royal college of nursing wales education strategy 2016 the ......every nurse, is fundamental to...

Royal College of NursingWales

Education Strategy 2016

The Future of Nursing Education

in Wales

3Royal College of Nursing Wales Education Strategy 2016 - The Future of Nursing Education in Wales

Contents

Foreword 4

e Future of Nursing Education in Wales 5

Introduction 5

Strategic Context 5

Population Factors and Care Settings 5

Professional Factors 6

Digital Technology and Analytics 7

Policy and Legislative Context 7

e Voice of Nursing in Wales 7

Overarching emes 7

Care and Compassion 9

Knowledge Generation and Implementation 13

Resilience 18

Bibliography 22

Education Summit Programme Contributors 23

Authoring Contributors and Critical Friends 23

Education Summit Attendees 23

Glossary of Terms 24

FOREWORD STRATEGY CARE & COMPASSION KNOWLEDGE RESILIENCE BIBLIOGRAPHY


The Future of Nursing Education in Wales

1. Introductione Royal College of Nursing (RCN) represents bothnurses and nursing, promotes excellence in practiceand shapes health policies. Its charter objectivesinclude:

“Promoting the science and art of nursing andthe better education and training of nurses andtheir efficiency in the profession of nursing”

and “promoting the advancement of nursing asa profession in all or any of its branches”.

e aspiration of this Royal College of Nursing WalesEducation Strategy is that patients and thoseaccessing health and care services in Wales shouldreceive the highest quality of care regardless of thetype of care or setting in which it is delivered.Realising this aspiration requires resilient andflexible nurses and health care support workers(HCSW) who have received the appropriateeducation and development to enable them to delivercare which is compassionate, evidence-based,prudent and safe and which impacts positively onboth patient outcomes and experience.

In addition to a commitment to patients, the RCNhas a key role in supporting nurses and HCSW toattain the necessary education and skills as part of itsremit in supporting and valuing nurses. Research

exists which demonstrates that when staff aresupported emotionally and professionally, they feelvalued and nurtured which, in turn, results in staffwho are more likely to remain in nursing and todeliver safe and compassionate care.

2. Strategic Contexte principles which have guided the developmentof the strategy include:

Population Factors and Care Settings

2.1 While the principles and values whichunderpin nursing have not changed, nursingpractice has changed dramatically over the lastdecade. As our population becomes older andthe number of individuals living with chronicconditions increases, the needs of patients andtheir families are becoming more complex. ishas resulted in nurses in acute settingsmanaging an increasingly complex range ofinterventions that incorporate advances intechnology and disease management whilstnurses in primary and community care settingsmanage the increasing burden of chronicdisease and support and encourage public self-management of their health.

2.2 e effects of lifestyle on the burden of diseaseare changing. Whilst cardiovascular disease is


ForewordFOREWORD STRATEGY CARE & COMPASSION KNOWLEDGE RESILIENCE BIBLIOGRAPHY

4 Royal College of Nursing Wales Education Strategy 2016 - The Future of Nursing Education in Wales

e role of the nurse is constantly evolving inorder to meet the changing needs of health serviceprovision and the changing needs of patients, theirfamilies and carers. What is required therefore isa highly skilled, motivated and engaged workforcewhich strives constantly to improve patient care.Education, which begins with pre-registrationcourses (or at induction for health care supportworkers) and persists over the entire career ofevery nurse, is fundamental to achieving such aworkforce.

Qualifying as a nurse involves an undergraduateprogramme (BSc Hons Nursing). Each StudentNurse must have evidence of having completed 2,300hours of study and 2,300 hours of clinical practice;achievement of all academic requirements andclinical competencies and a signed declaration ofgood health and good character from the universityprior to becoming a registrant of the Nursing andMidwifery Council (NMC). e Council has astatutory duty to protect the public throughregulating nurses by setting standards of education,training, conduct and performance so that nursesand midwives can deliver high quality healthcarethroughout their careers.

In 2000, A strategic plan for nursing, midwifery andhealth visiting education in Wales was published. Itwas called “Creating the potential” (NationalAssembly for Wales, 2000). Predicated on the needto ensure that service delivery and patient care wereof the highest quality for the people in Wales, themain aim of that strategy was:

“To ensure that all nurses, midwives andhealth visitors develop their practice in areflective and evidence based manner,

founded upon a standard of education whichenables them to practise as equal partners

with other healthcare professionals,supported by continuing professionaldevelopment and clinical supervision.”

Many of the recommendations of that strategy havebeen achieved, for example the Registered Nursingworkforce is educated to degree level so that theneeds of patients and their families can be met byindividuals who have the correct blend of intellectual

skills and clinical competencies. ose achievementsneed to be built upon in order to ensure that newways of preparing nurses and their support workersare developed to meet the challenges of the nextdecade and beyond.

In this strategy, the educational needs of the currentand future workforce are addressed. e nextgeneration of nurses need an education which isfuture-proofed, resulting in nurses who havedeveloped the intellectual skills of problem-solving,clinical decision making, professional judgment andresearch appraisal and application together with theessential clinical competencies, knowledge andattitudes. Education of the current nursingworkforce, however, is also crucially importantbecause:

• It will fall to the current workforce to enculturate,mentor and educate student nurses;

• It is essential that nurses and health care supportworkers are constantly and consistently supportedthrough education and training to be able to meetchanging service needs and new models of care;

• Registered Nurses are required; as a condition ofrevalidation to demonstrate the way in which theirprofessional development has impacted on patientcare.

It is intended that this Education Strategy will be akey enabler for ensuring that appropriate education,training and preparation underpins nursing practicefor the future.

e Royal College of Nursing inWales is indebted to ProfessorDonna Mead OBE, OStJ, FRCN,Welsh Board Member for herleadership in articulating theviews of the profession acrossWales in order to produce this

important strategy. e RCN in Wales would like tothank all those who engaged in the process.Particular thanks are afforded to Professor MarkDrakeford AM Minister for Health and SocialServices for agreeing to consider the strategy and itsrecommendations which set an important directionboth for nurse education and patient care.

Gaynor Jones Tina Donnelly, CBEChair, Royal College of Nursing in Wales Director, RCN Wales


revalidation of practice as a pre-requisite toperiodic re-registration.

2.11 Equipping the nursing workforce with thecapability to deliver language and culturalcompetence in healthcare can improve servicequality and effectiveness. Education andtraining programmes that reflect and addressthe bilingual context of Wales are essential.

