the KSF as defined by WAG (2008): ”The KSF is a broad generic framework which covers the functions that need to be carried out by most NHS staff. It links directly to the more detailed NWC/NOS [National Workforce Competences/National Occupational Standards] developed by Skills for Health. Each of the NWC/NOS shows an indicative link to the relevant KSF dimension and these links are established on the basis of the most likely relationship according to the content of the competence”
Induction and the role of training and development departments need to connect with individuals’ career progress and the career framework. And career progress and the career framework need to also link up with KSF post outlines and the required skills and competencies, with support from a workplace reviewer or preceptor.
Integrating the elements
To integrate all these elements into a single induction programme we first looked at creating a standardised process. We needed one that was flexible enough to incorporate the individual elements of any nursing role in any specialty, integrating them into a single model of knowledge and skills acquisition and development. We wanted to clearly map the pathway to progression in any band for the critical first 12 months and then the following years.
We decided an effective way to do this would be through an induction workbook programme, which would incorporate:
- KSF guidelines, including core and specific dimensions, levels and broad level descriptors;
- Definitions of responsibility for the team manager, reviewer and reviewee;
- Interview/progress records;
- Personal, local orientation and mandatory and statutory training checklists relevant to speciality;
- The KSF Competency Development Matrix;
- Practice record comments section;
- Reflective practice framework and record.
The pilot area targeted was community (district nursing) for band 5 nurses.
The main aim of the programme is to guide nurses’ essential knowledge and skills development for their first 12 months of employment after registration, and then introduce a secondary workbook to perform the same function for subsequent years. Some aspects of induction are prescribed, including those considered essential for a role, and mandatory organisational requirements are also included.
The system has multiple uses:
- It represents a PDP that ensures regular PDR;
- It forms the foundation of a professional portfolio, identifies learning needs and supports individuals’ CVs;
- It also acts as a hardcopy way of showing evidence of competency, and tracks how and where that competency was achieved;
- It also complies with the recommendation by Rennie (2009) that such formats should provide an assessment structure that determines safe competent practice, while stimulating continued learning.
The KSF competency development matrix
This matrix outlines the core competencies and identified learning needs nurses are expected to achieve within their first year of employment in a position. There are four designated levels of competency (Box 1), which are assessed through a combination of witnessed practical demonstration and nurses providing valid, reliable, up to date evidence that they have knowledge and skills in identified key areas. Workplacereviewers only sign off competencies when level 4 has been achieved.
Each section of the matrix focuses on a core or specific aspect of the KSF post outline that applies to the role. It states the competencies that need to be achieved within those aspects of the KSF to enable skilled practice. We identified role specific competencies and ways of meeting them by analysing the individual practice elements required within those roles. Practice records, reviewer and reviewee comments, and reflective practice frameworks are attached to each part of the matrix to provide an ongoing narrative of development.
Induction for new starters involves first attending mandatory corporate induction sessions and then starting a structured programme of work based induction that teaches and develops essential skills over time. The programme works in much the same way, whether staff members have been promoted or are taking up a position in another specialty. A typical example might be a nurse moving from a band 5 role on an acute medical ward to a band 6 community (district nurse) role. To provide a guided transition into that new role, the KSF Induction Programme Workbook for band 6 community nurses would be undertaken.
Box 1. Four levels of competency
- Level 1 Observation/demonstration. The nurse has observed and discussed the key skills within the activity and has demonstrated understanding.
- Level 2 Active involvement. The nurse can actively assist in completion of the key skills.
- Level 3 Supervised practice. The nurse has acquired and demonstrated sufficient knowledge and ability to undertake the activity within a guided or supervised context.
- Level 4 Independent practice. The nurse can consistently perform key skills and is deemed competent.
In Service training and development
The training and development department is responsible for coordinating and supporting the rolling out of the new induction and development programme. The original, two day divisional induction is replaced by a five day mandatory corporate induction and a half day KSF induction training session, which will instruct on the purpose of the new workbook and programme. These sessions will be used to advise team leaders or managers and KSF development reviewers on the system.
Training and development is also responsible for providing Open College Network accredited training modules to enhance and support structured staff development.
Implications for practice
The programme has organisational, individual and wider benefits.
- Mandatory and statutory requirements are met and monitored;
- The requirements of the KSF are met;
- The PDP and PDR system is automatic and prescribed, therefore instantaneous to implement;
- Failures in care relating to human error or skills gaps could decrease due to increased emphasis on skills based development and competency;
- The organisation provides opportunities and guidance for staff to develop competencies in their roles.
- Individual PDP and PDR is linked to career development and progression;
- The programme offers evidence supporting the negotiation of KSF pay gateways;
- It provides a basis for professional portfolio and CV;
- Improved skills mean improved confidence and ability and the capacity to deliver enhanced care and treatment.
- The programme is intended to be easily transferable to other trusts or health boards and organisations;
- It can be adapted to suit and reflect the knowledge and skills needs of other disciplines.
The ongoing development of this project is a major undertaking and the scope of the exercise is extensive. To cover all divisional nurses just in bands 2-7 in the disciplines of community, mental health and learning disabilities will require a total of 36 specific workbook programmes. This is giving attention to individual specialties, such as community psychiatric nursing, and other areas in mental health alone. Study modules and workshops also require thoughtful development and delivery in order to explain, instruct and train staff about the process. Meeting these challenges will therefore require the development of administrative staff and those in higher management positions - achieving delivery with only existing resources would take considerable time.
Although the multiple uses of this format are attractive, some might see it as a requirement for yet more paperwork or spending time away from delivering care and services. To avoid staff losing enthusiasm for the scheme they need to be aware that the is committed to a KSF review and PDP. It should also be presented as something that is positive, meaningful and of benefit to both staff and patients.
The programme can be launched by piloting it in a specified clinical area with one band of qualified nursing staff, in order to:
- Identify any difficulties and problems;
- Assess the effectiveness of the process– does it actually do what it is supposed to?
- Provide adequate training and development support and advice about the process to managers, team leaders and reviewers;
- Obtain feedback;
- Monitor progress.
Integrating personal development review and planning, induction and ongoing career development into one comprehensive and functional package has resulted in a format that succeeds on a number of levels. The programme’s flexible design means that any new skills nurses need to develop in the future can be added as required; it is comparatively simple and easy to use and its multiple uses makes it an efficient means of inducting nurses.
Practical clinical skills lie at the heart of nurses’ professional practice (Nicol and Freeth, 1998). When considering educational systems in nursing - whether the evidence is opinion or research based - structured training and an induction that focuses on essential skills is the bedrock of providing a quality nursing service that offers increased protection for both staff and patients.
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