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Competence, education andcareers in neonatal nursing:

RCN guidance

RCN CompetencesRCN Competences

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Acknowledgements

It is hoped that this RCN competency framework will be useful forall health care professionals working within neonatal nursing. TheRoyal College of Nursing and the working group would like to thankeveryone who has been involved in their development, particularlyDebra Teasdale that led this important initiative.

Fiona Smith RCN Adviser in Children and Young People’s Nursing

Document review group

Debra Teasdale, Lead for RCN Career and Education CompetenceDocument Development, RCN Paediatric and Neonatal IntensiveCare Community Steering Committee Member, Head of Health, Wellbeing and the Family, Canterbury ChristChurch University, Kent

Doreen Crawford, RCN Paediatric and Neonatal Intensive CareCommunity Steering CommitteeSenior Lecturer, De Montfort University

Denise Gray, Education Project Manager, NHS Education forScotland

Alison Gibb, British Association of Perinatal Medicine

Ruth Moore, Vice Chair, Neonatal Nurses AssociationProject Manager NIC/PIC - Staffordshire, Shropshire & BlackCountry Newborn Network East

Tina Pollard, Chairperson, Neonatal Nurses Association Clinical Service Manager – Neonates, Addenbrookes Hospital,Cambridge

Jackie Stretton, West Midlands Neonatal Pilot Project ManagerInstitute of Health and Society, University of Worcester

Alison Wright, Scottish Neonatal Nurses Group ChairpersonSenior Nurse Neonatal Services/ANNP Ninewells Hospital

Join the CYP acute care forum

If you want to learn more or getinvolved with the work of the RCNPaediatric and Neonatal Intensive CareCommunity join the CYP acute careforum today.

www.rcn.org.uk/joinaforum

R O Y A L C O L L E G E O F N U R S I N G

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RCN competences: Competence, education and careers in neonatal nursing:RCN guidance

Introduction 2- The background 2- A framework fit for purpose 3- Supporting the non-registered neonatal workforce 3- Who enters neonatal nursing? What might assist

recruitment of the future workforce? 4

1 A competence and education framework to support careers in neonatal nursing in the UK 5- Overview 5- Summary table 6- The application of level of practice to the

neonatal workforce 7- Ensuring an inclusive approach 8- Curriculum content and practical experience 9- Professional development opportunities 9

2 Competences for neonatal nursing 11- Communication and interpersonal relationships 11- Personal, professional and people development 13- Health, safety and security 14- Service development 15- Quality 16- Equality, diversity and rights 17- Responsibility for patient care 18

3 Core clinical skills for neonatal nurses 20- Fluid, electrolyte, nutrition and elimination

management 20- Neurological and pain management 22- Respiratory and cardiovascular management 23- Skin, hygiene and infection control management 24- Temperature management 24- Bereavement management 25- Investigations and procedures 26- Equipment 27

Conclusions 27

Appendices 28

1. Staffing summit working group members 28

2. Exemplar job descriptions 29

- Trainee advanced neonatal nurse practitioner

- Advanced neonatal nurse practitioner

- Senior advanced neonatal nurse practitioner

3. Mapping of competences against NHS knowledge and skills framework dimensions 42

4. Summary of recommendations 43

References 44

Glossary of acronyms 45

Contents

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R C N C O M P E T E N C E S – N E O N A T A L N U R S I N G

competency and core skills framework for Scottishneonatal nurses (SNNG, 2005). This framework drew onprevious work within Scotland (National Health Service[NHS] Education for Scotland [NES], 2002; SNNG, 2004)which was originally supported by a scholarship from theGeneral Nursing Council for Scotland (Education) Fund(1983) and Margaret Callum Rodger Midwifery Award. Inthe latest version (SNNG, 2005), the introduction of theKnowledge and Skills Framework (KSF) for the NHS(2004) allowed career pathways/progression to bedemonstrated.

The SNNG working group, which contributed to thedevelopment of the competency and educationframework, represented all those involved in neonatal careas it included clinical, managerial and neonatal nurseeducator staff from across Scotland. The intention was forit to be used by those Scottish higher education institutesthat provided post-registration neonatal education.

In England, the SNNG (2005) framework was recognisedfor its clarity and foresight in the development of neonatalnurses’ career structure. Following a detailed consultationwith local neonatal stakeholders, the framework was usedduring the revalidation of neonatal education within thehigher education institution in England (CanterburyChrist Church University, 2005). In the absence of anyEnglish, Welsh or Irish guidance the SNNG (2005)competency framework was adopted as it broadlymirrored local expectation for those who were toundertake and complete the ‘local neonatal educationmodules’ leading to recognition as a neonatal nurse.

Subsequently, and with minor adjustments, the SNNG(2005) framework has been successfully used as abenchmark of the expected standardised outcomes forcompetence and core skill development for local nursesundertaking education to allow recognition of being‘qualified in specialty’. The framework has also been usedfor neonatal nurses new to the area to help improve theirknowledge and practice to the required local standard.

It is acknowledged that a number of neonatalunits/networks have developed similar educational andcareer pathways, however, since the SNNG (2005)framework utilises the KSF (NHS, 2004) which has beenimplemented across the UK, it is considered to be easilytransferable and understandable in both practice and inhigher education environments.

In February 2008, a neonatal staffing summit wasorganised by the Royal College of Nursing’s (RCN) childrenand young people’s nursing adviser. Neonatal nursingrepresentatives from all four countries of the UnitedKingdom (Appendix 1, p.28) (UK) met to discuss anddebate the neonatal nurse staffing issues identified inreports during the previous 12 months. The issuesidentified included the need to recruit and retain nursesfrom a variety of backgrounds and to ensure that all thoseundertaking additional education to develop ‘qualified inspecialty’ status, have the same level of knowledge andskills. In addition, it was recognised that neonatal nursesrequire parity in pay and career opportunities.

As a result of the meeting the RCN published A right tocare – a position statement on neonatal nurse staffing(RCN, 2009) which was developed collaboratively andencompassed the recommendations from all parties at themeeting. One key recommendation was to establish a UK-wide competence and education framework to ensureequity in the expectations of neonatal nurses at differentlevels/stages of careers and in different geographicallocations.

This guidance presents a framework which should be usedby nurses, employers, managers, higher educationinstitutes and policy leads.

The development group also considered the changes thatare required within the current system to improverecruitment, career progression, educational provision andcompetence in this demanding specialty. A number ofrecommendations are made throughout (and summarisedin Appendix 4) to assist in the successful application of theframework within UK neonatal services.

The background

The concerns raised at the neonatal staffing summitmirrored some of those previously expressed within theScottish neonatal community over the last eight years(Scottish Neonatal Nurses’ Group [SNNG], 2003, 2004;Kerr, 2003). In addition, the situation in Scotland wascomplicated by pay inequities between midwives (who hadprovided a substantial portion of the neonatal workforce)and neonatal nurses (SNNG, 2004).

As a result, the SNNG developed a document to define a

Introduction


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A framework fit for purpose

To ensure currency, the original Scottish work (SNNG,2005) has been reviewed, adapted and developed to formthis document by representatives from the neonatalnursing community across the UK. This was undertakenin two phases.

The initial review and amendments were agreed withrepresentatives from the Neonatal Nursing Summit Groupbetween November 2008 and April 2009. This was followedby a nationwide consultation period where further minoramendments were made.

A second consultation and review (see Appendix 1, p.28) occurred during September 2010 prior to RCN approvaland publication. The draft content had already influencedpublications such as: Toolkit for high quality neonatalservices (DH, 2009), A career and development for neonatal nurses in Scotland(NES, 2010) and Standards for hospitals providingneonatal intensive and high dependency care (BAPM,2010). The second consultation ensured that this 2011document is congruent with these publications andreflects contemporary opinion.

This phase has also supported a mapping exercise of thiswork against the Skills for Health career framework. Inaddition, the nationally agreed job profiles available forNHS employers under the Agenda for Change (AfC)agreement were examined. Whilst there are a range of jobprofiles available in the profile library to support parity inpay scales across AfC Bands 4-7 (including for practiceeducator roles), there are gaps in the library in areas thatwould support specific roles such as the progressive natureof advanced neonatal nurse practitioner (ANNP)development. This document presents an exemplar jobdescription to address this issue and to assure parity inpay and conditions across the UK at all levels of neonatalnursing practice (see Appendix 2, p.29), reflecting thenature of advanced level nursing practice as definednationally (DH, 2010).

An overview of the RCN competence and educationframework to support careers in neonatal nursing in theUK is represented in table format in Section 1 (page 5),

followed by a supporting narrative within the descriptionsof Benner’s levels of practice (Benner, 1984). All threesections (Overview, Competences for neonatal nursing,and the Core skills for neonatal nursing) have beenupdated acknowledging the following:

� recent policy changes

� new/re-iterated NHS drivers

� the changing face of neonatal care

� the experience of application of the SNNG (2005)framework within the English and Scottish HigherEducation environment.

Although the framework makes reference to neonatalnurses, this term is used inclusively to describe bothnurses and midwives who are ‘qualified in specialty’ towork within neonatal care.

Supporting the non-registeredneonatal workforce

Whilst this guidance focuses on recommendations for theregistered professional workforce, it is recognised that theneonatal workforce includes non-registered support roles(nursery nurses and assistant practitioners). Individualsin such roles operate under the direct supervision of aneonatal nurse and contribute positively to babies andfamilies receiving care within the special care category. Towork within the neonatal environment, support workersmust also meet acceptable standards by undertakingadditional training and development to acquire skills inneonatal care. Initially, this should be at a minimum levelof S/NVQ 3 and should match appropriate performanceindicators: for example, the Skills for health maternitysupport worker competence summary (Skills for Health,2010).

In this context, career progression opportunities need tobe assured for all sectors of the workforce (Leitch, 2006).Following the initial embedding of knowledge to supportthe transition into neonatal care, individuals and theirorganisations may decide that the assistant practitionerrole would be mutually beneficial. The employee couldthen access a foundation degree programme, withneonatal managers determining which of the lower levelcore clinical skills are appropriate to the local neonatal-specific environments. These core clinical skills can thenbe slotted in within the work-based elements of the localfoundation degree to support the development of practicecompetence. This approach will help progression intoprofessional nursing or midwifery careers, since thefoundation degree will allow admission to professional

The RCN, and those involved in the creation of thisUK-wide career and education framework forneonatal nurses, are very grateful for the extensivework done by Scottish neonatal nurses and the SNNGduring the last eight years, and acknowledge that theirwork forms the backbone of this new document.

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registration programmes and continuous careerdevelopment as indicated within the Skills for Healthcareer framework (2006). Exemplars of how this can betranslated into neonatal environments are alreadyemerging, for example, in NHS West Midlands (2010).

Who enters neonatal nursing?What might assist recruitment ofthe future workforce?

Neonatal nurse recruits have historically come from avariety of different professional groups and many wouldargue that this enriches the neonatal teams (Blake andTeasdale, 2008). This variety is reflected in the educationlevel/qualification part of the framework. However, it isacknowledged that registered children’s nurses (RNChild) are considered the most desirable candidatessince their training encompasses core knowledge foreffective nursing of the child and family (RCN, 2003).Midwives are also educated to effectively care for aneonate who requires special care and their parents. InScotland, the predominant professionals within theneonatal workforce have, until recently, been midwives(SNNG, 2005). Many units in the UK continue to employand attract those trained as registered general nurses(RGN) or RN (Adult) who have limited, if any, directneonatal experience during their pre-registrationprofessional education.

Although midwives and children’s nurses experience‘neonatal care’ during the required pre-registrationeducational programme, the level of neonatal input varies.This inconsistency is compounded since placementopportunities on neonatal units may be limited due to thecompetitive pre- and post-registration curriculum.

To address the long-term needs of neonatal nurserecruitment the following recommendations have beenmade for the education of pre-registration children’snurses and midwives:

� all pre-registration children’s nurse and midwiferyprogrammes must include a course of study focusingon the care of the sick or compromised neonate

� this should be complemented by a neonatal placementopportunity of not less than four weeks (for example, intransitional care areas, special care/neonatal units).

There is a disparity in the recruitment policies across theUK, where employers refuse to accept newly qualifiedmidwives but accept newly qualified RN (Child) or RN(Adult) as recruits (Blake and Teasdale, 2008). This

disparity should be addressed at local level. The followingrecommendations are made for those employing newlyqualified nurses and midwives:

� newly qualified nurses or midwives who are offeredemployment within neonatal care should have access toa full preceptorship package as well as a full range offuture neonatal nursing career opportunities

� a contract of employment may offer rotationalplacement through the neonatal unit for the first 18months.

In England, problems with updating skills to maintainmidwifery practice have frequently led to those with dualqualifications opting to ‘lose’ their midwifery professionalstatus. However, the historical educational shift to ‘directentry’ midwifery means that newly qualified midwiveswanting to develop a career within neonatal care must beable to update to maintain their professional status (NMC,2004). Anecdotal evidence suggests that whilst themidwifery skills employed within neonatal nursing aredeemed sufficient for the purposes of updating in someareas, this is not uniformly accepted. As a result midwivesare dissuaded from pursuing a neonatal career. Whenemploying either newly qualified or established midwivesin neonatal care, it is recommended that:

� the organisation has a clear policy to allow for statutorymidwifery updating within normal working time in theneonatal unit so as to help maintain registration as amidwife.

Finally, when employing newly qualified staff or staff withno experience of neonatal care:

� all new members of staff who enter into neonatal careare viewed as ‘novices’ regardless of their background.

This last recommendation reflects the starting pointidentified within the work of Benner (1984), whichunderpins the levels of practice described within theframework. Additionally, this approach reflects thebackdrop to neonatal care where careers progress atdifferent speeds depending on external factors. Thiscontinuum of development for the neonatal nurseacknowledges that, whilst some nurses will movesystematically through the stages and take on leadershiproles, others may accelerate through the levels of practicedue to prior experience. Finally, some staff may chose toremain at a particular stage according to personal andprofessional need, continuing to make valuable andrelevant contributions within their sphere of competence.


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Overview

Table 1 (p.6) provides a visual representation of howneonatal nurses are able to develop from the point ofregistration across Benner’s stated levels of practice.Career progression through these levels of practice isachieved through three elements.

1. Knowledge acquisition demonstrated though specificprogrammes of education either within or external tohigher education.

2. Using this knowledge to demonstrate competence(which has been linked to the KSF (NHS, 2004).

3. The practical development of core clinical skills (whichrelate directly to responsibility for patient care).

The development of this framework reflects current goodpractice and the requirements for career progressionwithin health care settings (Skills for Health, 2006). It aimsto ensure equity in the career and educationalopportunities available to meet the needs of neonatalnurses, the employing organisation and the wider neonatalcommunity as a whole. As a result it is recommended that:

� this framework is used throughout the UK to informworkforce development and educational plans inpractice environments

� the associated competences, core clinical skill set andmatched educational requirements should be used atpractice level and by HEIs to underpin and benchmarklocal provision.

As such the ‘competences’ in this document are describedin more detail than the broad statements within theToolkit for high quality neonatal services (DH, 2009),which will be beneficial during any audit of local neonatalservices following the introduction of the specialistneonatal care quality standards (NICE, 2010).

The ‘Benner’s level of practice’ entry point into thestructure will vary depending on an individual’s priorexperience, skill set and educational attainment. To ensureequality in recruitment and career development practicesacross the UK it is recommended that:

� employers should be encouraged to use the knowledge,level of educational achievement, and specified skill setto support the development of job descriptions andspecifications

� the framework may also be used to map priorexperience and competence to determine individualdevelopment needs and potentially accelerate careerprogression.