Digital Technology and Analytics

2.12 New technology, and the way we use it isrevolutionising health care. In the same way asInformation Technology (IT) has made anenormous difference to commerce andindustry, it is changing the practice of everynurse. In particular, health care is increasinglyan information driven activity. Getting the rightdata and information to the right people at theright time in the right form to inform decisionsand make a difference is now fundamental toour ability to improve the health both of theindividual patient and populations. econsequence of not using these technologies issuboptimal care, inefficient use of resources,preventable clinical errors, and limitations onthe ability of patients and the public to takeresponsibility for their own health and care.

Policy and Legislative Context

2.13 Existing policies and reports and new andfuture legislation have informed the content ofthe strategy. e policy/strategy documentswhich have informed this strategy include: Aplanned primary care workforce for Wales(Welsh Government, 2015), Aligning nursingskills – guidance: an all Wales governanceframework (NHS Wales Shared ServicesPartnership, 2014), A framework for theadvanced nursing, midwifery and allied healthprofessional practice in Wales (NationalLeadership and Innovations Agency forHealthcare, 2010), Health professionaleducation investment review (Evans, 2015),Developing excellence in health care: an NHSWales skills and career framework for healthcare support workers supporting nursing andallied health professions (NHS Wales, 2015),Trusted to care: Report of the external,independent review of the Princess of WalesHospital and Neath Port Talbot Hospital atAbertawe Bro Morgannwg Health Board(Andrews, 2014), Report of the externalinvestigation into concerns regarding the care

and treatment of patients: Acute Mental HealthUnit, Glan Clwyd Hospital (Betsi CadwaladrUniversity Health Board, 2014); In search ofaccountability: a review of the neglected olderpeople living in care homes investigated asOperation Jasmine (Flynn, 2015); More thanjust words (Welsh Government, 2015).

Recent legislative changes affecting the contextin which Welsh health care is planned anddelivered have also informed the content of thestrategy. ese include the Social Services andWell-Being Act 2016, the Future GenerationsAct 2015, the Public Health (Wales) Bill 2015and the Nurse Staffing Levels (Wales) Bill 2016(both Bills are awaiting Royal Ascent).

3. e Voice of Nursing in WalesTo ensure this strategy reflects the professional voiceof nursing in Wales and more broadly within the UKand Europe, an extensive programme of engagementwith both practitioners and education providers hasbeen carried out.

Two education summits were held in order to obtainthe views of nurses across Wales. Each summitcomprised a series of presentations and workshopsincluding a stocktake on developments in nurseeducation across Europe. e summits were iterativei.e. one was not a repeat of the other and theyprovided an opportunity to engage colleagues indeveloping the key components of the strategy. Inaddition through a process of critical friend review, recommendations have been received from nursingcolleagues with particular expertise.

Key themes which persisted and survived criticalreview and debate over the two events have beengrouped and categorised and these are set out in theVenn diagram overleaf.

Overarching emes

3.1 Care and Compassion e need for nursing toreconnect with the public regarding its corevalues of care and compassion and the value ofeducation being crucially important in bothpromoting professional values and leading toimprovement in both patient outcomes andexperiences.

3.2 Knowledge e importance of generatingknowledge through research which can improvepatient care. As important is the role of educationin providing the tools to be effective in bothapplying and implementing knowledge to


decreasing, mortality and morbidity fromalcohol related diseases and other lifestyleissues such as obesity are increasing (CMOWales, 2015). is emphasises the importanceof public health in reducing the burden ofdisease and of coproduction, a component ofprudent health care (Welsh Government, 2013),as an important cultural change towardachieving this.

2.3 Increasingly pathways of care encompassprimary, community and acute health caresettings as well as social care and the thirdsector. is increases the urgency for health andsocial care to become fully aligned andintegrated.

2.4 More widely, the World Health Organization(WHO, 2015) highlight concerns relating to theshortfall of health workers globally and exploreways in which this might be addressed.

Professional Factors

2.5 e development of a health care workforcewhich will support the changes in health caredelivery planned for NHS Wales will dependboth on developing the existing and preparingthe future workforce to work in new models ofservice delivery which will be required to meetchanges in demand.

2.6 e evidence base for nursing skill mix and itseffect on patient outcomes such as morbidityand mortality is compelling. e links betweenlow staffing levels of registered/graduate nursesand a range of negative care outcomes has beendemonstrated. ese include increasedmortality rates; adverse events aer surgery;increased incidence of violence against staff;increased accident rates and patient injuries;increased cross infection rates and higher ratesof pneumonia, gastrointestinal bleeding;cardiac arrest and urinary tract infections inhospital in-patients.

2.7 Whilst care and compassion are amongst thefounding principles of professional nursing, itis important to understand that nursing is“knowledge work”. is term, first used byDrucker (Drucker, 1959), and which has beendeveloped ever since, serves to differentiatebetween knowledge work and routine work.e work of the Registered Nurse ischaracterised by its emphasis on non-routineproblem solving that requires creative thinking

utilising an extensive knowledge base which isapplied to a unique situation i.e. the assessmentand needs of individual patients. It is this, andnot just the task, which distinguishesprofessional nursing from the work of thesupport worker. Responsibility for the overallnursing care of a patient and clinical decisionmaking lies with the Registered Nurse andcannot be delegated to, or substituted by otherstaff. is does not in any way diminish ordevalue the work of the HCSW; theircontribution to care is invaluable but it isdifferent from that of the Registered Nurse. etwo roles are not interchangeable butcomplimentary. Recent research has shown thatthe inappropriate substitution of a HCSW for aRegistered Nurse increases the risk of poorerpatient outcomes. ese distinctions havealready been explained in the Royal College ofNursing documents Defining nursing (RoyalCollege of Nursing, 2014) and A summary ofRCN policy positions: registered nurses andhealth care support workers (Royal College ofNursing, 2015) .

2.8 Oen a false distinction is made betweenclinical skills and “hands-on” care as requiringless knowledge. e complexity of patients’ careneeds means that an apparently simple tasksuch as washing a patient requires both skilland knowledge for it to be undertakeneffectively. For nurses to make informeddecisions about care, and to carry out their fullrange of activities, they must be there with theirpatients observing, monitoring and, equallyimportant, assessing and doing, not relying onreports from other staff.

