1. The Challenges of providing an acute CCN service in Northern Ireland Peter Johnston Bsc, RGN, RSCN, CCN Community Paediatric Nurse Causeway Health & Social Services Trust

2. Northern Ireland 85 MILES 110 MILES

3. The Mourne MountainsThe Fermanagh Lakes The Giant’s Causeway

4. Statistics Population under 19 years of age=500,153 Population under 19 years of age=500,153 Population 2001 % total UK population England49,000,00083.6% Scotland5,000,0008.6% Wales3,000,0004.9% Northern Ireland 1,700,0002.9% Total Area :5,456 square miles

5. Current CCN provision in N.Ireland CCN teams are now available in every Community and combined Trust in NI CCN teams are now available in every Community and combined Trust in NI Each team has a unique skill mix and ethos but underlying is the dedication of care for sick children in their own home Each team has a unique skill mix and ethos but underlying is the dedication of care for sick children in their own home Generic teams covering all referrals Generic teams covering all referrals Specific complex needs and acute teams within Trust areas Specific complex needs and acute teams within Trust areas Limited provision of respite care in some but not all Trusts Limited provision of respite care in some but not all Trusts

6. What are the challenges ? Organisational Organisational Regional Regional Local Local Professional Professional Geographical Geographical Financial Financial Changing population profile of Changing population profile of N.Ireland N.Ireland

7. Organisational Review of Public Administration Review of Public Administration Challenges in integrating teams from previously separate trusts with differing priorities Challenges in integrating teams from previously separate trusts with differing priorities Further integration of health and social services MDT working Further integration of health and social services MDT working

8. Regional Inequalities of health Inequalities of health Inequalities of access Inequalities of access Differences in priority across trusts Differences in priority across trusts Lack of regional strategy and vision Lack of regional strategy and vision

9. Local Remaining small sizes of teams Remaining small sizes of teams Dominance of Chronic and Complex needs Dominance of Chronic and Complex needs Poor knowledge amongst GP’s and other health care professionals Poor knowledge amongst GP’s and other health care professionals

10. Professional Changing and evolving roles in community paediatrics specialisms, palliative, acute Changing and evolving roles in community paediatrics specialisms, palliative, acute Lack of representation at higher levels within trusts and board/ department level Lack of representation at higher levels within trusts and board/ department level Recruitment and training Recruitment and training

11. Geographical Largely rural population Largely rural population Inequality of access to regional services Inequality of access to regional services Closing of local hospitals / Reconfiguration of services Closing of local hospitals / Reconfiguration of services Emphasis on increased community care and specialisms Emphasis on increased community care and specialisms

12. Financial Focus on estates and revenue promotion Focus on estates and revenue promotion Reduction in service development Reduction in service development Trust priorities Trust priorities Competing service needs Competing service needs Direct rule Direct rule

13. Population profile Ethnicity -new language and cultural challenges Ethnicity -new language and cultural challenges De-urbanisation De-urbanisation

14. How we are meeting the challenges ? Regionally A Healthier Future –Twenty year vision A Healthier Future –Twenty year vision Developing Better Services Developing Better Services Children’s commissioner / Minister for Children Children’s commissioner / Minister for Children Children’s strategy Children’s strategy Strategic framework for children, young people and families Strategic framework for children, young people and familiesLocally Greater integration of services both within health and with social services Greater integration of services both within health and with social services Proposed establishment of children's directorates in each Trust area Proposed establishment of children's directorates in each Trust area Service initiatives Service initiatives

15. How we are meeting the challenges ? Quarterly CCN forum meetings Quarterly CCN forum meetings Sharing of best practice Sharing of best practice Development of equipment register Development of equipment register Guest speaker from specialist nurse forum from the regional children's hospital Guest speaker from specialist nurse forum from the regional children's hospital Biannual conference Biannual conference

16. The real challenge? Though there are many organisational and service challenges facing CCN’s in Northern Ireland the only way that we can realistically affect the future of our service is to actively become involved in the higher levels within the HPSS Though there are many organisational and service challenges facing CCN’s in Northern Ireland the only way that we can realistically affect the future of our service is to actively become involved in the higher levels within the HPSS We now have our first CCN in a senior nurse management role We now have our first CCN in a senior nurse management role Representation at Department level Representation at Department level Advancing roles of CCN’s across the region. Advancing roles of CCN’s across the region.

17. A Scottish Perspective of Community Children’s Nursing Services Presented by Karen Sinclair on behalf of the Scottish CCN network group the Scottish CCN network group March 2006

18. Scottish Demographics Scotland has a population of just over 5 million 20% of Scotland’s population are children aged 0-19years old

21. CCN Background Before Diana funding in 1999 only four health boards had established CCN services Today thirteen out of fifteen have a CCN service available

22. CCN Team Configurations

23. Qualified Community Children’s Nurses

24. Setting 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

25. Challenges of providing acute community services in Scotland Team size Travel Clinical responsibility Communication Funding for equipment and supplies Accountability

26. Challenges of providing acute community services in Scotland

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

28. The Future Promote CCN services Needs assessment and analysis Development Plans Increase skill mix in teams Employ practice development nurses Training future CCN

29. Conclusion 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

30. Acknowledgement 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

31. Advanced Practice Skills - What are they and how do we achieve them? Dr Fiona Smart Director of Studies: Advanced Clinical Practice with responsibility for CPD

32. 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?

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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.

40. So what was the question[s]? Advanced Practice Skills [1] What are they and [2] How do we achieve them?

41. 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

42. 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.

43. Catch up addressed [?] Future provision … M level thinking The next 5 years Thereafter all taught modules/ provision at Level 4

44. 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?

45. Nursing’s Past Status …. Potential … Internal tensions And its future ………………..

46. 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]

47. 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?

48. Thank you Questions?