The educational aspects reflect expected entryqualification for each level of the framework, continuingprofessional education for contemporary practice, and therequirements for progression to allow transition to higherlevel of practice/competence.

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A competence and education framework tosupport careers in neonatal nursing in the UK

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Benner Levelof practice

Minimum professional/educational entryrequirements

Continuous professionaldevelopment

Competence level and broaddescription of level of practice/role

SfH careerframework*

Novice/advancedbeginner

Registered nurse (RN) (Childor Adult)or registeredmidwife (RM)Diploma /degreequalification.

Preceptorship programme for newlyqualified staff.Induction/foundation education inneonatal care. To remain in role1. Work toward degree qualification(if diplomate).2. One year post qualification - NMCapproved mentorship course.3. Continuous updating to remaincontemporary.

Achieves and maintains competence and coreskills for new entrants.Initially - acquires basic skills and knowledgefor practice for supervised practice in specialcare. Once practice level has reachedconsistently high standards this role mayextend to high dependency care undersupervision, prior to undertaking postregistration qualification.

Level 5 –Practitioner

The nurse may remain at this level, maintaining competence but should be encouraged and supported to develop further toprepare for the specialist course.

- Undertake post-registration qualification in neonatal nursing (special, high dependency and intensive care) to supportdevelopment of competence and core skill as neonatal nurse (QIS) status.- Works towards neonatal nurse (QIS) competence and core skills under direct supervision of NMC qualified mentor in highdependency and intensive care environments.

Competent

RN (Child/Adult) or RMPost registration neonatalqualificationEngaged with degree levelstudyNMC mentor.

To remain in role 1. Consolidates knowledge andskills development.2. Continuous updating to remaincontemporary.3. NMC approved sign-offmentorship programme.

Achieves and maintains neonatal nurse (QIS)competence and core skills.

The neonatal nurse is qualified to work withinall areas of neonatal care.

Level 6 –Seniorpractitioner

The neonatal nurse may remain at this level, maintaining competence or may choose to develop further.– Undertake study in neonatal nursing at honours degree/postgraduate level to support development of competence andcore skill at experienced neonatal nurse status and potential role development.– Works towards competence and core skills for experienced neonatal nurses under the supervision of an experienced expertnurse with sign-off mentor qualification.

Proficient

RN (Child/Adult) or RMPost registration neonatalqualificationNMC sign-off mentorqualificationHonours degree qualificationor recognition of priorexperiential learning inclinical, education, leadershipor management roles.

To remain in role1. Consolidates knowledge andskills development.2. Continuous updating to remaincontemporary.3. NMC approved practiceeducator/lecturer programme forthose leading in-house/HEeducation.

Achieves and maintains competence and coreclinical skills for experienced neonatal nurses.

Experienced neonatal nurses work inprescribed nursing roles such as neonataltransportation, shift management roles (eg,ward charge nurse/sister), development carelead, lactation support, community outreachpractitioner, practice development/clinicaleducator.

Level 6 –Seniorpractitioner

Level 7 –Advancedpractitioner

The neonatal nurse may remain at this level, maintaining competence or may choose to develop further.- Undertake postgraduate study to support future role development and the development of competence as an expertneonatal nurse. - For clinical practice role development works towards core skills for expert neonatal nurses (or locally determinedequivalent) under supervision (expert nurse with an NMC approved sign-off mentor qualification or an appropriately qualifiedmember of the medical team)

Expert

RN (Child/Adult) or RMPost registration neonatalqualificationNMC mentor/practiceeducator qualificationEducated to Masters levelRecognition of priorexperiential learning inclinical, education,leadership or managementroles.

To remain in role1. Consolidates knowledge andskills development.2. Continuous updating to remaincontemporary.3. Access to doctoral and post -doctoral study to advance neonatalnursing in the future.

Achieves and maintains competence forexpert neonatal nurses.For those in clinical practice expert roles,achieves and sustains core clinical skills setas specified within expert level or as locallydetermined.Expert neonatal nurse roles include neonatalunit manager, neonatal practicedevelopment, facilitator/researcher,established advanced neonatal nursepractitioner, neonatal nurse consultant.

Level 7 –Advancedpractitioner

Level 8 –Consultant


Summary table

Table 1. Overview of RCN competence and education framework to support careers in neonatal nursing

* The career framework levels do not equate directly to Agenda for Change pay bands.


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The application of level ofpractice to the neonatalworkforce

Benner level – The novice/advanced beginner:new entrant For those with no prior experience of the sick orcompromised neonate following initial registration, thiswould be the point of entry into the RCN career andeducational framework to support neonatal nursing acrossthe UK.

All newly qualified entrants to the neonatal nursing willrequire a period of preceptorship in order to make thetransition from student to accountable practitioner (NMC,2006). Preceptorship programmes should be aligned withlocal induction programmes to help the new entrantbecome familiar with local policies and procedures.

During preceptorship and beyond, these ‘novices’ would besupported whilst developing the competences and coreclinical skills needed to help them provide basic carewithin special care situations. This practical developmentwould be complemented by the acquisition of additionalknowledge via in-house, network or HEI study sessions –so creating a foundation of knowledge to support initialand subsequent career development (DH, 2009).

An established nurse or midwife in this career level (oneyear post-registration) would be expected to commencework towards an NMC recognised mentorship qualification.They would then be in a position to mentor student healthcare professionals during neonatal placements in theirspecified area of expertise (NMC, 2008a).

Nurses and midwives working at this level would not beexpected to work routinely with complex neonates in anycare category and, although they should have insight intohigh dependency/intensive care, they would not beequipped to provide these levels of care without directsupervision.

Career progression

Those who aspire to advance their career should beencouraged to work towards the requirements for thecompetent level of practice by undertaking a recognisedpost registration specialist neonatal education course. Thiswill involve developing care knowledge and skills withinhigh dependency and intensive care environments underdirect supervision of a nurse who is qualified in specialty(QIS), plus the attainment of competence and core skill setof the neonatal nurse QIS.

Benner level – Competent: the neonatal nurse(QIS)Progression to neonatal nurse status can happen aftersuccessfully completing a post-registration course of studyand demonstrating the competences and core clinicalskills as a neonatal nurse QIS.

Although the term neonatal nurse is not recordable on theprofessional register, it is essential from a workforceperspective that the knowledge, skills and competencesinferred by this status are transferable across the UK.Therefore the theoretical component of the specialisteducation needed to be a neonatal nurse should be basedwithin the UK HE sector, which is subject to rigorousquality control to ensure a standardised level ofattainment. Such courses of study will be consistent withHE undergraduate degree level, specifically focused on theneonate across all the care categories as defined nationally(BAPM, 2001). Currently, in England, neonatal modules ofstudy within higher education are generally 40-60 HEcredits at HE level 5 or 6, which reflects the requirementsin Scotland where courses are 40 credits at SCQF level 9. Asthere is a move towards an all-graduate nursing/midwiferyprofession it is recommended that:

� future provision of specialist education to support the‘neonatal nurse’ should be offered at a minimum ofundergraduate degree level.

This will help those with diploma or equivalentqualifications, gained in the UK or abroad, attain degreesand promote graduate status for nurses1 . All nurses whoundertake this level of study and skill acquisition shouldbe recognised within the neonatal community as neonatalnurses in line with previous recommendations (NES,2002).

Career progression

The neonatal nurse may choose to remain within thecompetent level of practice, embedding education andcontinuing to demonstrate knowledge, competence and coreclinical skills of the neonatal nurse QIS. Neonatal nurses willassume personal responsibility for continuing professionaldevelopment to support practice (NMC, 2010a). Neonatalnurses will teach and supervise learners in the skills withintheir range of competence, so must work towards a

1 Whilst postgraduate study may be undertaken by graduatenovices, this is not considered essential, and there is anecdotalevidence to suggest that undergraduate study is more acceptable toNICU due to the novice nature of the nurses in clinical practice. Onesolution is for novice graduate nurses to be accommodated byundertaking 60 credits at a nationally defined level to gain a specificHEI award, e.g., Graduate Certificate in Neonatal Care or transfercredit towards an honours degree.

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recognised NMC mentorship qualification (with sign-offresponsibility – reflecting the principles already evidentwithin pre-registration assessment [NMC, 2009a]).

The neonatal nurse can progress if they engage inadditional experience and education to achieve theknowledge, competence and core clinical skill set for theexperienced neonatal nurse who operates at the proficientlevel of practice. Typically, this will require completion ofthe undergraduate degree programme of study.

Benner level – Proficient: the experiencedneonatal nurseExperienced neonatal nurses function at this level ofpractice and will provide effective management of alllevels of neonatal care. They are sufficiently experiencedto act independently within a multidisciplinary/multi-agency context and include roles such as:

� neonatal transportation

� shift management, for example, ward chargenurse/sister

� development care lead

� lactation support

� community outreach practitioner

� practice development/clinical educator.

The experienced neonatal nurse will have completed anacademic degree that supports an individual’s higher levelfunctioning in the neonatal unit. Such an award may givethem eligibility to record a professional qualification ofSpecialist Practitioner .

In collaboration with medical staff, the experiencedneonatal nurse will assess, plan, implement and evaluatethe overall management of babies requiring all levels ofneonatal care; will assess and manage critical and clinicalevents to ensure safe and effective care, summoningappropriate assistance as necessary; and will facilitatelearning by others in the neonatal unit (NMC, 2008a).

Career progression

Experienced nurses working at the proficient level ofpractice would, like all others, be required to maintainpractice (NMC, 2008b) and will demonstrate competenceand core clinical skills as an experienced neonatal nurse.

However, those that aspire to the expert practice level willdo postgraduate higher education study leading towards amaster’s degree qualification. The experienced nurse canalso work towards developing the competence and coreclinical skills associated with expert roles in neonatalnursing.

Benner level – Expert: specific andindependent neonatal nursing roles Experienced neonatal nurses may choose to furtherdevelop their knowledge, skills and competence to thislevel to become an expert neonatal nurse who is able tofunction in an independent role. An expert nurse will beinvolved in national guidance, debate and policy. Roles atthis level may include the following:

� neonatal manager – providing service management fora defined area

� neonatal practice development facilitator/researcher –promoting best practice, including undertaking clinicalresearch

� advanced neonatal nurse practitioner – providing totalcare for a caseload of babies, achieved through anaccredited educational programme and working withina designated advanced neonatal nurse practitioner role

� neonatal nurse consultant – championing strategicpolicy development.

Expert neonatal nurses will have undertaken postgraduatestudy to support and develop their roles. Whilst all operateat expert level of competence, only clinical practice expertswould be operating at expert level of the core skills as thisis not a requirement for those whose role have divertedfrom direct provision of neonatal care.

Career progression

Experts will engage with appropriate CPD opportunities toremain up to date (NMC, 2010a) and assist in theeducation and development of the future workforce asrequired locally (NMC, 2008a). To further developexpertise and enhance neonatal care will involve thecompletion of a master’s degree and/or commencing adoctoral study.

Ensuring an inclusive approach

Whilst the framework identifies a clear role for HEIs, thisshould not preclude those who have undertaken a locallyprovided in-house course from gaining recognition of thestatus as a neonatal nurse who demonstrates thecompetent level of practice. It is recommended that:

� local HEIs and neonatal intensive care unit (NICUs)should work in partnership to develop the Accreditationof Prior Experiential Learning (APEL) routes availablewithin HEI regulations to allow acknowledgment ofneonatal education packages within a recognised HEIbased programme of study. This will help ensure that a


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neonatal nurse isn’t disadvantaged by theorganisational approach.

Curriculum content and practicalexperience

This document does not include a specified curriculum ofcontent for each level, but it is recommended that thecontent of any theoretical programme of study offered tosupport development at any level in the framework should:

� reflect contemporary and evidence-based practiceconcurrent with the level of practice being aspired to

� ideally be determined by partnership, working betweenthe HEI and local neonatal providers

� take account of professional and subject benchmarksas these become available

� be organised as a package to span the requirements forthe full range of nursing care across each neonatal carecategory (BAPM, 2001).

It is also recommended that modules or courses of studycontributing towards any programme of study should:

� meet the needs of those across the career continuum byoffering flexibility.

For example, nurses who choose to remain employedsolely within the special care or high dependencyenvironments should be able to complete discreteelements/ modules of study to meet their needs, whilstother nurses wishing to develop full neonatal nurse statusare able to access additional study.

In order for the nurse to reach the required level ofpractice which is underpinned by the competence and coreskill set it is recommended that:

� the individual is concurrently accommodated in apractice environment which provides a level of carewhich complements the focus of study and allowssufficient time to develop the required competence.This should be specified within any prerequisite for HEstudy - arranging this would be the responsibility of thesponsor/employer

� all units must have established mechanisms forpreceptorship/mentorship, which may include medicalcolleagues where appropriate

� HEIs develop formal assessment of practice tools tosupport the programme of study (which should bebased on the competence and core clinical skill set) toensure equity in practice outcomes across the UK

� those undertaking the development of practice areformatively and summatively assessed by a mentor whomeets the NMC requirements for the profession

� that prior experience is mapped against the competenceset to help acceleration across the career frameworkwhere possible.

It is essential that all courses of study should produceneonatal nurses who are able to:

� operate effectively within the dynamic environment ofcare

� care effectively and advocate for the babies and thefamily

� care for themselves and others within themultidisciplinary team.

Professional developmentopportunities

There is a statutory requirement to ensure that individualsupdate their practice in order to ensure currency of theprofessional qualification. This is reflected in the structureat all levels. It is recommended that:

� strategic education and development plans shouldencompass this. In the UK this should be led bynetworks. The organisation is similar butgeographically determined in Scotland, Wales andNorthern Ireland

� events could also be considered by the local HEIs tocontribute towards academic credits under theAccreditation of prior experiential learning (APEL)system as above

� individual practice must remain contemporary sonetworks should explore rotational opportunities forstaff between units to support this (wheregeographically possible)

� mechanisms, such as the NHS staff passport, be utilisedeffectively to allow development opportunities betweenNHS providers.

It is recognised that all nurses involved in the delivery ofneonatal care must conduct themselves in a professionalmanner, to include: confidentiality; empathy; information-giving, and liaising with other staff. Effectivecommunication with parents, carers, staff and othercolleagues is essential at all levels of nursing practicethrough:

� active listening and acknowledging

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� responding and explaining

� questioning and negotiating

� analysing and facilitating.

At all levels, nurses should be aware of how to contactrelevant colleagues when required and understand thebarriers and boundaries to effective communication.

Planning, assessment and evaluation are essential parts ofall care and the decisions taken at all levels. Accuraterecord keeping and documentation is a fundamental partof all nursing, and midwifery practice and are importanttools in promoting high quality care. Records anddocuments must be legible, accurate, concise and up todate, and comply with the NMC standards (NMC, 2009b).At all levels, the nurse must be able to initiate andmaintain accurate care plans and document the outcomesof nursing and other interventions.

In neonatal environments nurses and midwives need towork in partnership with parents, families and carers.Arguably, this is implicit within the professional educationof child nurses and midwives; however, it is recommendedthat:

� additional input regarding partnership working withparents, families and carers should be available for allnurses and midwives during the initial preceptorshipperiod.

This is especially important since neonatal nurses are in aunique position to act as an advocate for the neonate andcan play a vital role in child protection.