2.9 e development of a plethora of differentnursing titles and overlapping roles confusespatients and public alike. In Wales thedevelopment of a career ladder for HCSW (withthe widest possible access) is needed. It shouldinclude step on and step off points so thatHCSW can be developed and provided withopportunities to enter the work force asgraduate nurses. Such an initiative, as wellproviding essential training for staff, will createworkforce resilience through HCSW whowould be available to complete a RegisteredNurse training in two years. (It takes up to fouryears to recruit and train graduate nurses).

2.10 Regulatory changes which introduce newstatutory requirements for nurses, for example

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Care & Compassion

Care and compassion are among the foundingprinciples of professional nursing. ese have neverchanged. Many recent high profile reports haveemphasised the need for care to be patient centredand compassionate. It is no accident that the recentWillis report commissioned by Higher EducationEngland (HEE) is entitled, “e shape of caring”(Willis, 2015).

Evidence exists that healthy, well-supported andwell-motivated staff improve the care experience andoutcomes for patients. erefore creating positivework environments, career opportunities,professional recognition and rewards for nurses isimportant. It leads to reduced sickness levels,encourages staff retention and continuedengagement in the workplace and delivery of healthcare. If we have learned anything from recent reportsinto unacceptable practice, it is the way in whichprolonged lack of CPD and clinical supervision,together with poor staffing levels and leadership canlead to an insidious deterioration in standards whichspreads and becomes harmful for patients. Whennurses can no longer take pride in their work aprocess of disengagement occurs which worsens thealready pernicious effects on patient care and patientexperience.

Key enablers for facilitating a nurturing workenvironment, one which fosters continued staffengagement and commitment, include systems forclinical supervision, mentorship and appraisal. eseprocesses can be powerful in improving patientoutcomes because they involve focusing on theachievements and learning development needs of staffand, in the case of clinical supervision, can be animportant means of preventing work-related stress.Mentorship is most oen associated with thepreparation of undergraduate learners. Whereasparticular arrangements must be in place forundergraduate students in order to comply with NMCrequirements, mentorship arrangements should beavailable for all staff according to circumstances.

For patients whose first language or language of choiceis Welsh, compassionate care, dignity and respect isrealised by being able to communicate with healthcare professionals in Welsh. Workforce planning andskill mix should be predicated on this principle. Nurseeducation needs to be pivotal in assisting the NHS indelivering and embedding the principle of the ActiveOffer as set out in More than just words, the WelshGovernment strategic framework for Welsh languageservices in health, social services and social care(Welsh Government, 2012).


eradicate or ameliorate the time lag betweendiscovery and implementation.

3.3 Resilience e health service of the future willrequire a workforce which is flexible and,importantly resilient to enable the workforce torespond rapidly and appropriately as servicedelivery models develop and new roles arerequired. In particular patients with complexneeds require, and consistently ask for, holisticcare delivered by a nurse who can provide “wholeperson care”. Current undergraduate trainingmilitates against this due to curricula which aredivided into four fields of nursing whilst postgraduate nurse education has tended to be drivenby professional aspirations to specialise.Furthermore, access to continuing professionaldevelopment education (CPD) for nurses andHCSW is not guaranteed and nurses wishing totrain for a particular role or develop along a

particular career pathway can experience delays inobtaining education and oen are required to self-fund. is in turn affects the ways in which nursesperceive their value as part of the health care team.It can also result in less than optimal skills andknowledge to underpin nurses’ work.

e points at which these key themes intersectprovide the substance of what needs to be includedin this strategy together with the role of educationproviders working in partnership with each otherand service colleagues in the provision of educationand training. Inevitably there is some overlapbetween such closely related and important themes.

Workforce planning is seen as a key enabler whichrequires radical reform. is is considered alongsidethe Ministerial Written Statement following thepublication of the Health professional educationreview (2015) and the Chancellor of the Exchequer’sannouncement regarding the future funding of nurseeducation NHS England (2015).


KnowledgeGenerationApplication

Implementation

ResilienceSustainability

CaringCompassion

CPDRevalidationAccreditationInnovation

RevalidationNew RolesAdvanced

PractitionerConsultant NurseClinical Academic

Clinical SupervisionMentorshipSkill Mix

Image of Nursing

CORE THEMES


11Royal College of Nursing Wales Education Strategy 2016 - The Future of Nursing Education in Wales10 Royal College of Nursing Wales Education Strategy 2016 - The Future of Nursing Education in Wales

Education becomes a key driver for promoting professional values and enhancing patient experiences and outcomes

CLINICAL/COLLEGIALSUPERVISION

A methodically definedprocess for sharingconcerns and ideasthrough a scheduledmeeting and astructured process.

MENTORSHIPA relationship in whichan individual nurturesin another profess-ionally defined values,knowledge & skillswhich ultimately resultin a judgement beingmade regarding thementee's competence.

APPRAISALA means of assessingperformance to makeplans for correctingshortcomings,developing potential,and initiating training.

SKILL MIXThrough levels ofstaffing and expertise,the creation of asupportive workingenvironment whichenables staffdevelopment toflourish.

RECOMMENDATIONS FOR EDUCATION PROVISION

1. Recommendations: Appraisal

Appraisal is not merely a review of pastperformance. It is a means of staffdevelopment in a service which dependson on-going development for the deliveryof safe, effective care. Talking about thejob and the work it involves can remindstaff of why they wanted to do it in the firstplace. It gives nurses an idea of their worthand encourages them to develop theirtalents while helping them overdifficulties. Appraisal can provide anopportunity to re-engage with the valuesand behaviours which underpin nursingcare. To ensure appraisals are performedto the same standard throughout theorganisation, appraisers need to betrained and a reasonable time set aside toundertake appraisal.

1.1. NHS organisations should aspire tohave a 100% of its nursing and HCSWworkforce undertaking appraisal. Thisprovides the foundation for bothindividual and organisationaldevelopment through plannededucation and training which meetsboth service needs and the needs ofpatients.

1.2 Ongoing education and training forappraisers is essential. Its contentshould go beyond the appraisalencounter to include leadership forembedding appraisal goals intoorganisational CPD plans.

2. Recommendations: Mentorship

There is robust evidence of the correlationbetween strong nursing leadership, thequality of learning environments andmentor effectiveness (Kings Fund 2012,RCN, 2013). Mentorship and clinicalsupervision should be the means by whichstaff continue to understand and realisetheir personal and professional obligationsand commitment to creating a positive,compassionate culture of care (CTUHB ,2015).