In addition, all neonatal environments should aspire todevelop and sustain a culture of personal development,lifelong learning and support. It is recommended that:

� clinical supervision is separate to managerialsupervision within neonatal units as a way to promotedevelopment and reflective practice on a personal level

� in addition, the unit processes should providemeaningful opportunities for regular team debriefing,such as neonatal and perinatal audit meetings.


11

The development of competences are integral to theneonatal nurse career development as seen above. In orderto fit in with current NHS career structure anddevelopment, the competences were derived with guidancefrom the KSF (NHS, 2004) core dimensions. Aspects offamily-centred and developmental care are part of the coredimensions which are presented under the followingheadings:

� communication and interpersonal relationships

� personal, professional and people development

� health, safety and security

� service development

� quality

� equality, diversity and rights

� responsibility for patient care.

The competences included under each heading overlapwith several of the specific dimensions of the NHS (2004)KSF, therefore these are included as subheadingsthroughout (see Appendix 3, p.42).

Communication andinterpersonal relationships

Including data processing and management, productionand communication of information and knowledge, andthe design and production of visual records.

The neonatal nurse will use a wide range of media tocommunicate effectively with babies, parents, carers andhealth care workers. The neonatal nurse will demonstrateinterpersonal behaviour and skills conducive to developingand maintaining therapeutic and professionalrelationships.

Elements� Communicate effectively with babies, families, relatives,

carers and other professional colleagues.

� Act as the neonate’s advocate.

� Maintain effective and supportive communicationwithin the neonatal nursing team and with otherprofessionals.

� Contribute to creating an environment that fosters opencommunication and trust with families and colleagues.

� Liaise with health care professionals and individuals inother disciplines from within and outside theorganisation to support quality patient care.

Tools� All forms of communication – oral, written, electronic,

body language, tone of voice.

� Active listening.

� Facilitating.

� Advising and counselling.

� Influencing and persuading.

2

Competences for neonatal nursing

7 Appendix 3 – Mapping of the proposed competences to NHS(2004) KSF

12


New entrant Neonatal nurse (QIS) Experienced neonatal nurse Expert neonatal nurse

• Understand theimportance ofeffectivecommunication.

• Demonstrate theability to communicateeffectively andefficiently withcolleagues.

• Communicate tactfully,maintaining trust,integrity andconfidence.

• Use effectivecommunicationstrategies to work withbabies and inpartnership withparents/carers, givethem all informationnecessary to helpinformed choice, tomeet the needs of theneonate.

• Collect, collate, record,input and reportroutine and simpledata and information.

• Maintain accurate andup to date records.

• Develop a rapport andcommunicateeffectively within theneonatal team andwith other health care.professionals, aboutroutine and dailyactivities, overcomingdifferences that mayexist.

• Promote effectivecommunication withbabies, families andcolleagues.

• Within the realm ofallocated responsibilityinfluence and teachothers.

• Structure, analyse,interpret and reportfactual data andinformation andsupervise others in themaintenance ofaccurate and up todate records.

• Check information,confirm accuracy,recognisediscrepancies and takeappropriate action.

• Process, modify and managedata and information.

• Write complex reports.• Prepare and deliver

presentations.• Establish and maintain

communication withindividuals and groups aboutcomplex and difficultneonatal matters, overcomingany problems.

• Actively support and leadinitiatives to ensure optimalcommunication of local andnational policy directives andinformation relevant toneonatal care.

• Persuade, motivate, influenceand negotiate with a widerange of people to assist withdecision-making and actionas required.

• Analyse, interpret and reportinformation and knowledgerelated to ideas andconcepts.

• Influence strategic policymaking at local and nationallevel.

• Lead meetings, givepresentations and influence awide range of individuals andgroups at strategic level to takeaction and make changes.

• Receive and process complex,sensitive and contentiousinformation, initiating actionsrequired.

• Establish and maintaincommunication with variousindividuals and groups oncomplex, wide ranging,potentially stressful topicsrelated to neonatal services.

• Enable effectivecommunication to overcomebarriers.

• Design/develop strategies toprocess and manage data andinformation.

• Analyse, synthesize andpresent knowledge andinformation about complexsubjects and concepts toinfluence key decisions.

Competences for the four levels of neonatal nursing practice


13


• Contribute to ownpersonaldevelopment.

• Be aware of limitationsof skills, scope ofprofessional practicein neonatal nursing,exercise accountabilityand seek advice andsupport accordingly.

• Demonstrate acommitment tocontinuousprofessionaldevelopment andactively participate inthe appraisal process.

• Actively participate inteaching programmesand facilitate learning .

• Recognise signs ofown negative stressand seek appropriatesupport.

• Develop knowledgeand skills to remain‘current’ in practice,disseminating newknowledge and skillsfor wider benefit.

• Identify ownlimitations and/orknowledge and skilldeficits, formulate aplan of action andorganise developmentopportunities toenhance continuousprofessionaldevelopment.

• Recognise limitationsof others, providesupport, informationand teaching to othersto help theirdevelopment.

• Recognise signs ofnegative stress inothers, offer supportand work towardsalleviation of tension.

• Develop own knowledge,skills and practice andcontribute to thedevelopment of others.

• Act as a resource of specialistknowledge and clinicalpractice.

• Foster an environment thatencourages staffdevelopment, supporting andcounselling staff asnecessary.

• Develop, deliver and evaluatestaff developmentprogrammes that support theachievement of clinical skills,leadership and best practicein neonatal nursing.

• Demonstrate knowledge ofpublic policies and participatein professional activities thatrelate to the advancement ofneonatal nursing practice.

• Develop and evaluate own andothers’ knowledge and practiceacross professional andorganisational boundaries.

• Identify and deliver strategiesto ensure the provision ofeducation and developmentprogrammes to meet the needsof the neonatal service.

• Support the development of aculture in which professionalslearn together .

• Support the development of aculture in which individuals arevalued and interprofessionallearning is encouraged.

Personal, professional and people development

The neonatal nurse will assume responsibility for personal professional development, demonstrating a commitment tolifelong learning and activities that enhance knowledge, skills, values and attitudes required for safe and effective neonatalnursing practice.

Elements� Practice at all times within current legislation, professional rules, codes and guidelines.

� Provide ongoing evidence of competence through maintenance of a personal professional portfolio.

� Develop self and others.

� Contribute to practice development through active participation in clinical working groups.

� Contribute to the development of the philosophy of shared governance within the neonatal team.

� Facilitate and actively participate in clinical support activities and orientation of colleagues and learners.

Tools� Formal learning.

� On-the-job training opportunities.

� E-learning.

� Access to specific training and awards.

� Networking.

� Clinical supervision.


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• Be aware of, andcomply with, local andnational health andsafety legislation,infection controlpolicies, and clinicalgovernance and riskmanagementregulations.

• Assist in maintaining asafe and secureenvironment.

• Identify potential risksin the workplace andtake appropriateaction to minimiserisk.

• Participate in thepreparation andmaintenance ofneonatal equipment.

• Identify emergencysituations, summonhelp and act withinown level of expertise.

• Actively implementlocal and nationalhealth and safetylegislation, infectioncontrol policies,clinical governanceand risk managementregulations, andintegrate these intopractice.

• Manage emergencysituations, summonappropriate help, andact within own level ofprofessionalcompetence.

• Monitor and maintainthe health, safety andsecurity of self andothers in the neonatalunit.

• Prepare and maintainequipment.

• Support others to deal withemergency situations.

• Carry out risk assessmentsrelated to neonatal care andmanage those risksappropriately.

• Ensure all appropriatemeasures are taken inrelation to infection control.

• Act as a role model andpromote best practice inhealth, safety and security.

• Prepare and maintainequipment and ensure stafftraining is current and up todate.

• Contribute to staff training.

• Ensure the workingenvironment complies withorganisational, professionaland legal requirements andguidelines.

• Monitor safe work practices.• Assume line management

responsibility for accident/incident reporting andmonitoring.

• Develop a culture that activelyimproves health, safety andsecurity.

• Promote risk managementstrategies in the neonatal unit.

• Acknowledge/identify trainingneeds of staff, negotiateresources, facilitate training tomeet needs.

• Ensure best practice in health,safety and security, includingadequate training for staff.

• Develop and provideappropriate trainingopportunities.

• Assess the need for, andmanage the purchase of,equipment to support neonatalcare.

Health, safety and security

The neonatal nurse will use a range of policies, procedures and protocols that optimise a safe and secure environment thatsupports neonatal practice.

ElementsMaintain and promote health, safety and security.

Demonstrate knowledge of and comply with local and national health and safety legislation, infection control policies, andclinical governance and risk management regulations.

Contribute to maintaining a safe and secure environment.

Tools� Health and safety legislation and policies.

� Infection control policies.

� Clinical governance.

� Risk management.

� Moving and handling.

� Staff governance.

� Training/mandatory updates as defined in employer’s health and safety policies and procedures.



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• Assist in maintenance anddevelopment of theneonatal service.

• Act as a role model forjunior colleagues andlearners and superviselearners as appropriatewithin predeterminedparameters and providefeedback.

• Comment on policies,procedures or possibledevelopments.

• Participate in partnershipworking within theneonatal unit.

• Assist with the logistics ofmoving babies andequipment within theservice.

• Recognise the need toorganise and prioritiseworkload as part of ateam, taking note ofactivities within theneonatal unit.

• Be aware of, andmaintain, the physicalresources in the neonatalunit.

• Be aware of, andefficiently use, thefinancial resources in theneonatal unit.

• Supervise junior staffwithin predeterminedparameters andprovide feedback.

• Develop leadershippotential within theclinical environment,acting as a role modelfor staff and peers.

• Participate inpartnership, workingwith individuals,groups and otherswithin the neonatalunit.

• Within the realm ofallocatedresponsibility,effectively manageresources in theneonatal unit.

• Within the realm ofdelegatedresponsibility,contribute to thedevelopment ofneonatal care.

• Plan own time andprioritise over a dailyand weekly time-scale.

• Organise the logisticsto move babies andequipment.

• Actively contribute and participatein the development of neonatalservices.

• Provide effective professionalleadership, facilitating change anddeveloping the service in responseto changing health care needs.

• Proactively organise andparticipate in resource andneonatal unit management,maximising resources andcontributing to the managementand development of staff.

• Highlight and instigate actionplans to manage deficits inresources.

• Deputise for the line manager.• Be involved in the

recruitment/selection andpersonal professionaldevelopment of staff.

• Develop and sustain working withindividuals, groups, agencies andothers involved in neonatal care.

• Propose policy/service changes.• Allocate, delegate, co-ordinate,

monitor and assess work of theteam and individuals.

• Plan and organise several complexneonatal care activities.

• Organise and prioritise conflictingworkload demands.

• Prioritise the movement of babiesand equipment.

• Develop strategies and policies for neonatalservice development at local and national level.

• Monitor staff development.• Lead a team with complex work activities by

establishing objectives and standards.• Develop, sustain and evaluate partnership

working with individuals, groups, agencies andothers involved in the provision of neonatalcare.

• Develop, implement and evaluate policies andstrategies for recruiting, deploying, developingand retaining staff.

• Demonstrate a critically analytical approach tostrategic decision making and judgementsrelated to neonatal care.

• Provide leadership and management inneonatal nursing through effective rolemodelling, offering vision for the advancementof neonatal nursing.

• Empower neonatal nurses in practice andstimulate co-operation and enthusiasm withinthe neonatal nursing team.

• Prepare, develop and monitor financial andmaterial resource for a range of complexneonatal care activities.

• Identify success criteria and establishmonitoring systems for neonatal nursingpractice.

• Plan and manage projects related to servicedevelopment.

• Develop strategies to ensure safe and efficientmovement of babies and equipment.

• Secure physical and financial resources andestablish strategies for their use.

Service development

Including logistics, facilities maintenance and management,partnership, leadership, management of people, andmanagement of physical and/or financial resources.

The neonatal nurse will demonstrate knowledge of effectiveinter-professional working practices that respect and utilisethe contribution of all members of the health care team.

The neonatal nurse will contribute effectively to theplanning and organisation of neonatal care services tomaximise the provision of a high quality service to babies,parents, families and carers.

Elements� Demonstrate ability to co-ordinate, organise and

prioritise workload.

� Demonstrate leadership skills within the neonatalnursing practice.

� Maintain collaborative working relationships with themultidisciplinary team, the general public and externalagencies.

� Setting goals andobjectives

� Supervising andfacilitating

� Delegating

� Equipment

� Operational planning

� Budgeting

� Controlling andmonitoring

� Administration

� Leading, managing anddeveloping staff

� Coaching andmentoring

� Visioning

� Resources

� Time management

� Prioritising

� Project planning

� People management

� Manage resources effectively.

� Be receptive to new developments in the provision ofneonatal care.

� Participate in clinical governance initiatives.

Tools


16



• Adopt aquestioning/reflectiveattitude towardsclinical practice,seeking and utilisingbest evidenceguidelines in theprovision of care tobabies and theirfamilies.

• Assist with audit,research anddevelopment projects.

• Adopt a criticalapproach to clinicalpractice and encouragequestioning/reflectionin others to promote aculture of best practicein neonatal care.

• Identify areas forpractice development,suggest improvementsutilising localmechanisms and assistwhere appropriate withthe change process.

• Demonstrate skills andunderstanding of auditmethodology,principles andevidence basedpractice.

• Assess and analyseinformation to solveproblems.

• Make recommendations thathave a positive impact onneonatal care.

• Instigate and facilitateresearch and audit.

• Proactively foster a culture ofenquiry and facilitate changeto integrate best evidenceinto neonatal care.

• Make decisions and developsolutions to problems thatinvolve clear risk and may haveno clear answer.

• Make significant decisions thathave a direct impact on themedium or long-termperformance of the neonatalunit.

• Analyse and develop solutionsfor complex professional,clinical or managerialproblems.

• Identify areas for research inclinical practice.

• Participate in and/or leadresearch projects incollaboration with others.

• Participate in the systematicreview of protocols, treatmentplans and outcomes todetermine their effectiveness inmeeting established standardsof care.

Quality Including research and development.

The neonatal nurse will demonstrate commitment to evidence-based practice, using research, quality standards andclinical audit tools.

The neonatal nurse will demonstrate critical thinking approach to problem solving to enhance neonatal care.

Elements� Actively use a problem solving approach to care delivery and the needs of the neonate.

� Utilise research skills, critically appraise and evaluate neonatal practice.

� Contribute to the maintenance of an environment within the neonatal unit where research, quality and clinical auditare valued.

� In collaboration with the multiprofessional team, audit standards of care delivery.

� Use decision-making skills.

Tools� Creative thinking.

� Decision making.

� Research.

� Audit.

� Evaluation.

� Making recommendations.

� Reflective practice.



17


• Assist in maintaining anenvironment in whicheveryone – includingbabies, parents/carers,families and colleagues– is treated equitablyand with respect.

• Act in a manner thatsupports equality,diversity and rights of allindividuals.

• Act as an advocate forbabies’ rights.

• Recognise and respectthe preferences andbeliefs of thefamily/carers.

• Reflect on and challengepersonal assumptionsand ways of working.

• In relation to childprotection, be aware ofrole and responsibilitiesand activatesafeguardingprocedures whennecessary, seekingsupport as required.

• Reflect on andchallenge assumptionsand ways of working ofothers.

• Support anenvironment in whicheveryone – includingbabies, parents/carers,families andcolleagues – is treatedequitably and withrespect.

• Provide parents withthe informationrequired for them tomake informeddecisions regardingtheir baby.

• Promote an environment inwhich everyone is treatedequitably and with respect.

• Enable parents to makeinformed decisions regardingtheir baby and support themin their decisions.

• Identify the potential for andtake action to prevent orrectify discrimination andcompromise of rights.

• Interpret and challenge waysof working and developappropriate solutions.

• Act as an advocate on behalfof those whose rights havebeen compromised.

• Actively develop and promotean environment in whicheveryone is treated equitablyand with respect.

• Develop anti-discriminatorypolicies/procedures andprovide appropriate supportservices for babies, parents,carers and staff that complywith legislation, professionalregulations and best practice.

• Monitor effectiveness ofequality, diversity and rightspolicies and proceduresthroughout the neonatal unit.

• Regularly reviewimplementation, effectivenessand compliance with equalityand diversity legislation.

Equality, diversity and rightsThe neonatal nurse will practice within a legal, professional and ethical framework that includes local guidance, employerguidance, policies and procedures, ensuring that their own actions support and promote equality, diversity and rights.

ElementsKnow, understand, use and integrate into practice all current legislation, rules and codes that are relevant to neonatalnursing practice, including:

� Code of Professional Practice

� Midwives’ Rules and Standards

� The Children Act, Safeguarding Framework and local procedures

� International Convention on Human Rights/The Rights of the Child.

Tools � Creative thinking.

� Decision making.

� Research.

� Audit.

� Evaluation.

� Making recommendations.

� Reflective practice.

� Mandatory training and updates.


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Responsibility for patient careIncluding assessment of, addressing individuals’,improvement of, and the protection of, health andwellbeing needs, biomedical investigation and thereporting, measuring, monitoring and treating ofphysiological conditions through the application ofspecific technologies.

The neonatal nurse will, within agreed parameters, applyknowledge, clinical judgement, and a range of skills toprovide safe, effective care to babies and theirfamilies/carers.

Elements

� Develop and maintain a sound knowledge base relevantto neonatal care.

� Develop and maintain own clinical competence.

� Critically appraise own level of competence, identifyingareas for further development.

� In collaboration with the family and themultidisciplinary team, assess, plan, deliver andevaluate neonatal care that reflects individual physical,social, cultural and spiritual needs.

� Ensure that the most appropriate, individual clinicallyeffective neonatal care is achieved within the confinesof available resources.

� Implement care under the direction of current unit andprofessional policies, procedures and guidelines, andthe law.

� Demonstrate effective decision making in the context ofcurrent role.

� Use health promotion strategies to support and adviseparents and families.

� Ensure care is taken to safeguard babies and theirfamilies/carers at all times.

� Ensure written documentation is clear, concise, timely,and complies with professional and local guidelines andstandards.

� Demonstrate an awareness of current developments inneonatal practice.

� Demonstrate that neonatal practice is embedded inevidence/best practice.

� Maintain and improve quality in all areas of neonatalpractice.

Tools

� Education and training.

� Health promotion.

� Guidelines, protocols, policies and standards.

� Biomedical investigations and reporting.

� Neonatal care assessment tools.

� Quality standards.

� Legislation.

� Specific technologies.


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• Develop a soundknowledge baserelevant to neonatalnursing.

• Provide quality basicroutine neonatal carewithin clearly definedguidelines.

• Respond to the needsof the neonate and thefamily, providingquality care usingcurrent informationand knowledge.

• Undertake routineassessment tasksrelated to the healthand wellbeing of theneonate.

• Assist in deliveringprogrammes ofneonatal care tosupport future healthand wellbeing,including delivery ofspecific healthpromotioninformation/teaching.

• Perform routine testsand tasks related toneonatalinvestigations andreporting.

• Assess, intervene,evaluate and reportthe outcomes ofplanned care.

• Ensure actions assistthe maintenance ofhigh quality neonatalcare.

• Use core clinical skillsand develop criticalreasoning skills toprovide safe andeffective care tobabies in partnershipwith parents/carersand the multi-professional team.

• Contribute to practicedevelopment.

• Be accountable forown practice.

• Be responsible andaccountable for overallcare delivery for adefined group ofbabies with indirectsupervision.

• Plan, implement andevaluate nursing care tomeet the health andwellbeing needs of theneonate when the conditionis stable.

• Assist in the care of theneonate whose needs arecomplex and ever changing.

• Use critical judgement andreasoning to facilitate anddeliver care to babies inpartnership withparents/carers and themulti-professional team.

• Recognise and takeappropriate action when theneonate’s condition isbecoming unstable or isdeteriorating, includingreferral and initiation ofemergency interventions.

• Apply technology formeasurement, monitoringand treatment, interpret andrespond to the needs offamilies/parents/carers.

• Assist parents/carers andother staff to assess babies’health, wellbeing andrelated needs.

• Maintain a comprehensiveknowledge and skills basethat relate to neonatalnursing.

• Act as a resource tocolleagues.

• Supervise care delivery ofjunior colleagues.

• Ensure actions promotequality and alert others torelevant quality issues

• Anticipate the need for, planand participate in ,programmes of care tosupport future health andwellbeing including,audiology and ophthalmicscreening, vaccination,discharge planning anddelivering specific healthpromotioninformation/teaching.

• Ensure actions promotequality and alert others torelevant quality issues.

• Supervise care delivery ofjunior colleagues.

• Apply technology formeasurement, monitoringand treatment.

• Manage theimplementation of qualitycare/service.

• Act as a role model,providing support andguidance to others inimplementing care.

• Assess, plan, deliver andevaluate neonatal care toaddress needs that arecomplex and ever changing.

• Plan, analyse, interpret andreport biomedicalinvestigations within ownlevel of practice.

• Plan, monitor and qualityassure the application oftechnology formeasurement, monitoringand treatment.

• Contribute to qualityimprovement.

• In partnership withparents/carers and themulti-professional team,use highlydeveloped/specialistknowledge and clinicalskills in the neonatal unit tocreate a culture and climatethat is proactive andresponsive to meet thehealth care needs of babies.

• Supervise the care given byjunior colleagues.

• Develop and maintainknowledge, skills andcompetence to the level ofthe expert who is able tofunction in an independentrole.

• Develop practice in applyingtechnology formeasurement, monitoringand treatment.

• Develop practice inbiomedical investigationand reporting.

• Demonstrate a criticallyanalytic approach tostrategic decision makingand judgements related toneonatal care.

• Continuously monitoractivities against qualitystandards, anticipatefactors that may reducequality and take effectiveaction to address them.

• Develop, implement andevaluate initiatives andstrategies to improve thequality of neonatal care.

• Improve quality of neonatalcare through practicereview.

• Develop and implementstrategies for neonatal care,include standards, policiesand guidelines for caredelivery.

• Develop policies andstrategies to improve thehealth and wellbeing ofbabies.

• Foster a proactive careculture

• Seek opportunities to addvalue to care provision.

• Role model effectiveleadership in neonatalnursing and contribute tocreating a vision for theadvancement of neonatalnursing, stimulating co-operation and enthusiasmin neonatal nursing.

• Empower neonatal nursingpractice by publishinglocally, nationally andinternationally.


To achieve the competences expected for each of the fourlevels of neonatal nursing practice (new entrant to expert),the neonatal nurse must develop specific skills. The skillsrequired are diverse (DH, 2010 pg. 53), may be transferableacross several competences, and will change over time,therefore the working group chose to restrict theclarification of core clinical skills in this document tothose that specifically relate to patient care within thecompetence ‘Responsibility for patient care’.

20


3

Core clinical skills for neonatal nurses


• Recognise normal gastro-intestinal function, urinarytract function and bilirubinelimination, reportingdeviations.

• Implement interventionsto sustain homeostasisaccording to unitguidelines.

• Initiate management andfollow guidelines.

• Investigate, prescribe andmanage treatments for any GIproblems, and problems withurinary tract function andbilirubin elimination.

• Assist the mother tobreastfeed according toevidence base/unitguidelines.

• Inform and advise onstorage of breast milk,breastfeeding, hand andmechanical expression andsupplementary methods offeeding.

• Participate and involveothers in research anddevelopment of practice topromote breastfeeding.

• Devise, audit and reviewguidelines for best practicein partnership with medicalstaff.

• Assist parents/carers inother enteral feedingtechniques.

• Inform and advise on allaspects of other enteralfeeding methods.

• Use evidence-basedpractice for enteral

feeding.


• Safely carry out all formsof enteral feeding (exceptbreast) according toevidence base/unitguidelines.

• Assess enteral feedingneeds, devise plan andreview appropriately.

• Deviseprocedures/guidelines forenteral feeding.

• Monitor and evaluate, auditand review implementation.

Fluid, electrolyte, nutrition and elimination management

Following on from the categorisation of skills previouslyused (NES, 2002), the core clinical skills are presentedunder the following headings:

� fluid, electrolyte, nutrition and eliminationmanagement

� neurological and pain management

� respiratory and cardiovascular management

� skin and hygiene management

� thermal control management

� bereavement management

� investigations and procedures

� equipment.

The neonatal nurse must have the knowledge and theability to rationalise the strategy chosen in the applicationof all clinical skills.


21


• Administer nutritionalsupplements accordingto prescription.

• Ensure the requirednutritional supplements areprescribed.

• Monitor the need fornutritional supplementsand ensure compliance.

• Prescribe nutritionalsupplements as required.

• Review the need fornutritional supplements.

• Safely administerintravenous therapyaccording to unitguidelines, recognisingand reporting deviations/complications.

• Set up, maintain anddiscontinueintravenous/intra-arterialtherapy, according to unitguidelines.

• Maintain central lines.• Intervene appropriately to

reduce/avoid deviations/complications.

• In specific situations, insertperipheral intravenouslines.

• Supervise insertion ofintravenous lines by others.

• Manage appropriatetreatment fordeviations/complications.

• Establish intravenous andintra-arterial access.

• Remove central lines.• Instigate and prescribe

treatment.• Select and prescribe

appropriate fluidmanagement.


• Monitor input andoutput.

• Calculate intakerequirements according toguidelines.

• Measure output.

• Calculate intake and outputaccording to clinicalcondition and environmentwithin set guidelines.

• Calculate and prescribe fluidintake according to clinicalcondition and environment.

• Measure weight andlength.

• Monitor growth anddevelopment throughmeasurement of weight andlength, reporting ofdeviations.

• Act on deviations fromnormal growth anddevelopment and referappropriately.

• Investigate, prescribe andmanage treatments forproblems with weight orlength.

• Obtain capillary bloodsample to measure andmonitor blood glucoselevels, reportingdeviations.

• Implement interventionsaccording to unit guidelinesfor blood glucoseregulation.

• Ensure implementation ofevidence-based guidelines.

• Interpret and instigateappropriate managementand further investigation.


• Care for neonaterequiring phototherapy.

• Initiate phototherapyaccording to predeterminedcriteria.

• Prescribe phototherapyaccording to clinical need.

• Investigate cause ofpathologicalhyperbilirubinemia.


Fluid, electrolyte, nutrition and elimination management (continued)

22



• Recognise normalbehaviour in babies ofdifferent gestations,including sleep/awakestates.

• Report deviations fromnormal.

• Recognise physiological andbehavioural differencesbetween stress, distress,discomfort, pain,convulsions and drugwithdrawal.

• Alleviate neonate’sdiscomfort, pain etc usingstandard nursing strategies.

• Provide anticipatoryguidance and support forstaff to recognisephysiological andbehavioural differences.

• Initiate referrals basedon need.

• Completeavailable/appropriateassessment tools andreport findings.

• Interpret outcomes ofassessment and implementstrategies according to localguidelines.

• Devise, audit and reviewguidelines for bestpractice in partnershipwith medical staff

• Initiate appropriatetreatment.

• Anticipate potentiallyadverse events andminimise their impact.

• Plan, implement andevaluate care toavoid/minimise the impactof adverse events.

• Review care andmanagement strategies toavoid/minimise the impactof adverse events.

• Devise, audit and reviewguidelines for bestpractice in partnershipwith medical staff.

• Recognise and reportovert signs of pain.

• Provide routine nursingcare to alleviate pain andstress to the neonate.

• Recognise and report subtlesigns of pain.

• Implement strategies thatminimise painfulexperiences.

• Devise protocols to reducestress and relieve pain.

• Audit stress relief andpain reduction protocols.

• Recognise behaviourassociated with neonatalabstinence syndrome(NAS).

• Provide routine nursingcare to alleviate effects ofNAS.

• Implement strategies thatminimise the effects of NAS.

• Provide support andguidance for staff involvedin the care associated withmaternal drug dependencyand NAS.

• Develop strategies forstaff regarding maternaldrug dependency andNAS involvingmultidisciplinary/agencygroups.


• Use developmental carestrategies: includingenvironmental aspects,positioning and handling.

• Adapt strategies to meet theneeds of specific babies.

• Promote the use ofdevelopmental carestrategies.


Neurological and pain management


23


• Recognise normalrespiratory/cardiovascular function.

• Report deviations fromnormal.

• Intervene torestore/maintainhomeostasis according tolocal guidelines.

• Interpret trends andevaluate management,including blood gasanalysis.

• Define normal limits.• Instigate appropriate

investigations andmanagement.

• Observe resuscitation ofthe neonate.

• Initiate basic life supportmeasures.

• Recognise need for andrequest assistance.

• Perform basic life support.• Recognise need for and

request assistance.• Assist with advanced

resuscitation andstabilisation.

• Team lead in basic lifesupport situation andstabilisation.

• (In some situations performthe role of an advancedresuscitator).

• Perform and leadsadvanced resuscitation.

• Safely administer oxygentherapy via the incubator,head box, nasal cannulaeand facially, includingadequate humidificationas prescribed.

• Safely care for the neonaterequiring mechanicalventilation/continuouspositive airways pressure.

• Adjust respiratory supportaccording to need withinlocal guidelines.

• Initiate and managerespiratory support.


• Use safe and effectiveoral and nasal suctiontechniques.

• Assess the need for suctionof respiratory secretions.

• Use safe and effectiveendotracheal tube/tracheostomy suctiontechniques.

• Perform chestphysiotherapy techniquesas prescribed.

• Review and evaluate theeffectiveness ofphysiotherapy and suctioninterventions.

• Prescribe chestphysiotherapy.



• Assist withelective/emergencyintubation/extubation.

• Recognise the need forintubation/extubation.

• Perform extubation.

• Perform intubation.

• Assist with theinsertion/removal of chestdrainage.

• Provide care for neonatewith chest drain in situ.

• Insert, secure andremove chest drainage.

• Devise, audit and reviewguidelines for bestpractice in partnershipwith medical staff .

Respiratory and cardiovascular management

24



• Implement correct handwashing and otherinfection controlmeasures as per localguidelines.

• Police compliance withinfection controlguidelines.

• Perform aseptic and non-touch techniques.


• Audit compliance withbest practice in relationto infection controlmeasures.

• Research evidence-basedpractice to supportguidelines for infectioncontrol.

• Examine skin andmucous membranes,eyes and cord base fordeviations from normaland report.

• Implement treatment fordeviations as prescribed.

• Implement strategies toprevent iatrogenic damageand potential injury.

• Prescribe, managetherapies to promoteskin integrity.


• Use appropriatemeasures to maintainhygiene and skinintegrity, including stomacare.

• Assess wound healingprocesses.

• Perform therapeutic woundcleansing techniques.

• Apply therapeuticdressings.

• Refer as appropriate. • Devise, audit and reviewguidelines for bestpractice in partnershipwith medical staff.