2.1 An organisational culture whichsupports practice based learningneeds to be developed and prioritisedby those in key leadership roles.Nurses in leadership roles should beaccountable for the supportmechanisms for mentors.

2.2 Comprehensive organisationalsystems which support mentorshipneed to be built upon, furtherdeveloped and prioritised.


2.3 Sufficient time for mentorship shouldbe a priority. This includes time forstaff to benefit from the mentorshiprelationship and time to enable staff togain mentorship skills. It is predicatedupon the availability of appropriateeducation and training of mentorswhich includes experiential learningaligned with the NHS Wales’ staffpsychological health and well-beingresource (NHS Wales, 2014).

2.4 NHS Wales and the RCN shouldcollaborate in the development of on-line resources to support mentors.

3. Recommendations: Mentorship forundergraduate student nurses

Mentorship is included in the All WalesInitiative for undergraduate nurseeducation. The initiative is highly valuedby both service and education colleagues.It has resulted in consistency of standardsand competencies for mentorship.

3.1 The All Wales initiative shouldcontinue. Several new models formentorship have been proposed(Willis, 2015). CYNGOR shouldconsider evaluating the currentapproach to undergraduate nursementorship in Wales and makerecommendations for future models.

3.2 The All Wales initiative could be furtherstrengthened by establishing amechanism to enable participation ina community of mentors whichfacilitates a shared and consistentapproach to assessment and decisionmaking through ongoing educationinvolving case reviews anddissemination of good practice.

3.3 The quality of practice learningenvironments for nurses should be aBoard level priority. Regular reportingto the Board should include:

Placement metrics and data on mentorcompliance with NMC Standards.

National (National Student Survey)and local analysis of student nurseplacement evaluations includingconcerns raised by students aboutboth the quality of care andmentorship.

3.4 The extent to which practice-basedlearning is valued and supportedshould be included in the NHS Walesstaff survey and other relevant audits.

3.5 The RCN in Wales should consider howit can support Nurse Directors inensuring appropriate Board levelscrutiny of the practice learningenvironment.

3.6 A programme of research whichaddresses the impact of mentorshipand appraisal on both patientoutcomes and staff engagementshould be commissioned.

3.7 The importance of mentorship shouldbe recognised by including evidence ofeffective mentorship in RCNaccreditation of advanced practice.

4. Recommendations: Skill Mix

Safe staffing and skill mix is determined byusing appropriate professional judgement,guidance and tools to aid decision making.Setting staffing levels and skill mixdepends on a range of factors includingthe clinical setting, patient acuity, thenature of clinical decision making andprofessional judgement being exercised.

Guidance and tools exist to support theprocess which should aim to ensure theright number of staff with the appropriateskills to enable both safe patient care andthe provision of a supportive environment.The process for determining appropriatestaffing establishments for a clinical area

GOAL

KEY ENABLERS



Knowledge Generation and Implementation

Nursing is an evidence-based profession that uses thelatest and best research to improve nursing practiceand patient outcomes. Nursing research is needed togenerate knowledge and develop nursing care. eInternational Council of Nurses (ICN, 2007)describes research-based practice as the ‘hallmark ofprofessional nursing’ and states that quality researchis integral to best practice, evidence-based care andcost-effective health care. Nursing research has comea long way since the Briggs Report, (Briggs, 1972)which recommended that nursing should become aresearch-based profession.

e Research Excellence Framework (REF, 2014),which for the first time included a measure of theimpact of research, demonstrated how outcomes forpatients are being transformed by the research workof nurses. Nevertheless we need to ensure that thereis capacity in both our universities and in service tocontinue to carry out ground breaking research.

Importantly we need to ensure that the connectionbetween research, education and evidence-basedpractice is understood by all stakeholders and weneed to strive to achieve even greater impact onpatient care through research. For this to happen thebarriers which prevent nurses combining a career inpractice and research need to be removed.Opportunities for clinical academic careers need tobe provided underpinned by courses which addressclinical research, for example a Master’s degree inClinical Research (MClinRes) as well as conventionaldoctoral training.

As important is the understanding of theimplications of research findings for practice andpolicy together with the ability implement researchfindings into practice.

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(including skill mix) together with the dailyrequirements for staff need to beunderstood by everyone who hasaccountability for ensuring safe patientcare.

The ability to calculate establishments andensure appropriate skill mix is predicatedupon a supply of Registered Nurses andHCSW with the requisite skills,competencies and decision making ability.Current commissioning of education inWales has led to repeated cycles of overand undersupply of nurses leading to thenecessity to recruit from overseas, aprocess which has been demonstrated tobe costly and inefficient and which isvulnerable to changes in UK Visarequirements.

4.1 Building on existing guidance, inparticular that of the Chief NursingOfficer for Wales, as highlighted in theevidence given to the Health andSocial Care Committee (2015); an AllWales model for determining staffinglevels and skill mix should bedetermined. This will allow sufficientAll Wales data to be collected,enabling further research into therelationship between staffing, skillsmix and patient outcomes to beundertaken.

4.2 It is essential that all nursing staff,managers and Board members havean understanding (appropriate to theirrole in the organisation) of howstaffing levels and skill mix are set.Training for this should be available.

4.3 Consideration should be given toestablishing All Wales education andtraining for those staff who are heldaccountable for ensuring appropriatenursing skills mix and staffing levels.

4.4 It should be a requirement that thoseresponsible for commissioningundergraduate and post graduateeducation for nurses can demonstrateachievement of an appropriate level ofcompetence in workforce planningfollowing appropriate educationpreparation.

4.5 Consideration should be given toremoving the cap on student nursecommissioning numbers. This couldresult in an increased supply of nurseswho, through access to student loans,will have more disposable incomethroughout training. Should thedecision be to remove the cap onstudent numbers in Wales,consideration needs to be given tofinancial modelling which wouldalleviate potential financial hardship.Consideration is currently being givenby the Welsh Government to develop apolicy for repaying student loans ofWelsh students if they work in Walesafter graduating and student nursescould be a part of that policydevelopment.

4.6 A pan Wales review of placementcapacity is needed together with aplan to maximise placementopportunities. Removing the cap onstudent numbers has the potential toresult in innovative and flexibleprogrammes of study leading toregistration and contributing toresilience. Such innovation isconstrained by current commissioningprocesses.

4.7 Level One Welsh Language trainingshould be a feature of commissioningin undergraduate and post-graduateeducation.



Build nursing research capacity in order to develop the scientific knowledge-base and the ability both to engage in critical inquiry

and to implement research findings in practice.