• Prescribe treatments.• Refer as appropriate.

Skin, hygiene and infection control management


• Assess neonatal bodytemperature usingappropriate method andsite for babies whorequire special care andreport deviations fromnormal.

• Assess neonatal bodytemperature usingappropriate method andsite for babies who requirehigh dependency andintensive care, and reportdeviations from normal.

• Monitor central andperipheral temperature gap,and report deviations fromnormal.

• Devise, audit and reviewnursing guidelines fortemperature monitoring.

• Use appropriatestrategies to maintainbody temperature withinnormal limits, includingenvironmental aspects,clothing and equipmentfor babies who requirespecial care.

• Anticipate the neonate’s riskof temperature deviations.

• Use strategies to preventtemperature deviations forbabies who require highdependency and intensivecare.

• Devise, audit and reviewnursing guidelines fortemperature regulationstrategies.

• Use appropriateinterventions to correcttemperature deviationsfor babies who requirespecial care.

• Use appropriateinterventions to correcttemperature deviations forbabies who require highdependency and intensivecare.


• Investigate and treattemperature deviations.

Temperature management


25


• Sensitively and empathetically carefor the dying neonate and his/herparents with support and guidancefrom senior staff.

• Support and guide staffcaring for the dyingneonate.

• Initiate and facilitatesensitive discussion withparents and seniormedical staff.

• Sensitively and empathetically carefor the neonate who has died andthe bereaved parents in accordancewith bereavement protocol withsupport and guidance from seniorstaff.

• Support and guide staffcaring for the neonate andparents after neonate’sdeath.

• Devise bereavementprotocol.

• Access the unit’snetwork ofsupport availableat time of aneonate’s death.

• Participate in support network/seek appropriate guidance.

• Support and guide staff. • Facilitate sensitivediscussion with staff.

Bereavement management

26


New entrant Neonatal nurse (QIS) Experiencedneonatal nurse

Expert neonatal nurse

• Perform routine diagnostic andtherapeutic proceduresaccording to protocols andguidelines.

• Implement prescribedmanagement.

• Recognise the significanceof results and seekappropriate management.

• Instigateappropriatemanagement.

• Request specimens and samples.• Prescribe appropriate

management according toresults.

• Devise, audit and reviewguidelines for best practice inpartnership with medical staff.

• Assist in the care of babiesrequiring special careundergoing non-invasiveinvestigations and procedures.

• Assist in the care of aneonate requiring highdependency and intensivecare, undergoing non-invasive and invasiveinvestigations andprocedures.

• Perform non-invasive andinvasive procedures.

• Assist in the care of babiesrequiring special careundergoing blood sampling.

• Perform capillary bloodsampling.

• Assist in the care of babiesrequiring high dependencyand intensive careundergoing blood sampling.

• Performvenepunctureaccording to localguidelines.

• Perform arterial andcentral linesampling.

• Insert arterial, percutaneouscentral venous catheter andcentral lines.

• Measure blood pressure usingnon-invasive techniques,reporting deviations fromnormal.

• Set up arterial bloodpressure transducer.

• Measure arterial bloodpressure.

• Interpret bloodpressure recordings.

• Prescribe appropriate therapy tomaintain homeostasis.

• Care for neonate receiving bloodtransfusion.

• Care for neonate receivingexchange and partialexchange transfusion.

• Prescribe blood and bloodproducts according to nationaland local policies.

• Perform exchange and partialexchange.

• Administer drugs via oral,topical, rectal and intramuscularroutes, according toprofessional and local policies.

• Assess the therapeuticresponse.

• Identify side effects and reportappropriately.

• Administer drugs via IVroute according toprofessional and localpolicies.

• Assess the therapeuticresponse.

• Identify side effects and actappropriately within localguidelines.

• Review therapeuticresponse and actaccordingly withinlocal guidelines.

• Prescribe and administer drugsvia all routes, according tonational and local policies.

• Plan, implement and evaluatedrug therapies.

• Evaluate therapeuticresponse/side effects and actaccordingly.

Investigations and procedures


27


• Clean and storeequipment necessary forthe care of babiesrequiring special care inaccordance with local andmanufacturer’sinstruction.

• Clean and store equipmentnecessary for the care ofbabies requiring highdependency and intensivecare in accordance withlocal and manufacturer’sinstruction.

• Set up and testequipment necessary forthe care of babiesrequiring special care inaccordance with local andmanufacturer’sinstruction.

• Set up and test equipmentnecessary for the care ofbabies requiring highdependency and intensivecare in accordance withlocal and manufacturer’sinstruction.

• Devise guidelines for thesetting up and testing ofequipment.

• Efficiently and safely useequipment necessary forthe care of babiesrequiring special care inaccordance with local andmanufacturer’sinstruction.

• Efficiently and safely useequipment necessary forthe care of babies requiringhigh dependency andintensive care in accordancewith local andmanufacturer’s instruction.

• Devise guidelines for thesafe use of equipment.

• Assess the need forequipment used inneonatal care and adviseappropriately.

• Interpret significance ofequipment alarms inbabies requiring specialcare and respondappropriately.

• Interpret significance ofequipment alarms in babiesrequiring high dependencyand intensive care andrespond appropriately.

• Troubleshoot equipmentproblems.

• Devise, audit and reviewguidelines for bestpractice in partnershipwith medical staff foralarm parameters.

Equipment

Conclusion

The career and educational framework for neonatal nursing in the UK is underpinned by the development of knowledge,competence and specific core skills as detailed in this document. However, the success of this document in supportingcareer development will depend on:

� adoption within neonatal /HEl environments

� changes to established educational provision

� a review of employment practices.

In short, if neonatal nurses are prepared and developed effectively and comparably, then this will have wide-rangingbenefits for individuals, for organisations and, most importantly, for the infants and families cared for across the UK.

In addition to the framework, a series of recommendations have been presented here which require action from allinvolved in neonatal care . The consultation process indicates that these will be received positively in the main. Due to thepace of change in neonatal care this document will require review and updating within the next five years.

Document review group (September 2010)Debra Teasdale, Lead for RCN Career and EducationCompetence Document DevelopmentRCN Paediatric and Neonatal Intensive Care SteeringCommittee MemberHead of Health, Wellbeing and the Family, CanterburyChrist Church University, Kent

Doreen Crawford, RCN Paediatric and Neonatal IntensiveCare Community Steering CommitteeSenior Lecturer, De Montfort University

Denise Gray, Education Project Manager, NHS Educationfor Scotland

Alison Gibb, British Association for Perinatal Medicine

Ruth Moore, Vice Chair, Neonatal Nurses AssociationProject Manager NIC/PIC - Staffordshire, Shropshire &Black Country Newborn Network East

Tina Pollard, Chairperson, Neonatal Nurses Association Clinical Service Manager – Neonates, AddenbrookesHospital, Cambridge

Jackie Stretton, West Midlands Neonatal Pilot ProjectManagerInstitute of Health and Society, University of Worcester

Alison Wright, Scottish Neonatal Nurses GroupChairpersonSenior Nurse Neonatal Services/ANNP Ninewells Hospital

Fiona Smith RCN Adviser in Children and Young people’sNursing (Chairperson)

Jackie Baker, Senior Nurse, Maelor Hospital, Wrexham,Wales

Pamela Boyd, Senior Sister, Royal Gwent Hospital, Wales

Andy Cole, Chief Executive, BLISS

Doreen Crawford, RCN Paediatric and Neonatal IntensiveCare Community Steering Committee Member, SeniorChild Nursing Lecturer, De Montfort University

Marian Campbell, Belfast Trust, Northern Ireland

Moira Gray, Scottish Neonatal Nurses Group Chairperson,Practice Development Centre, Wishaw General Hospital,Wishaw

Claire Greig, Scottish Neonatal Nurses Group ExecutiveMember, Senior Lecturer, Edinburgh Napier University

Philomena Farrell, Belfast Trust, Northern Ireland

Neil Marlow, President, British Association for PerinatalMedicine

Tina Pollard, Chairperson, Neonatal Nurses AssociationClinical Service Manager, Neonates, AddenbrookesHospital, Cambridge

Katy Swaine, Children’s Rights Alliance for England

Debra Teasdale, RCN Paediatric and Neonatal IntensiveCare Community Steering Committee Member, Head ofHealth, Wellbeing and the Family, Canterbury ChristChurch University, Kent

Sheila Thorne, BLISS

28


Appendix 1: Staffing summit working group members

Appendices


29

Appendix 2: Exemplar job descriptions2

Trainee advanced neonatal nursepractitioner (ANNP) - KSF Band 7

ANNP - KSF Band 8a Senior ANNP - KSF Band 8b

Job purpose

This ANNP role is distinct from nursingbut arises from extended nursingpractice. The role incorporates thetraditionally medical role enabling aholistic approach to neonatal careproviding advanced clinical skills tobabies and supporting families withinthe neonatal service. The ANNP works in collaboration withthe senior nurse neonatal services (orequivalent) and consultantneonatologist/paediatricians: thetrainee ANNP will be undertaking aperiod of master’s level academic studywhilst simultaneously gaining clinicalexperience under direct supervision ofexperienced ANNPs or senior medicalstaff. This will facilitate working towards:• providing specialised clinical care at

an advanced level to a neonate andfamily, making complex autonomousdiagnosis and management decisionsabout patient care, using advancedskills and knowledge

• acting as an educator, highlyspecialised clinician, consultant,auditor and researcher

• providing specialised advice andsupport within the neonatal sphere

• participating in the formulation andupdating of neonatal guidelines

• demonstrating and maintainingadvanced newborn life supportresuscitation skills by acting as amember of the neonatal resuscitationteam, taking lead role as required

• advising junior medical staff,midwifery/nursing staff, medical,nursing and midwifery students,acting as an educational resourceensuring that evidence-based practiceis promoted

• establishing interchanging roles withjunior medical staff on a regular,planned basis by working inpartnership to ensure the neonatereceives the most appropriatespecialist care, regardless of theunpredictability of the workload

• participating in the safe transfer of theneonate where appropriate

• participating at meetings at unit,directorate and senior managementlevel at the request and on behalf ofthe directorate management

• providing specialist advice to themultidisciplinary team.

The ANNP role encompasses thatof educator, expert clinician,consultant, auditor, researcher anddeveloper. In collaboration with thesenior nurse neonatal services andconsultant paediatricians theadvanced neonatal nursepractitioner (ANNP) will:• have specialist knowledge of

neonates across a range ofclinical issues, underpinned bythe theory and practice acquiredthrough an ANNP educationprogramme at master’s level

• provide expert clinical care andmanagement of the neonate andhis/her family, making complexautonomous decisions utilisingexpert practice

• have responsibility for theassessment of care needs,development, implementationand evaluation of programmes ofcare, to deliver optimal medicaland nursing care

• will be expected to work acrossrole boundaries, providingcomprehensive holistic caresensitive to the needs of babiesand families accessing neonatalservices in the network

• act as a role model and provideleadership, clinical support andexpert advice to junior medical,nursing/midwifery staff andstudents

• participate in the provision ofspecialist education and trainingprogrammes for health careprofessionals and otherprofessional groups dealing withneonates across the network

• be responsible for a designatedgroup of senior nurses within theNICU to identify their educationaland training requirements viaappraisal, clinical supervisionand personal developmentplans.

The ANNP role encompasses that ofeducator, expert clinician, consultant,auditor, researcher and developer. TheANNP works strategically and incollaboration with the senior nurseneonatal services and consultantpaediatricians. The ANNP should:• maintain highly specialist knowledge of

neonates across a range of clinicalissues, underpinned by the theory andpractice acquired through an ANNPeducation programme at master’s level

• ensure clinical excellence by providingexpert clinical care at an advanced levelto neonates and their families, makingcomplex autonomous diagnosis andmanagement decisions about patientcare, using advanced skills, knowledgeand expert practice

• manage the unpredictable workload andmultidisciplinary team within theneonatal service, workinginterchangeably with middle grademedical staff on a frequent basis,working across role boundaries toensure neonates receive the mostappropriate expert, specialist care

• have responsibility for the assessment ofcare needs, development,implementation and evaluation of highlyspecialist programmes of care, to deliveroptimal medical and nursing care

• act as a role model and provideleadership, clinical support and expertadvice to medical, nursing/midwiferystaff, students and other staff in themultidisciplinary team

• take the lead role in providing advancedneonatal resuscitation across a range ofsettings

• develop and deliver specialist educationand training programmes for health careprofessionals and other professionalgroups dealing with neonates across thenetwork

• lead on research, clinical audit, quality,practice development and clinicalgovernance initiatives pertinent to thewellbeing of neonates and their familiesand the provision of neonatal services

• provide expert knowledge and advice ata strategic level, both locally andnationally

• offer support and development to adesignated group of senior nurses andANNPs within the NICU, identify theireducational and training requirementsvia appraisal, personal developmentplan and supervision.

2 The information presented has been collated from job descriptions presented at the September 2010 document review meeting

30




Dimension

The post holder:

• will be mentored and initiallyshadowed by an experienced ANNPand/or senior medical staff,progressively working towardsbecoming an autonomouspractitioner, prioritising ownworkload and being accountablefor the direct delivery of care

• works across professionalboundaries, undertaking duties ofan advanced practitioner under thedirection of the ANNP or consultantneonatologist/paediatrician. Thisincludes participating in medicalrotas under supervision

• teach and deliver core specialistneonatal training and education tonursing/midwifery staff andstudents to ensure safe, evidence-based practice is delivered

• attends neonatal clinicalemergencies in all areas, deliveringadvanced resuscitation skills andstabilisation of the infant prior totransfer to the neonatal unit, whilebeing supported by an experiencedpractitioner until competence isachieved

• will use high levels of judgement,problem solving and decisionmaking in the assessment,investigation, diagnosis,prescription and evaluation ofhighly specialised treatment plans.

The post holder:

• works across professional boundaries,under the direction of the consultantpaediatrician/neonatologist.Participates within the Medical/ANNProta, along with ST1, ST2 and FY2colleagues, deputising occasionally forthe specialist registrar (ST3 andabove)

• carries the medical pager coveringNICU (21 cots), postnatal wards andlabour suite, as well as acceptingreferrals from community. All areas arecovered simultaneously out of hours.ANNPs will attend clinics carrying outappropriate assessment, diagnosisand management of babies referredfrom community post discharge

• works autonomously within thenursing structure, developing theservice, occasionally contributing tothe nursing clinical rota, criticallyappraising and undertaking researchand audit to ensure best practice andstandards

• is responsible for initial assessment,investigation, diagnosis, prescriptionand evaluation of treatment plans.They will work autonomously toprovide first-line high quality clinical,emergency and supportive care in themanagement of neonates and theirfamilies in frequently dynamic andstressful situations

• attends all clinical emergenciesspecific to neonates. This care maytakes place in different environmentsand the areas covered by the neonataltransport service, including, laboursuite, NICU, postnatal/antenatalwards and community midwifery units,requiring collaboration with multiplestaff groups.