Develop ClinicalAcademic Partnershipstogether withappropriate educationand clinical training,career pathways andaccreditation.

Advanced Practice andconsultant nurse rolesbased on serviceneeds andunderpinned byinnovative educationprogrammes andaccreditation.

ACCREDITATIONAccreditation appliedto an organisation, acourse or to aprogramme of clinicaland academicexperience whichresults in theacquisition ofacknowledgedcompetencies.

ANALYTICSIncreasing nurses andsupport workersunderstanding of andability to use data andresearch findings inquality improvement.


1. Recommendations: Digital Technology and Analytics

Digital technology is now central toimproving the quality of patient carewhether this is through eHealth or healthinformatics. As well as having the potentialto improve patient experience, these newtechnologies will make health careprocesses more prudent. Systems currentlyin use include patient administrationsystems, which in Wales includes theWelsh Clinical Portal and Myrddin. Newtechnologies which the NHS in Wales isdeveloping, in collaboration with NHSWales Informatics Service, include(amongst others) electronic referral anddischarge; the single patient electronicrecord (Master Patient Index) and theCommunity Care Information Solution(CCIS) which will enable information to beshared between health and socialservices. The Master Patient Index will bepopulated with data on patient care,treatment and experience, which will beinvaluable to nurses in improving patientcare if its potential and the ability toexploit it is understood. eHealth assistsnurses in keeping up to date with newknowledge and is an important tool in

supporting decision making. In addition,through technologies such as text alertpatients can become empowered inmanaging their health care. Nurses andHCSW will have to learn new skills if IT is tofulfil its promise in improving nursing care(RCN, 2014).

1.1 All clinicians need to appreciate therelationships and differences betweendata, information and knowledge inhealth and how they contribute to theeffective delivery of care and patientsafety. Informatics, therefore shouldnot be regarded only as a subject to betaught separately in the curriculum. Itneeds to be embedded into allcurriculum content. Considerationneeds to be given by both service andeducation providers as to how thismight be achieved. This shouldinclude a review of the All Wales ICTcurriculum content for undergraduateeducation.

1.2 There should be commissionedprovision for nurses and HCSW whichensures a level of informatics literacy.Education provision should includeinformation governance, clinical

GOAL

KEY ENABLERS


information systems, clinical recordkeeping, clinical coding, access toinformation and information sharingand the relationship between data,information and knowledge.

1.3 As health care is increasingly a datadriven activity, nursing staff will needto keep abreast of emergingtechnologies. In particular, nursingstaff need to ensure that they areinvolved in working with systemdevelopers to ensure new systems fitwith nursing practice. Educationprovision, which addresses the skillsnecessary to work with systemdevelopers should be available.

2. Recommendations: Clinical AcademicCareers

Clinical academic careers in health careare not a new phenomenon. They haveexisted in medicine and dentistry for sometime. The clinical academic nurse is anindividual who engages concurrently inclinical practice and research providingclinical and research leadership in thepursuit of innovation and serviceimprovement. Strong evidence exists onthe benefit and return on investment ofRegistered Nurses who successfullycombine clinical and academic work.(Department of Health, 2012). The ChiefNursing Officer for Wales hascommissioned a pilot programme todevelop clinical academic nursing staff inWales.

A successful pilot will need to address thefollowing:

2.1 A strategy for clinical academics inWales is needed. Its implementationwould enable the serviceimprovements which emanate fromclinical academics to be realised. Sucha strategy needs to be developed,endorsed and implemented by serviceand education providers working incollaboration. The strategy would need

to address the followingrecommendations:

2.2 Workforce planning arrangementswhich identify the role and the criticalmass required to enable serviceimprovement needs to be established.

2.3 Sufficient capacity and capability ofstaff with appropriate academiccompetencies to lead research andsupervise and mentor clinicalacademics is essential. A plan todevelop sufficient numbers of staffwith the appropriate academicqualifications and experience needs tobe agreed and implemented as soonas possible.

2.4 Clinical academic positions and theprogrammes of inquiry which they willundertake should be considered afeature of University Health Board(Trust) status. Under the leadership ofNurse Directors, a network for drivingforward this agenda should beestablished. As well as fostering thedevelopment of clinical academiccareers, this network should have akey objective of integrating researchand innovation across the nursingworkforce.

2.5 The pathway to a clinical academiccareer should begin on qualifying orsoon afterwards. A mechanism foraccreditation of such pathways needsto be established.

2.6 Human Resources (HR) mechanismswhich will enable clinical academics towork flexibly in both universities andcare settings need to be established.

2.7 Programmes of inquiry predicated onimprovement science should beagreed to provide a focus for grantapplications and importantly to ensurethat the quality of knowledgegeneration is sufficiently robust forintegration into practice.

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2.8 As an individual moves through theclinical academic pathway,appropriate education in the form ofMasters degree in Clinical Researchand professional doctorates will needto be established and funded.

3. Recommendations:Accreditation/Credentialing

Accreditation is a professionally-ledsupportive process involving both self andexternal peer assessment to assess thequality of clinical services in relation toestablished standards and to promotecontinuous quality improvement.

Accreditation can be applied to services,individuals or training pathways. Theprocess of formal accreditation ofcompetencies (which include knowledge,skills and performance) in a defined areaof practice, provides confidence that theindividual is fit to practise at a particularlevel.

In the absence of a consistent postregistration regulatory framework, theRoyal College of Nursing has a plan toinfluence the standards of nursing bycredentialing advanced nursing practice.Advanced nursing practice frameworks areestablished in each of the UK countries.These, along with previous RCN work onspecialist nursing and advanced nursingwill form the basis of RCN advancedpractice credentialing. The Welshperspective on the design andimplementation of the process ofcredentialing will be obtained throughmembership of the Advanced PracticeCredentialing Advisory Group. In addition,an outstanding individual who meets a setof criteria, qualities, skills and attributescan be conferred an RCN Fellowship. Thesefellowships will represent an importantmeans of demonstrating the value ofnurses and nursing.

It is recommended that accreditationshould also address:

3.1 Developing clear pathways for nursesfrom registration through to advancelevel practice (including clinicalacademic pathways).

3.2 Defining the standards for theprofession. This will include theeducational requirements, the skillssets required for practice and theability to influence the required outputof a standard of practice.