The post holder:

• works autonomously, acrossprofessional boundaries, beingaccountable to the consultantneonatologist/paediatrician.Participates in the middle grademedical/ANNP rota

• carries the senior medical trainee/ANNP pager covering NICU, postnatalwards and labour suite, as well asaccepting referrals from community,providing support and advice to thefirst on bleep holder (ANNP or FY2 –ST2 medical staff )

• will attend clinics carrying outappropriate assessment, diagnosisand management of babies referredfrom community post discharge

• works autonomously within thenursing structure, developing theservice, occasionally contributing tothe nursing clinical rota, criticallyappraising and undertaking researchand audit to ensure best practice andstandards

• is responsible for assessment,investigation, diagnosis, prescriptionand evaluation of treatment plans,frequently teaching, giving support,guidance and advice to juniordoctors/ANNP undertaking initialassessment and formulation ofmanagement plans

• will work autonomously to providefirst-line high quality clinical,emergency and supportive care in themanagement of neonates and theirfamilies in frequently dynamic andstressful situations

• attends all clinical emergenciesspecific to neonates. This care takesplace in different environmentsthroughout the designated area andextends to the areas covered by theneonatal transport service, including,labour suite, NICU,postnatal/antenatal wards andcommunity midwifery units, requiringcollaboration with multiple staffgroups.

Appendix 2: Exemplar job descriptions (continued)


31



Main duties

Professional

The post holder works as a traineeANNP within the statutes andguidelines governed by the Nursingand Midwifery Council (NMC), underdirect supervision during the trainingperiod. The trainee ANNP will:

• comply with local and nationalguidelines and policies

• be an accountable and responsibleprofessional, managing self,his/her own practice and that ofothers within an ethical and legalframework that ensures theinterest of neonates and theirfamilies come first

• act as an ambassador for the NNU,ANNP and the neonatal specialty

• ensure that written nursing andmedical documentation is clear,concise, up to date andchronological, and complies withNMC Standards of Record andRecord Keeping

• act as an advocate on behalf ofbabies and families

• convey the role of the ANNP tostaff and parents

• liaise with ANNPs throughout thelocal network or region, ensuringadvanced practice and nationalguidelines are comparative andresearch based.

The post holder works as an ANNPwithin the statutes and guidelinesgoverned by the Nursing and MidwiferyCouncil (NMC). The ANNP will:


• be an accountable and responsibleprofessional, managing self, his/herown practice and that of others withinan ethical and legal framework thatensures the interest of neonates andtheir families come first

• act as an ambassador for the NNU,ANNP and the neonatal specialty

• ensure that written nursing andmedical documentation is clear,concise, up to date and chronological,and complies with NMC Standards ofRecord and Record Keeping

• act as an advocate on behalf of babiesand families

• convey the role of the ANNP to staffand parents

• liaise with ANNPs throughout the localnetwork or region, ensuring advancedpractice and national guidelines arecomparative and research based.

The post holder works as a senior ANNPwithin the statutes and guidelinesgoverned by the NMC. The SANNP will:


• the ANNP is an accountable andresponsible professional, managingself, his/her own practice and that ofothers within an ethical and legalframework that ensures the interest ofneonates and their families come first

• act as an ambassador for the neonatalunit, ANNPs and the neonatalspecialty

• ensure that written nursing andmedical documentation is clear,concise, up to date and chronological,and complies with NMC Standards ofRecord and Record Keeping

• act as an advocate on behalf of babiesand families

• conveys the role of the ANNP to staffand parents

• network with consultant nurses andANNPs nationally, ensuring advancedpractice and national guidelines arecomparative and research basedacross regions and networks.


32




Main duties

Clinical

The trainee ANNP will:• use highly specialised clinical and

theoretical knowledge toundertake a comprehensive healthhistory and examination of anyneonate in order to diagnose andtreat the neonate (including theprescription of drugs as necessary)

• work in partnership with theconsultant neonatologist,developing medical and nursingpatient management plans for acase load of babies, that deliver aholistic approach to the care ofneonates throughout the patientpathway from admission todischarge

• regularly weigh up differentialdiagnosis and the potential rangeof treatment options, selectingfrom variable options, some ofwhich may be contentious. Usespecialised clinical and theoreticalknowledge to assess theimmediate health status of theneonate

• review identified/perceivedproblems, analyse complexinformation and take responsibilityfor decisions made, ensuring thatthe care provided to all neonates issafe and effective

• attend high-risk deliveries andother emergencies as anautonomous practitioner, ensuringthat neonates receive safe andeffective advanced resuscitation

• carry the emergency neonatalbleep/pager during consolidationperiod

• on completion of relevantacademic programme, undertakenon-medical prescribing –including calculating, prescribing,administering and evaluating theeffects of drug and fluid therapiesin accordance with local policies

• initiate and authorise bloodtransfusions and volumeexpanders as clinically indicated, inaccordance with local policies

• order and interpret X-rays anddiagnostic investigations to ensureaccurate diagnosis and treatmentof the neonate. Act on results anddevelop management plans

• participates in, and perform,advanced procedures for ill andpremature neonates

• participates in the stabilisation,

The ANNP will:• assess the health-related needs of

babies and families by identifying andinitiating appropriate steps foreffective care, exercising higher levelsof judgement and clinical decisionmaking under the direction ofmultidisciplinary neonatal clinicalguidelines

• under the direction of senior medicalstaff and in collaboration with nursingcolleagues, the post holder hasresponsibility for clinical managementof infants requiring neonatal carewithin the designated area

• use advanced knowledge and highlyspecialised clinical skills to take acomprehensive health history,examine, diagnose and treat neonatesand their families within theparameters of neonatal clinicalguidelines and protocols

• calculate, prescribe, administer andevaluate effects of drug therapies

• recognise abnormalities, early signs ofillness and act accordingly and followup evaluation of care

• initiate and order laboratory and otherdiagnostic investigations, including X-rays, collect specimens as required,interpret results and alter medicalmanagement plans accordingly

• provide care to very sick, unstablebabies in the neonatal unit or duringretrieval and transport episodes, usingcomplex life support therapies

• participate in neonatal transport oncall rota

• initiate and manage emergencyresuscitation of the newborn in laboursuite and NICU

• maintain and build on effectivecommunication with parents/carers,relatives, and other members of themultidisciplinary team to ensure thatappropriate information is shared andthe needs of babies and their familiesare met

• communicate with various individuals,specialties and professionals oncomplex neonatal matters to ensureeffective co-ordination of clinicaltreatment

• support the multidisciplinary team toinvolve parents/carers and relatives inplanning and delivery of individualisedcare

• be involved in antenatal discussionsregarding care of mother and neonatewhen an abnormality of pregnancy is

The senior ANNP will:• assess health-related needs of babies

and families by identifying andinitiating appropriate steps foreffective care, exercising higher levelsof judgement and clinical decisionmaking, using multidisciplinaryneonatal clinical guidelines

• use highly developed specialistknowledge and advanced clinical skillsto undertake a comprehensive healthhistory and examination of anyneonate in order to diagnose and treatthe neonates (including theprescription of drugs as necessary)

• frequently weigh up differentialdiagnosis and the variety ofpotentially contentious treatmentoptions, which require the post holderto weigh up possibilities and justifythe clinical rationale. Initiate furtherinvestigations and treatment plansfrom a range of options, analysingresponse and altering plans asnecessary, as further data becomeavailable to ensure care is safe andeffective

• develop comprehensive medical andnursing patient management plans fora case load of neonates, that deliver aholistic approach to their carethroughout the patient pathway fromadmission to discharge

• recognise abnormalities, early signs ofillness and act accordingly, ensuringfull range of investigations ininstigated and follow-up action taken,including evaluation of careprogrammes

• attend high-risk deliveries as the leadpractitioner, ensuring that neonatesreceive safe and effectiveresuscitation carry the emergencyneonatal bleep/pager, acting as thesenior responder

• non-medical prescribing – includingcalculating, prescribing, administeringand evaluating the effects of drug andfluid therapies in accordance withlocal policies

• initiate and authorise bloodtransfusions and volume expanders asclinically indicated, in accordance withlocal policies

• order and interpret X-rays anddiagnostic investigations to ensureaccurate diagnosis and treatment ofthe neonate. Interpret and act onresults and develop managementplans



33



Main duties

Clinical (continued)

transfer and admission of theextremely ill neonate to, or from,the neonatal unit, includingcomplex life support therapies

• ensure that parents are aware oftheir neonate’s condition andprovide complex communicationsand support to parents

• participate in palliative care forneonates, leading to a pain-free,dignified ending to life

• provide intensive support, adviceand care for families of neonateswho are receiving terminal care

• co-ordinate referral to otherservices, e.g. physiotherapist,occupational therapist, dietician,surgeon, cardiologist or any otherservice which is vital to theappropriate care of the neonate

• contribute to health promotionactivity, raising awareness ofhealth and wellbeing to promotehealthy lifestyle choices for thebenefit of neonates and theirfamilies.

identified• comply with and promote policies

relating to child protection• if holding a qualification in midwifery

(who have submitted their intention topractice to the NMC) carry outpostnatal examinations and providematernity care in the transitional carearea. ANNPs who have no qualificationin midwifery or a lapsed qualification,will provide support and advice onreferral pathways to midwives caringfor mothers in transitional care

• initiate, provide and support others tocare for the terminally ill or dying babyand their family, and undertake lastoffices

• make appropriate referrals tospecialist services and consultants.This will include referring toconsultants and specialists outsideneonatal services (orthopaedics,ophthalmology, radiology, plastics,genetics, surgery)

• dictate discharge and referral lettersto GPs and specialty consultants.

• perform advanced procedures for illand premature neonates if required

• lead in the stabilisation, transfer andadmission of the extremely ill neonateto or from the neonatal unit, includingcomplex life support therapies

• maintain and build on effectivecommunication with parents/carers,relatives, and other members of themultidisciplinary team to ensure thatappropriate information is shared andthe needs of babies and their familiesare met

• participate in palliative care forneonates, leading to a pain-free,dignified ending to life. Provideintensive support for families ofneonates who are receiving terminalcare

• as a clinical expert, act as a resourcefor the multidisciplinary team

• communicate with various individuals,specialties and professionals oncomplex neonatal matters to ensureeffective co-ordination of clinicaltreatment

• co-ordinate referral to other services,e.g. physiotherapist, occupationaltherapist, dietician, surgeon,cardiologist, or any other servicewhich is vital to the appropriate careof the neonate

• lead health promotion activity, raisingawareness of health and wellbeing topromote healthy lifestyle choices forthe benefit of neonates and theirfamilies

• be involved in antenatal discussionsregarding care of mother and neonatewhen abnormality of pregnancyidentified

• dictate discharge and referral lettersto GPs and specialty consultants.


34




Main duties

Managerial and leadership

The trainee ANNP will:• prioritise own workload and

delegate work to others• act as a role model and provide

specialist advice and clinicalsupport to neonatal staff and themultidisciplinary team whenrequired

• comply with policies relating tochild protection and protection ofvulnerable adults, instigatingactions and developingmanagement plans

• share responsibility with seniorclinicians and managers for clinicalgovernance issues, including,clinical risk management and staffgovernance

• attend internal and organisationalmeetings to promote thedevelopment of neonatal servicesand to disseminate informationand action plans to colleagues

• liaise with colleagues andmanagers to ensure that sufficientresources are available to meetclinical need

• promote equality and diversity.

The ANNP will:• lead and co-ordinate the nursing

and junior medical staff within theNICU, organising and prioritisingworkload to ensure that theinterests of babies and theirfamilies are met

• foster an environment thatencourages staff development,supporting, appraising andcounselling staff

• in partnership with themultidisciplinary team, lead thedevelopment, implementation andmaintenance of policies,procedures and guidelines for theneonatal service. Ensure adherenceto these in order to deliver thehighest possible level of patientcare within available resources

• as a senior practitioner, supportthe multidisciplinary team toensure that the appropriate clinicalskills and competences are usedeffectively to meet the needs of thebaby and family

• participate in performance reviewsof nursing and medical staff. Whereappropriate, counsel staffregarding performance

• participate in recruitment of staff• share responsibility for clinical and

staff governance with seniornursing and medical colleagues

• investigate and deal sensitivelywith complaints and clinicalincidents within their remit, makingrecommendations to preventrecurrence

• participate in internal and externalcommittees relating to neonatalservices in order to contribute tothe development of future serviceprovision.

The senior ANNP will:• collaborate with nursing and medical

colleagues to ensure effective use ofresources to provide 24-hour cover

• as the clinical lead of the resident team,ensure the management of neonates intheir care is assessed, planned,implemented and evaluated, and thatthere is consultation and involvement ofrelevant staff groups and parents/carers

• lead and co-ordinate the nursing andmedical staff within the NICU, organisingand prioritising workload to ensure thatthe interests of babies and their familiesare met

• as a senior practitioner, support themultidisciplinary team to ensure that theappropriate clinical skills andcompetences are used effectively tomeet the needs of the babies andfamilies

• provide a high level of expert leadershipto neonatal unit staff, acting as a rolemodel and providing expert advice andclinical support

• comply with policies relating to childprotection and protection of vulnerableadults, instigating actions anddeveloping management plans

• share responsibility with senior cliniciansand managers for clinical governanceissues, including clinical riskmanagement and staff governance

• attend, or take a lead in, local andnational meetings to promotedevelopment of neonatal services anddisseminate information to colleagues

• liaise with colleagues and managers toensure that sufficient resources areavailable to meet clinical need

• participate in recruitment and inductionof nursing and medical staff andstudents

• promote equality and diversity• participate in performance review of

nursing and medical staff. Whereappropriate, counsel staff regardingperformance

• share responsibility for clinical and staffgovernance with senior nursing andmedical colleagues

• investigate and deal sensitively withcomplaints and clinical incidents withintheir remit, making recommendations toprevent recurrence

• input data into patient records (paperand electronic), ensuring quality ofrecords are maintained. Use electronicdatabases to source information andmaintain records.



35



Main duties

Education

The trainee ANNP will:• identify own educational and

training support needs • maintain a professional

development portfolio• teach and deliver core specialist

neonatal training, and participatein the supervision of medicaltrainees, midwives and nurses.They will also provide a supportivelearning environment, whichpromotes continuous professionaldevelopment and lifelong learning

• teach specialist neonatal skills tostaff and parents/carers, forexample, neonatal resuscitation,home oxygen, nasogastric feeding,stoma care and suction.

The ANNP will:• in partnership with other staff and

education institutes, contribute to theformulation of the on-goingeducational agenda for all grades anddisciplines of staff

• participate in the delivery of specialisteducation programmes within a corecurriculum for institutes of highereducation

• participate in on-going personaldevelopment and professionaleducation of all members of theneonatal nursing team, usingmentorship, objective setting andappraisal, helping nursing staff tomeet their education needs

• direct and support the provision ofclinical practice for pre and postregistration nurse/midwife learners,junior medical staff and students, tofulfil curriculum requirements andensure that appropriate educationalopportunities are provided

• develop, deliver and evaluate staffdevelopment programmes thatsupport the achievement of clinicalskills, leadership and best practice inneonatal care within NICU andpostnatal environments

• teach, advise and coach parents andcarers about their baby’s conditionand treatment options

• contribute to health promotion activityraising the awareness of health andwellbeing to promote healthy lifestylechoices for the benefit of the neonateand their family.