3.3 Working with partners, identify and seteducational criteria and practicecomponents for advanced levelpractice in different nursingspecialties. A successful credentialingprocess for nurses has already beenagreed with the Royal College ofEmergency Medicine.

4. Advanced Practice and ConsultantNurse Roles: the full range and scopeof nursing practice

Advanced Practice, Consultant Nurse andClinical Nurse Specialist roles havedeveloped organically albeit that in Walesthere is a system to ensure that allConsultant Nurse job specifications adhereto an agreed set of skills andcompetencies. Many Registered Nurses areachieving Advanced Practice Mastersdegrees (which until recently were almostentirely self-funded). These new roles havebeen extensively researched and theevidence demonstrates that when patientsreceive care from nurse practitioners,educated to Masters level, outcomes areenhanced, waiting times reduced and thequality of care compares favourably withthat provided by medical practitioners.

In the absence of an agreed All Walesframework for Advanced Practice, theseroles have almost entirely been alignedwith particular clinical specialties (e.g. theEmergency Room, control of infection andso on). There is evidence, too, thatpatients want generalists because what isrequired is holistic and coordinated careand not fragmented care, duplication andgaps in service. Professional allegiance toparticular clinical specialities have tendedto undervalue and undermine the role ofthe generalist which is a category mistake.Specialist practice is defined by a greaterdepth of knowledge in a particular field.Advanced practice, which may bespecialist or generalist is defined by higher


levels of decision making (and usuallygreater knowledge) required for morecomplex problems. The term generalistmeans “competent across a range offunctions”. Interestingly, The shape oftraining review for medical education andtraining (Greenaway, 2013) acknowledgedthe need for a rebalancing betweengeneralist and specialist skills. Theframework for advanced nursing andmidwifery and allied health practice inWales (National Leadership andInnovations Agency for Healthcare, 2010)illustrates clearly the specialist togeneralist, novice to expert continuum innursing which should aid in thecommissioning of education for requiredroles.

4.1 The future workforce must maintain adegree of generalism and adaptabilityin order both to meet patient needsand to provide the resilience which theNHS and other health care providersrequire.

4.2 Education for advanced level practicewhich provides a generalist (notgeneric) skill set is needed to enablenurses to work with confidence acrossa range of settings in order to respondto patient needs.

4.3 A strategic approach to both workforceplanning and educationcommissioning is required to ensurethat the issues set out above areaddressed.

FOREWORD STRATEGY CARE KNOWLEDGE RESILIENCE BIBLIOGRAPHY FOREWORD STRATEGY CARE KNOWLEDGE RESILIENCE BIBLIOGRAPHY


ResilienceFOREWORD STRATEGY CARE & COMPASSION KNOWLEDGE RESILIENCE BIBLIOGRAPHY


Resilience has become a frequently used term in theprovision of healthcare. Its popular use signals thechallenges currently being experienced whichinclude significant workforce issues of capacity andcapability; the urgent need for service redesign, andthe increasing burden of complex chronic diseases.Resilience is also seen as an important asset inundermining austerity measures. It can be describedas an organisation’s ability to maintain performance,compensate for difficult circumstances and avoidharm. Fragility, the opposite of resilience, carries

negative connotations so that without resilience theNHS and other healthcare providers become fragileand vulnerable. e more positive notion ofresilience requires the ability of both organisationalsystems and individual ability and commitment todesign and implement positive adaptive behavioursmatched to the immediate situation. Since we arefacing a world of rapid and constant change,resilience needs to be an ongoing feature to ensurethat services for patients remain sustainable and fitfor purpose.


Create a flexible, knowledgeable and resilient workforce throughinnovative educational developments to meet changing service

needs and new models of care

REVALIDATIONRegistrants have tocomplete at least 450hours of practice, 35hours of CPD,complete 5 pieces ofpractice relatedfeedback and 5 writtenreflective accounts. Allconfirmed by a 3rdparty.

WORKFORCEPLANNING

Identification of futureroles (in HigherEducation andPractice) together withHR systems whichenable roles acrosssectors to flourish.

MODELS OF CAREDELIVERY

New and developingmodels of care requirean ability both to movebetween care settingsand sectors and todraw upon a widerange of skills in orderto provide holisticcare.

NEW FORMS OFPREPARATION

Holistic care requires:A rebalancing ofspecialist andgeneralist careIncreased flexibilitywithin roles, careerpathways and crosssector workingA workforce than canpractice co-productively.


1. Recommendations: CareerDevelopment and Role Preparation

Resilience is a concomitant of flexibility.The resilience of a health care system is itscapacity to respond, adapt and maintainperformance when exposed to shock suchas disease outbreak or natural disaster. Inthe UK winter pressures is another.Adaptation is required also in order tomeet the requirement to provide carecloser to home. Building on thedevelopments contained in “Aligningskills” (NHS Wales Shared ServicesPartnership, 2014) and the “Postregistration framework” (NationalLeadership and Innovation Agency forHeath Care, 2010):

1.1 Create in Wales a structured andcoordinated approach to post-graduate education and developmentactivity which facilitates, for eachnurse and HCSW, career developmentand role preparation.

1.2 Plan to provide education to supportnew models of care such as rural

health care, integrated health andsocial care, transitional andunscheduled care in communitysettings. The plan should makeprovision for the necessary advancedknowledge and skills. Providingsupport to maintain resilience andappropriate adaptive behaviours willalso be essential. Considerationshould be given as to how best toachieve this through appropriatesupport structures.

1.3 Ensure access to training for nursesand HCSW providing care to definedgroups which should include thoseliving with dementia, children andfamilies during early years, thoseliving with mental health problemsand learning disabilities. Sucheducation and training should bedetermined by the care setting inwhich the individual works, and notthe field of practice for which he orshe is qualified, to ensure thatpatients receive holistic andcoordinated care.

GOAL

KEY ENABLERS



1.4 To promote resilience and flexibilityand to better meet patient needs,opportunities for Registered Nursesand HCSW to develop competenciesin more than one field of nursing needto be provided. This includes, forexample adult nursing and mentalhealth nursing. Specific one year post-registration programmes should bedeveloped (possibly at Masters level)to enable nurses on one part of theregister to qualify for another part.

2. Recommendations: Revalidation

Revalidation is a statutory requirement forRegistered Nurses. More importantly, it is aprocess of continued collation of evidencewhich demonstrates that registrants haveengaged in professional updatingactivities. Importantly at least 20 of therequired hours must involve engagementwith other health care professionals toensure that nurses who are professionallyisolated are engaged in educationallybased networking activities.

2.1 Whereas revalidation is theresponsibility of individual nurses, theprocess must be supported byorganisational systems and inparticular by senior nurses to ensureboth compliance with the statutoryrequirements and professionalgrowth. Support includes identifyingopportunities for registrants to engagein CPD activities.

2.2 The process of revalidation can leadto both organisational learning andthe identification of practice basedtheories. Consideration should begiven to developing a means ofcapturing the learning made possiblethrough revalidation as a way ofinforming nursing practice andimproving patient care.

2.3 On-going education and training inthe skills of reflection are necessary toensure that nurses both develop andretain the ability to identify practicebased learning.

3. Recommendations: WorkforcePlanning

A radical review of workforce planning isrequired in order to ensure that theworkforce is able is able to support servicechanges and to meet the changing needsof the population. In a written statementfollowing the publication of the Healthprofessional education investment review(Evans, 2015), the need for shiftingresources towards multi-disciplinaryprimary and community care teams,working closely with social care systemswas endorsed in order that care can bedelivered closer to home in ways which aremore prudent.

In 2015 the NHS Shared ServicesPartnership published Developingexcellence in health care: an all Walesskills and career framework for healthcaresupport workers supporting nursing andthe allied health professions (NHS Wales,2015). Its purpose is to provide agovernance mechanism to inform the skillsand career development of the HCSWworkforce.

3.1 NHS Boards and Trusts, together witheducation providers (includingUniversities, Further EducationColleges, Agored Cymru and others)should ensure that appropriateeducation and training is available tomeet the objectives of Developingexcellence in health care (NHS Wales,2015). This will need to be supportedby appropriate commissioningarrangements.


3.2 There needs to be a move away from apreoccupation with commissioningnumbers towards a focus on what isrequired in terms of role, skill mix andcompetencies to deliver the workforcefor the future. This requires afundamental revision incommissioning the total workforce.

3.3 Workforce planning should identifyboth the number of HCSW which arerequired and the roles andresponsibilities they will undertake.This is a precursor to the developmentof appropriate education provision.

3.4 Education provision for HCSW needsto be flexible predicated on work-based learning with outcomesmapped to curriculum which enablethe HCSW largely to remain in practicewhile developing clinicalcompetencies.

3.5 A plan for recruiting nurses in areaswhich experience difficulty inproviding a Registered Nursingworkforce (e.g. remote and rural areasor in particular clinical specialties e.g.older age mental health) is required.This could entail recruiting a cohort ofHCSW from a local community whowould be committed both to the areaand to undertaking nurse trainingthrough flexible and innovativepreparation over a period of years.

3.6 When undertaking workforce planningthe requirement for nurses to workacross sectors in order to provideintegrated care must be included. Thisshould include mapping of health andsocial care competencies into bothroles and curricula.



Education Summit ProgrammeContributors Dr omas David Barton, Associate Professor ofNursing (retired)

Lesley Bevan, Assistant Director of Nursing,Abertawe Bro Morgannwg University Health Board

Professor Christopher R Burton, Senior ResearchFellow, Deputy Head of School, Bangor University

Gill Coverdale, Professional Lead for Education(Standards and Professional Development), RCN

Professor Dame June Clark, DBE, PhD, RN, RHV,FRCN

Carol Hall, Vice President of the Federation ofEuropean Nurse Educators (FINE)

David Jenkins OBE, Chair, Aneurin BevanUniversity Health Board

Professor Donna Mead, OBE, OSt.J, FRCN, RCNWelsh Board Member

Professor Ceri Phillips, Head of the College ofHuman and Health Sciences, Swansea University

Professor Jo Rycro-Malone, Head of School ofHealthcare Science, Bangor University

Annette omas, Community Psychiatric Nurse,Betsi Cadwaladr University

Professor Jean White, Chief Nursing Officer(Wales)/Nurse Director NHS Wales

Lynda Williams, Director of Nursing, Midwiferyand Patient Services, Cwm Taf University HealthBoard

e Rt. Hon. Lord Willis of Knaresborough.

Authoring Contributors and CriticalFriendsJudith Benbow, Senior Lecturer/ RCN Wales PhDStudent, School of Healthcare Sciences College ofBiomedical and Life Sciences Cardiff University

Simon Cassidy, Practice Education Facilitator,Abertawe Bro Morgannwg University Health Board


Anne Phillimore, recently retired Director ofWorkforce and Organisational Development –Aneurin Bevan

Sharon Pierce, Darlithydd Nyrsio (Cyn-gofrestru)Cyfrwng Cymraeg, Nurse Lecturer (Pre-registration) Welsh Medium, Coleg CymraegCenedlaethol

Diane Powles, Principal Lecturer, Associate Headof School (Care Sciences), University of SouthWales

Jo Rycro-Malone, Professor of Implementation &Health Services Research, Head of School ofHealthcare Sciences, Bangor University

Sian omas, Chair of Consultant Nurse, Midwifeand Allied Health Professionals (CNMHP) Cymru

Dr Dafydd Trystan, Registrar, Y Coleg CymraegCenedlaethol

Education Summit AttendessSue Bale, RCN Fellow

Judith Bowen, Senior Nurse for Professional &Practice Development, Hwyel Dda UHB

Andrew Davies,Assistant Director, WorkforceDevelopment, NWSSP


Jayne Elias, Assistant Director of Nursing, VelindreNHS Trust

Stephen Griffiths, Assistant Director, WorkforceDevelopment, NWSSP

Chris Hayes, Assistant Director of NursingPractice, Workforce and Professional Standards,Hywel Dda UHB

Judith Hill, Assistant Nurse Director forSafeguarding Cardiff & Vale UHB

Angela Hopkins Executive Director of Nursing,Midwifery and Patient Services, Betsi CadwaladrUniversity Health Board

Nicky Horne Primary and Community StrategyDevelopment Nurse, Betsi Cadwaladr UHB

Deb Jackson, Assistant Director of Nursing,Aneurin Bevan UHB

Dr Neil James, Senior Lecturer in LearningDisabilities, University of South Wales