The senior ANNP will:• identify own educational and training

support needs • maintain a professional development

portfolio• devise personal and professional

development packages for colleagues,undertaking appraisal and objectivesetting

• in association with unit management,develop, update and evaluate servicetraining plan

• participate in teaching andsupervision of ANNPs, medicaltrainees, midwives and nurses. Act asan expert practitioner to provide asupportive learning environment,which promotes continuousprofessional development and lifelonglearning

• participate in on-going personaldevelopment and professionaleducation of all members of theneonatal nursing team, usingmentorship, objective setting andappraisal, helping nursing staff tomeet their education needs

• develop, deliver and participate in,and evaluate, formal specialisteducational and developmentprogrammes to nursing/midwiferyand medical staff, including thoseprovided by higher educationinstitutes. Use computers andmultimedia technologies asappropriate

• participate in national meetings andconferences, delivering presentationsto audiences, which may include largegroups from varying backgrounds

• act as a role model and mentor toANNPs, junior medical staff,nurses/midwives and students

• teach specialist neonatal skills to staffand parents/carers, for example,neonatal resuscitation, home oxygen,nasogastric feeding, stoma care andsuction

• act as formal clinical superviser forcolleagues undertaking professionaldevelopment programmes.


36




Main duties

Quality, research and development

The trainee ANNP:• creates an environment conducive

to research and evidence-basedneonatal care and encourage itsimplementation

• initiates audit, participates inresearch within the NNU, andencourage others to do so. Usesthe results to make changes topractice where indicated

• evaluates newly generatedresearch findings. As part of theneonatal team, disseminatesfindings and incorporates theminto practice using advancedknowledge and skills to influencebest practice

• initiates, develops, implementsand reviews specific guidelines andclinical management plans

• ensures standards are maintained,monitored, and reviewed inadherence with local, national andNMC guidelines

• supports initiatives in clinicalpractice which deliver advancedlevels of neonatal care

• contributes to, and take an activerole in, key clinical research andaudit projects.

The ANNP will:• ensure awareness and encouragement

of best practice, lead and participatein research and audit programmes,recognising the need for andpromoting evidence-based practice

• create an environment for researchand evidence-based nursing andencourage its implementation

• lead practice development initiativesthrough participation in clinicalworking groups in NICU and thenetwork

• develop and continually review clinicalguidelines to promote best practice inneonatal care/management in NICU

• work within an ethical and legalframework using defined policies,procedures, standards and protocolsof the department, organisation andthe network to promote safe andeffective care and report quality issuesto the multidisciplinary team

• actively participate in clinicalgovernance, clinical effectiveness andrisk management, be proactive inimplementing organisational agendasand strategies

• be responsible for maintaining patientrecords within the agreed standards toensure the care management plan iscommunicated to parents/carers andthe health care team, and is reflectiveof their current care needs

• ensure the team maintains standardsof record keeping

• seek views of families and carers toimprove the health care experience forservice users.

The SANNP will:• create an environment conducive to

research and evidence-basedneonatal care and ensure relevantchanges are implemented

• initiate audit and research within theneonatal unit and supervise others toundertake audits. Use the results tofacilitate changes to practice whereindicated

• present at national conferences andwithin peer-reviewed journals

• devise own audit plan for severalaudits on an annual basis, feeding theplan into neonatal annual objectives,generating a report on auditsundertaken for annual neonatal report

• evaluate newly generated researchfindings. Disseminate findings andincorporate them into practice usingadvanced knowledge and skills toinfluence best practice

• in line with GCP standards (goodconsent practice), seek consent fromparents and recruit neonates to multi-centre randomised controlled trialsand other research projects. Use on-line randomisation software andresearch databases to completerecruitment process

• initiate, develop and implement andreview specific guidelines and clinicalmanagement plans

• ensure standards are maintained,monitored, and reviewed in adherencewith local, national and NMCguidelines

• initiate evidence-based changes inclinical practice which deliveradvanced levels of neonatal care

• lead practice development initiativesthrough participation in clinicalworking groups in NICU and thenetwork

• develop and continually review clinicalguidelines to promote best practice inneonatal care/management in NICUand throughout the network

• seek the views of families and carersto improve the health care experiencefor service users

• use IT systems to generate proposalsand reports, leading on practicedevelopment initiatives.



37



Main duties

Decision making and judgement

The trainee ANNP: • is accountable for their own

practice; therefore answerable forall actions and omissions,regardless of advice or directionfrom other professionals

• acts decisively under supervisionas clinical lead in complexsituations

• independently analyses, interpretsand compares a range of optionsand differential diagnosis toresolve clinical problems

• has the authority, within theboundaries of their developingknowledge and skills, to orderinvestigations and prescribespecialist treatment followinganalysis of the results and withoutrecourse to medical staff

• will use own initiative and actindependently within theboundaries of their own existingknowledge and skills

• will recognise when additionalsupervision is needed and seekadvice appropriately

• is accountable for optimal use ofresources balanced against theneeds of each individual neonate

• has the freedom to act and makeclinical decisions, guided byprecedent and clearly definedpolicies, procedures and codes ofconduct (in accordance with NMCregulations, clinical and staffgovernance framework and the EUclinical trials directive).

The post holder is expected to:• be accountable for their own

practice; thereforeanswerable for all actionsand omissions, regardless ofadvice or direction fromother professionals

• make daily complex clinicaland professionalautonomous decisions(without direct supervision)regarding the clinicalmanagement of babies. Thiswill include the provision ofexpert advice to themultidisciplinary team

• justify clinical decisionmaking on a patient’s healthcare, through stringentmonitoring of the patient’scondition and acting onclinical judgement

• act as a patient’s advocate toensure their rights areupheld

• be accountable for optimaluse of resources, balancedagainst the needs of eachindividual neonate

• be free to act and makeclinical decisions, is guidedby precedent and clearlydefined policies, guidelines,procedures and codes ofconduct in accordance withNMC regulations

• recognise staff performanceissues and appraiseaccordingly.

The post holder is expected to:• make daily complex clinical and professional

autonomous decisions (without directsupervision) regarding the clinical managementof babies. This will include the provision ofexpert advice to the multidisciplinary team

• act decisively as clinical lead in time-sensitivesituations, leading the multidisciplinaryneonatal team and independently anticipatingand resolving clinical problems

• justify clinical decision making on a patient’shealth care, through stringent monitoring of thepatient’s condition and acting on clinicaljudgement

• will make highly complex judgements aboutmultiple aspects of care and treatment whichmay result in conflicting and/or uncleardiagnoses

• consider differential diagnosis and the varietyof potentially contentious treatment options,which require the post holder to weigh updifferent possibilities and justify the clinicalrationale. They will be required to initiatefurther investigations and treatment plans froma range of options, analysing response andaltering plans as necessary as further databecomes available.

• has the authority and is expected to orderinvestigations and prescribe treatmentfollowing analysis of the results withoutimmediate recourse to medical staff

• be accountable for their own practice, thereforeanswerable for all actions and omissions,regardless of advice or direction from otherprofessionals

• be an autonomous practitioner with thefreedom to act and initiate actions to implementmedical and nursing patient management plansfor a case load of neonates

• act as the patient’s advocate to ensure theirrights are upheld

• be free to act and make clinical decisions, isguided by precedent and clearly definedpolicies, procedures and codes of conduct (inaccordance with NMC regulations, clinical andstaff governance framework and the EU clinicaltrials directive)

• to judge, as clinical lead within the residentteam, the competence of other multidisciplinaryteam members, assigning responsibility toothers appropriately

• to use initiative and acts independently withinthe bounds of their existing knowledge andskills

• will exercise judgement in recognising whensupervision is required and seek advice, askingfor help from consultant staff as appropriate

• be accountable for optimal use of resourcesbalanced against the needs of each individualneonate


38




Main duties

Most challenging parts of the job

• Studying at master’s level andlearning new skills while acceptingincreased responsibility.

• Attending high risk deliveries andcaring for critically ill neonates,whilst simultaneously prioritisingother work demands.

• The unpredictability of theworkload and the dynamic changefrom routine to emergency with noprior notice.

• Adapting to the change in role andmaking complex and high levelindependent clinical decisions.

• Complex nature of the job and theemotional demands within thespecialty, for example, when caringfor critically and terminally illneonates.

• Supporting parents, families andcolleagues in difficult andemotional circumstances.

• Requiring an awareness of thesupport mechanisms forwomen/families with complexhealth or social issues whichimpact on the management of theneonate’s care.

• Gaining the confidence of stressedparents who are perceived as beingaggressive and abusive.

• Dealing with stressed staff andmanaging conflict in the workplace.

• Integrating professional roleboundaries.

• Attending high-risk deliveries aloneand leading resuscitations.

• Fulfilling the role of clinical expert andacting as a resource to colleagues.

• Motivating and inspiring staff.• Providing the highest standards of

care whilst addressing the equalityand diverse needs of the families.

• Implementing change effectively in amultidisciplinary environment.

• Time management.• Responding to unexpected patient

activity, demand and changing clinicalstatus of individual neonates.

• Making referrals to supportmechanisms for women/families withcomplex health or social issues whichimpact on the management of theneonate’s care.

• Gaining the confidence of stressedparents who are perceived as beingaggressive and abusive.

• Dealing with stressed staff andmanaging conflict in the workplace.

• Integrating professional roleboundaries.

• Leading resuscitation at high-riskdeliveries and having theresponsibility for the care of criticallyill neonates, whilst simultaneouslyprioritising and managing other workdemands for the service.

• Fulfilling the role of clinical expert andacting as a resource to colleagues.

• The unpredictability of the workloadand the dynamic change from routineto emergency with no prior notice.

• Making highly complex and high levelindependent clinical decisions at alevel of experienced medical staff.

• Complex nature of and emotionaldemands within the specialty, forexample - when caring for criticallyand terminally ill neonates andsupporting parents, families andcolleagues in difficult and emotionalcircumstances.

• Supervision, training anddevelopment of medical and ANNPstaff in all aspects of their work.

• To motivate and inspire staff.• To provide the highest standards of

care whilst addressing the equalityand diverse needs of the families.

• To implement change effectively in amultidisciplinary environment.

• Time management.• To respond to unexpected patient

activity, demand and changing clinicalstatus of individual neonates.

• Giving presentations at local andnational conferences, teachingsessions and meetings.



39



Main duties

Communications and relationships

Physical, mental, emotional and environmentalThe ANNP provides care and management for infants born on the on the edge of viability (~ 500g birthweight) and thosewho are extremely sick and unstable. The ANNP undertakes procedures that require extreme manual dexterity, accuracyand using highly developed skills, as well as intense concentration in an emotionally charged, hot and busy environment.

Physical skillsWhilst the following provide aninsight into expected procedures,these will be determined locally.• Venepuncture• Capillary blood sampling• Insertion/withdrawal of umbilical

catheters • Insertion of percutaneous

catheters • Insertion of intraosseous needle• Connection/calibration of invasive

blood pressure transducer• Sampling from indwelling umbilical

catheters • Perform direct arterial sample

aspiration• Blood gas analysis • Endotracheal intubation/

extubation (emergency andelective)

• Implementing/managingrespiratory support, includingventilation

• Cold light transillumination of thechest

• Insertion/removal of chest drain• Insertion and removal of urinary

catheters• Suprapubic aspiration of urine• Lumbar puncture • Examination of the newborn

Physical skillsWhilst the following provide an insightinto the expected procedures, these willbe determined locally.• Advanced maintenance of neonate’s

airway (resuscitation and intubation)• Ventilation management• Extubation• Prescribing of drug and fluid therapies• Administer intravenous injections,

intravenous infusions and intra-muscular injections

• Intravenous additives• Intravenous cannulation/

venepuncture• Insertion of long-lines, umbilical

venous and arterial lines• Radial arterial lines/arterial puncture • Transillumination• Needle thoracentesis• Chest drain insertion/management

and withdrawal• Blood cultures• Lumbar punctures• Suprapubic bladder aspiration• Insertion of urinary catheters• Placement of gastric tubes• Blood gas analysis• Arterial blood gas sampling/

monitoring• Blood pressure monitoring (invasive

and non-invasive)• Specimen collection (nasopharyngeal,

endotracheal, swabs)• Urinalysis• Stoma care• Cranial ultrasound

Physical skillsWhilst the following provide an insightinto the expected procedures, thesewill be determined locally.• Advanced maintenance of neonates

airway (resuscitation and intubation)• Ventilation management• Extubation• Prescribing of drug and fluid

therapies• Administer intravenous injections,

intravenous infusions and intra-muscular injections

• Intravenous additives• Intravenous

cannulation/venepuncture• Insertion of long-lines, umbilical

venous and arterial lines• Radial arterial lines/arterial puncture • Transillumination• Needle thoracentesis• Chest drain insertion/management

and withdrawal• Blood cultures• Lumbar punctures• Suprapubic bladder aspiration• Insertion of urinary catheters• Placement of gastric tubes• Blood gas analysis• Arterial blood gas

sampling/monitoring• Blood pressure monitoring (invasive

and non-invasive)• Specimen collection

(nasopharyngeal, endotracheal,swabs)

• Urinalysis• Stoma care• Cranial ultrasound

Physical demands• Performing complex medical

procedures whilst standing in arestricted position over incubatorsand cots.

• Extensive walking/prolongedstanding for majority of shift.

• Adapting to changing shift patterns• Use of computer keyboards and

VDU screens.• Frequent lifting, moving of

moderate weights, includingequipment weighing more than25kg for short periods.

Physical demands• Performing highly complex medical

procedures while standing in arestricted position over incubators andcots.

• Extensive walking/prolonged standingfor majority of shift.

• Adapting to changing shift patterns.• Use of computer keyboards and VDU

screens.• Frequent lifting, moving of moderate

weights including equipment weighingmore than 25kg for short periods.

• Frequent moving of cots andincubators.

Physical demands• Performing highly complex medical

procedures while standing in arestricted position over incubatorsand cots.

• Extensive walking/prolongedstanding for majority of shift.

• Adapting to changing shift patterns.• Use of computer keyboards and VDU

screens.• Frequent lifting, moving of moderate

weights including equipmentweighing more than 25kg for shortperiods.


40




Main duties


Physical, mental, emotional and environmental (continued)

Physical demands• Frequent moving of cots and

incubators. • Frequent bending at awkward

angles to assist breastfeedingmothers.

• Frequent bending at awkwardangles over cots to carry outnursing procedures.

• Transporting sick or preterminfants receiving respiratorysupport using a transportincubator/resuscitaire whichrequire manipulation en route.

• Shifts frequently in excess of 10hours.

• Irregular breaks. • Breaks which are not bleep/pager

free.

Physical demands• Frequent bending at awkward

angles to assist breastfeedingmothers.

• Frequent bending at awkwardangles over cots to carry outnursing procedures.

• Transporting sick or preterminfants receiving respiratorysupport using a transportincubator/resuscitaire whichrequire manipulation en route.

• Shifts frequently in excess of 10hours.

• Irregular breaks. • Breaks which are not bleep/pager

free. • Running to respond to emergency

situations.• Working and adapting to a

changing shift pattern adverselyaffects Circadian rhythms.

Physical demands• Frequent moving of cots and incubators • Frequent bending at awkward angles to

assist breastfeeding mothers.• Frequent bending at awkward angles

over cots to carry out nursingprocedures.

• Transporting sick or preterm infantsreceiving respiratory support using atransport incubator/resuscitaire whichrequire manipulation en route

• Shifts frequently in excess of 10 hours.• Irregular breaks. • Breaks which are not bleep/pager free. • Running to respond to emergency

situations.• Working and adapting to a changing shift

pattern adversely affects Circadianrhythms.

Mental demands• Concentration is required on every

shift while undertaking intricateclinical care to neonates, includinginvasive procedures with little orno margin for error.

• The clinical condition of babiesrequiring neonatal care can changevery quickly and requiresmeticulous attention to detail toensure that any changes incondition are acted onimmediately. This can result in anunpredictable workload, changingfrom one task to another to dealwith changes in condition.

• Concentration to undertakecomplex calculation of drugs inminute doses.

• Maintaining work/life balance.• Providing telephone support and

advice to remote areas withoutdirect access to the patient.

Mental demands• Concentration required due to the

nature of the ANNP role.• Complex clinical decision making.• Frequent direct and indirect

interruptions from parents,relatives, bleeps.

• Complex prescription, calculationand administration of drugs.

• Working for prolonged periods oftime, concentrating on an acutelyill infant.

• Neonatal transports.• Recognising and responding to

ethical issues due to the nature ofthe post.

• Time management.• Dealing with unpredictable

workload.• Challenging inappropriate and

poor clinical practice.• Maintenance of precise and

accurate records.• Change management.

Mental demands• Concentration is required on every shift

while undertaking intricate clinical careto neonates, including invasiveprocedures with little or no margin forerror.

• Frequent requirement for concentration isrequired as the workload is unpredictableand subject to very frequentinterruptions from colleagues, parentsand bleeps.

• Intense concentration required forprolonged periods when dealing withresuscitation, stabilisation andmanagement of acute emergencies,balanced against other competingpriorities.

• The clinical condition of babies requiringneonatal care can change very quicklyand requires meticulous attention todetail to ensure that any changes incondition are acted on immediately. Thiscan result in an unpredictable workload,changing from one task to another todeal with changes in condition.

• Concentration to undertake complexcalculation of drugs.

• Maintaining work/life balance.• Providing telephone support and advice

to remote areas without direct access tothe patient.

• Being lead clinician and making complexdecisions about cases and priorities.



41



Main duties


Physical, mental, emotional and environmental (continued)

Emotional demands• Dealing on a daily basis with

distressing and highly emotivesituations involving neonate,parents, siblings and the extendedfamily, for example, death of aneonate, breaking bad news,supporting distressed parents,their families and staff.

• Coping with the fluctuatinganxieties of parents of unstableneonates.

• Conveying distressing news anddealing with severely challengingbehaviour.

• Diffusing potential complaints.• Dealing with complaints.• Dealing with verbally abusive

parents, relatives and visitors.• Coping with the erratic,

unpredictable behaviour of parentsinvolved in substance misuse.

Emotional demands• Communicating with

distressed/anxious/worriedparents/carers and otherrelatives.

• Caring for and supporting othersto care for dying babies and theirfamilies.

• Imparting bad news to parentsand families.

• Caring for babies who are verysick and unstable, or who have apoor prognosis.

• Caring for babies with neonatalabstinence syndrome (drugwithdrawal), and theirparents/carers who may displaychallenging behaviour.

• Supporting parents/staff whomay be emotionally fragile.

• Supporting novice neonatalnurses and junior medical staff inthe intensive care environment.

• Dealing with staff/ familycomplaints.

• Dealing with child protectionissues.

Emotional demands• Dealing on a daily basis with distressing

or highly emotive situations involvingneonate, parents, siblings and theextended family, for example, death of aneonate, breaking bad news, attendingresuscitations, supporting distressedparents, their families and staff.

• Attending traumatic neonatalresuscitations where there is a pooroutcome, or dealing with a suddencollapse of a previously well neonatewithin the neonatal unit.

• Frequently coping with the fluctuatinganxieties of parents of unstable neonates.

• Frequently caring for babies who are verysick and unstable, or who have a poorprognosis.

• Conveying distressing news and dealingwith very challenging behaviour.

• Diffusing potential complaints.• Dealing with complaints.• Dealing with verbally abusive parents,

relatives and visitors.• Coping with the erratic, unpredictable

behaviour of parents involved insubstance misuse who may displaychallenging behaviour.

• Frequently supporting parents/staff whomay be emotionally fragile.

• Dealing with child protection issues.

Environmental demands• Constantly working in a hot

environment (>24°) which isnecessary to maintain the bodytemperature of small neonatesnursed in cots.

• Frequent daily exposure to bodyfluids, hazardous and infectiousmaterials.

• Using complex medical equipmentinvolving noxious gases, forexample, nitric oxide.

• Exposure to phototherapy lights.• Holding patients for radiological

investigations.• Working in personal protective

equipment.• Lone working.• Extremes of temperature. During transport:• working in confined, cramped

conditions• adverse weather conditions• motion sickness• travelling in hazardous conditions.

Environmental demands• Constantly working within a hot

environment (>24°) which isnecessary to maintain the bodytemperature of small neonatesnursed in cots.

• Frequent daily exposure to bodyfluids, hazardous and infectiousmaterials.

• Using complex medicalequipment involving noxiousgases, for example, nitric oxide.



equipment.• Lone working.• Extremes of temperature. During transport:• working in confined, cramped

conditions• adverse weather conditions• motion sickness• travelling in hazardous

conditions.

Environmental demands• Constantly working in a hot environment

(>24°) which is necessary to maintain thebody temperature of small neonatesnursed in cots.

• Frequent daily exposure to body fluids,hazardous and infectious materials.

• Using complex medical equipmentinvolving noxious gases, for example,nitric oxide.



equipment.• Lone working.• Extremes of temperature. During transport:• working in confined, cramped conditions• adverse weather conditions• motion sickness• travelling in hazardous conditions.


42


Appendix 3: Mapping of competences against NHSknowledge and skills framework dimensions (NHS, 2004)

Competences Knowledge skills framework dimensions

Communication and interpersonal relationship, including:• data processing and management• production and communicating of information and

knowledge• design and production of visual records.

Core dimension - 1Information and knowledge - IK 1Information and knowledge - IK 2Information and knowledge - IK 2 /3

Personal, professional and people development Core dimension - 2Learning and development - G 1Development and innovation - G 3

Health, safety and security Core dimension – 3

Service development, including:• logistics, facilities and maintenance management• partnership • leadership • management of people• management of physical and/or financial resources.

Core dimension - 4Estates and facilities – EF1 /2Core dimension - 4Core dimension - 4People management - G 6Financial management - G 4

Quality, including:• research and development.

Core dimension - 5Information and knowledge - IK 2

Equality, diversity and rights Core dimension – 6

Responsibility for patient care, including:• assessment, addressing and improving the health and

wellbeing of babies, families and carers• biomedical investigation and reporting• measuring, monitoring and treating physiological

conditions through application of specific technologies.

Promotion of health and wellbeing and prevention of adverseeffects on health and wellbeing dimension - HWB 1-10. Health and wellbeing - HWB 1, 2, 3, 4, 5, 6 and 7.Health and wellbeing - HWB 8, 9 and 10.

1. Assisting future recruitment to, andretention of, the neonatal nursing workforce

� All pre-registration children’s nurse and midwiferyprogrammes must include a course of study focusingon the care of the sick or compromised neonate.

� This should be complemented by a neonatal placementopportunity of not less than four weeks during the pre-registration programme (for example, in transitionalcare, special care/ neonatal units).

� When newly qualified nurse/midwives are offeredinitial employment within neonatal care, they musthave access to a full preceptorship package and the fullrange of future neonatal nursing career opportunities.

� Contracts of employment may offer rotationalplacements through the neonatal unit for the first 18months.

� The organisation has a clear policy to allow formidwifery statutory updating, to facilitate continuedregistration as a midwife, within normal working timesin the neonatal unit.

� All new members of staff who enter into neonatal careare viewed as ‘novices’ regardless of their background.

2. Using the career and education framework –a partnership approach

� This framework is used throughout the UK to informworkforce development and educational plans inpractice environments.

� The associated competences, core clinical skill set andmatched educational requirements should be used atpractice level and by HEIs to underpin and benchmarklocal provision.

� Future provision of specialist education to support the‘Competent neonatal nurse’ (for example, qualified inspecialty as a Level 2 neonatal nurse) should be offeredat a minimum of undergraduate level.

� Employers should be encouraged to use the knowledge,level of educational achievement, and specified skill setto support the development of job descriptions, jobspecifications and, consequently, short-listing criteria.

� Local HEIs and NICUs should work in partnership todevelop the Accreditation of Prior ExperientialLearning (APEL) routes available within HEIsregulations to allow acknowledgment of neonataleducation packages within recognised HEI-basedprogrammes of study, to ensure that no neonatal nurseis disadvantaged by the organisational approach.

3. Developing curriculum content for post-registration neonatal nurse education

� Must reflect contemporary and evidence-based practiceequal to the level of practice being aspired to.

� Should ideally be determined by partnership workingbetween the HEI and local neonatal providers.

� Should be organised as a package to span therequirements for the full range of nursing care acrosseach neonatal care category.

� Should meet the needs of those across the careercontinuum by offering flexibility.

� The individual should be concurrently accommodated ina practice environment which provides a level of carewhich complements the focus of study and allowssufficient time to develop the required competence. Thisshould be specified within any prerequisite for HE study- arranging this would be the responsibility of thesponsor/employer.

� All units must have established mechanisms forpreceptorship/mentorship, which may include medicalcolleagues where appropriate.

� HEIs develop formal assessment of practice tools tosupport the programme of study (which should be basedon the competence and core clinical skill set) to ensureequity in practice outcomes across the UK.

� Those undertaking the development of practice areformatively and summatively assessed by a practicementor who meets the NMC requirements for theprofession.

4. Continuous professional development forneonatal nurses

� Strategic education and development plans shouldencompass this. In the UK this should be lead bynetworks. The organisation is similar but geographicallydetermined in Scotland, Wales and Northern Ireland.

� CPD events could also be considered by the local HEI tocontribute towards academic credits under the APELsystem as above.

� Individual practice must remain contemporary sonetworks should explore rotational opportunities forstaff between units to support this (where geographicallypossible).

� Additional input regarding partnership working withparents, families and carers should be available for allnurses and midwives.

� Clinical supervision is separate to managerialsupervision within neonatal units as a way to promotedevelopment and reflective practice on a personal level.

� In addition, the unit processes should providemeaningful opportunities for regular team debriefing,such as neonatal and perinatal audit meetings.


43

Appendix 4: Summary of recommendations

Benner, P (1984) From novice to expert: excellence andpower in clinical nursing practice. California: Addison-Wesley Publishing Company.

Blake, D and Teasdale, DT (2008) Supervision of midwivesin neonatal environments – the mists of uncertainty.Journal of Neonatal Nursing 14, (1) 22-27.

British Association of Perinatal Medicine (2001) Standardsfor hospitals providing neonatal intensive and highdependency care (Second Edition) and categories of babiesrequiring neonatal care. London: BAPM.

British Association of Perinatal Medicine (2010) Servicestandards for hospitals providing neonatal care (ThirdEdition). London: BAPM.

Canterbury Christ Church University (2005) A documentfor revalidation; The Dip HE/BSc interprofessional healthand social care continuing professional developmentframework. Canterbury. CCCU – local publication.

Department of Health (2009) Toolkit for high qualityneonatal services. London: DH.

Department of Health (2010) Advanced level nursing: aposition statement. London: DH.

Kerr, L (2003) Midwives in neonatal units. Unpublished.Available from Lynne Kerr, Clinical Manager, NeonatalUnit, Royal Infirmary of Edinburgh.

Leitch, S (2006) Leitch review of skills. Prosperity for all ina global economy - world class skills. London: TheStationery Office.

NHS West Midlands (2010) West Midlands women andchildren workforce development project; pre-registrationneonatal pathway pilot project report. Available fromJackie Stretton, Project Lead. West Midlands Neonatal PilotProject Manager Institute of Health and Society, Universityof Worcester

National Health Service Education for Scotland (NES)(2002) A route to enhanced competence in neonatalnursing. Edinburgh: NES.

National Health Service Education for Scotland (NES)(2010) Scottish Neonatal Nurse Group: a career anddevelopment framework for neonatal nurses in Scotland.Edinburgh: NES.

National Health Service (2004) Knowledge and SkillsFramework and the development review process. London:NHS.

National Institute for Heath and Clinical Excellence (2010)Specialist neonatal care quality standard. London: NICE.

Nursing and Midwifery Council (2004) NMC Circular35/2004. Maintaining midwifery registration in neonatalunits. London: NMC.

Nursing and Midwifery Council (2006) NMC Circular21/2006. Preceptorship guidelines. London: NMC.

Nursing and Midwifery Council (2008a) Standards tosupport learning and assessment in practice (SecondEdition). London: NMC.

Nursing and Midwifery (2008b) The code: standards ofconduct, performance and ethics for nurses and midwives.London: NMC.

Nursing and Midwifery (2009a) Additional information tosupport the implementation of NMC standards to supportlearning and assessment in practice. London: NMC.

Nursing and Midwifery Council (NMC) (2009b) Recordkeeping: guidance for nurses and midwives. London: NMC.

Nursing and Midwifery Council (2010a) The prephandbook. London: NMC.

Nursing and Midwifery Council (2010b) Regulation ofAdvanced Nursing Practice, London: NMC. Accessed Nov2010. Available at; http://www.nmc-uk.org/About-us/Policy-and-public-affairs/Politics-and-parliament/PMs-Commission-on-the-future-of-nursing-and-midwifery/Regulation-of-advanced-nursing-practice-/(Accessed 7 May)

Royal College of Nursing (RCN) (2003) Preparing nursesto care for children and young people. London: RCN.Publication code 001 997.

Royal College of Nursing (RCN) (2009) A right to care: aposition statement on neonatal staffing. London: RCN.

Scottish Neonatal Nurses Group (2003) Staffing survey.Unpublished. Available from Miss Moira Gray,Chairperson, SNNG, Practice Development Department,Wishaw General Hospital.

44


References

Scottish Neonatal Nurses Group (2004) Report on neonatalnurse staffing and career pathways. Unpublished. Availablefrom Miss Moira Gray, Chairperson, SNNG, PracticeDevelopment Department, Wishaw General Hospital.

Scottish Neonatal Nurses Group (2005) The competencyframework and core clinical skills for neonatal nurses.Unpublished. Available from Miss Moira Gray,Chairperson, SNNG, Practice Development Department,Wishaw General Hospital.

Skills for Health (2006) Career framework for the NHS,Bristol: Skills for Health. Available at:www.skillsforhealth.org.uk/careerframework (Accessed 7 May 2011).

Skills for Health (2010) Maternity care of the newborn –maternity support worker competency set, Bristol: Skillsfor Health. Available at:www.skillsforhealth.org.uk/competences (Accessed 7 May 2011).

AfC Agenda for Change

ANNP Advanced neonatal nurse practitioner

APEL Accreditation of Prior Experiential

Learning

BAPM British Association of Perinatal Medicine

CPD Continuing professional development

DH Department of Health

GCP Good consent practice

HEI Higher education institute

JDs Job descriptions

KSF Knowledge and Skills Framework

NES National Health Service Education for

Scotland

NICE National Institute for Heath and Clinical

Excellence

NICU Neonatal intensive care unit

NMC Nursing and Midwifery Council

QIS Qualified in specialty

RM Registered midwife

RN Registered nurse

SCQF Scottish Credit and Qualifications

Framework

SfH Skills for Health

SNNG Scottish Neonatal Nurses Group


45

Glossary of acronyms

July 2011

Review date June 2016

Published by the Royal College of Nursing20 Cavendish SquareLondonW1G 0RN

020 7409 3333

RCN Onlinewww.rcn.org.uk

RCN Directwww.rcn.org.uk/direct0345 772 6100

The RCN represents nurses and nursing, promotesexcellence in practice and shapes health policies

Publication code 004 118

ISBN 978-1-906633-71-4

rcn competences - nhs networks · it is hoped that this rcn competency framework will be useful for...

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