Alison Kedward, Clinical Director HealthInspectorate Wales

Professor Maggie Kirk, RCN Fellow


BibliographyFOREWORD STRATEGY CARE & COMPASSION KNOWLEDGE RESILIENCE BIBLIOGRAPHY


Andrews, J. & Butler, M., 2014. Trusted to care: reportof the external, independent review of the Princess ofWales Hospital and Neath Port Talbot Hospital atAbertawe Bro Morgannwg Health Board. Cardiff: WelshAssembly Government.Bailey-McHale, J. & Hart, D., 2013. Masteringmentorship: a practical guide for mentors of nursing,health and social care. London: Sage.Betsi Cadwaladr University Health Board, 2014. Reportof an external investigation into concerns raisedregarding the care and treatment of patients: Tawel FanWard, Ablett Acute Medical Unit, Glan Clwyd Hospital,Bangor: Betsi Cadwaladr UHB.Bradley, P. et al. 2014. Achieving prudent healthcare inNHS Wales. Cardiff: Public Health WalesBriggs, A., 1972. Report of the Committee on nursing,London: HMSO.Chief Medical Officer for Wales, 2015. Annual report2014-15; healthier, happier, fairer, Cardiff: CMO.Department of Health, 2012. Developing the role of theclinical academic researcher in nursing, midwifery andallied health professions, London: Department ofHealth.Drakeford, M., 2015. Prudent healthcare one year on.Cardiff: Ministerial statement.Drucker, P., 1959. e landmarks of tomorrow. NewYork: Harper and Row.eICE, 2012. Embedding informatics in clinical education,London: Department of Health.Evans, M., 2015. Health professional educationinvestment review, Cardiff: Welsh Government.Flynn, M., 2015. In search of accountability: a review ofthe neglect of older people living in care homesinvestigated as Operation Jasmine, Cardiff: WelshAssembly Government.Greenaway, D., 2013. Securing the future of excellentpatient care: final report of the independent review,London: Shape of Training.Health and Social Care Committee, Safe Nurse StaffingLevels (Wales) Bill, 25th February 2015.King's Fund, 2012. Leadership and engagement forimprovement in the NHS: together we can, London:King's Fund.Middleton, C., Ryley, N. & Llewellyn, D., 2015.Revalidation: implications for senior nurses. NursingManagement, 22(2), pp. 32-6.National Assembly for Wales, 2000. Creating thepotential: a plan for education, Cardiff: NationalAssembly for Wales.National Leadership and Innovations Agency forHealthcare, 2010. Framework for advanced nursing,midwifery and allied health professional practice inWales. Llanharan: NLIAH.

NHS Wales Shared Services Partnership, 2014. Aligningnursing skills - guidance: an all Wales GovernanceFramework, Cardiff: NHS Wales.NHS Wales, 2014. Caring for staff: the NHS Wales staffpsychological health and well-being resource. Cardiff:NHS Wales.NHS Wales, 2015. Developing excellence in health care:a NHS Wales skills and carer framework for health caresupport workers supporting nursing and the allied healthprofessions. Cardiff: NHS Wales.Nursing and Midwifery Council, 2008. Standards tosupport learning and assessment in practice: preparationfor mentors, practice teachers and teachers. London:NMC.REF, 2014. Research excellence framework. [Online]Available at: http://www.ref.ac.uk/pubs/[Accessed 3rd March 2016].Royal College of Nursing, 2014. Defining nursing.London: RCN.Royal College of Nursing, 2013. Response of the RCN tothe Mid Staffordshire NHS Foundation Trust publicinquiry report. London: RCN.Royal College of Nursing, 2014. Putting information atthe heart of nursing care. London: RCN.Royal College of Nursing, 2015. Summary of RCNpolicy positions: registered nurses and health care supportworkers. London: RCN.Welsh Government, 2012. More than just words:strategic framework for Welsh language services inhealth, social services and social care, Cardiff: WelshGovernment.Welsh Government, 2015. Chief Medical Officer forWales annual report 2014-15: healthier, happier, fairer,Cardiff: Welsh Government.Welsh Government, 2015. Planned primary careworkforce for Wales: approach and development actionsto be taken in support of the plan for a primary careservice in Wales up to 2018, Cardiff: Welsh Government.Welsh Language Commissioner, 2014. My language, myhealth: the Welsh Language Commissioner's inquiry intothe Welsh language in primary care, Cardiff: WelshLanguage Commissioner.Wheeler, J., 2001. Staff development through appraisal.Nursing Times, 97(39), p. 34.Willis, Phil (Lord of Knaresborough), 2015. Raising thebar: shape of caring: a review of the future education andtraining of registered nurses and care assistants, Leeds:Health Education England.World Health Organization, 2015. Options analysisreport on strategic directions for nursing and midwifery(2016-2020), Geneva: WHO press.


Denise Llewellyn, Executive Director of Nursing,Aneurin Bevan UHB

Kate Parry, RCN Welsh Board member

Sharon Pierce, Nurse Lecturer, Pre-Registration,Coleg Cymreg, Cenedladthol

Anne Phillimore, Director of Workforce and OD,Aneurin Bevan UHB

Diane Powles, Associate Head of School of CareSciences, University of South Wales

Liz Rees, RCN Welsh Board Member

Anne Marie Rowlands, Assistant Director ofNursing, Betsi Cadwaladr University Health Board

Professor Jo Rycro-Malone, Head of School ofHealthcare Science, Bangor University

Dr Martin Steagall, Dean of Faculty of Life Sciencesand Education, University of South Wales

Annette omas, Community Psychiatric Nurse,Betsi Cadwaladr University Health Board

Dr Dafydd Trystan, Registrar, Y Coleg CymraegCenedlaethol

Sian omas, Consultant Nurse Child Health,Aneurin Bevan University Health Board

Ruth Walker, Director of Nursing, Cardiff and ValeUHB

Sue Ward, Professional Head for Adult Nursing,Cardiff University

Lynda Williams, Executive Nurse Director &Midwifery, Cwm Taf UHB

Cath Williams, Senior Lecturer in Clinical Practice,Swansea University

Glossary of TermsAgored Cymru – is a Welsh organisation thatdevelops qualifications to meet skills needs inWales

CMO – Chief Medical Officer

CYNGOR – represents health departments inWelsh Higher Education and works collaborativelywith key stakeholders in the NHS, Welsh AssemblyGovernment, the Council of Deans of Health, UKand others.

HCSW – Health Care Support Worker

Nurses/Nursing - ese terms include all healthcare professionals regulated by the Nursing andMidwifery Council.

Royal College of Nursing WalesTŷ MaethKing George V Drive EastCardiffCF14 4XZ

Telephone: 029 2068 0769Email: [email protected]


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