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Fracture clinic ESP Competency Framework

Document History and Control

Version / Date / Brief summary of change / Reviewer
1.0
Status of document: / Version 1
Date approved by Integrated Clinical Governance Committee:
Review Date:
Review Cycle: / Every two years or if any major legislation changes come into effect
Awareness:
All ESP’s working for the service need to understand this document in detail and their signature of understanding/acknowledgement will be obtained (sign and return Appendix XV to Clinical Lead)

Contents

1Introduction. 4

2Equality Impact 4

3Scope. 4

4The Extended Scope role. 5

4.1Developing the role. 6

4.2Induction programme & Ongoing Competency. 7

4.2.1Induction program.. 7

4.2.2Radiology requesting. 10

4.2.3Haematology / Biochemistry and Immunology requesting. 11

4.2.4Ongoing competency. 11

Appendix I - Clinics Attended. 14

Appendix II - Competency Clinical session sheet 15

Appendix III - Clinical Session Sheet 16

Appendix IV - Knowledge and Skills. 18

Appendix V - Radiology Interpretation Sheet 70

Appendix VI -Case study. 71

Appendix VII - Levels of Supervision Checklist 72

Appendix VIII - Reflective practice. 73

Appendix IX - clinic letter Audit 74

Appendix X - Patient Reviews - Informal discussion. 77

Appendix XI - Problem Patients Informal discussion. 78

Appendix XII - Supervision Agreement and Record. 79

Appendix XIII - 360 Degree Feedback Form.. 81

Appendix XIV - Triager Competency Assessment 82

Appendix XV - Declaration Form.. 86

1 Introduction

The electronic copy of the Competency Framework is located on– and if for any reason you are unable to access this file please inform Lucy Cassidy[CL1]fracture care ESP in order to rectify.

2 Equality Impact

We aim to deliver this framework in a way that respects the needs of each individual and not to discriminate on the basis of gender, age, disability, race, religion, sexuality or social class.

3 Scope

This document outlines a process of development of the roles of Extended Scope Practitioners (ESP) and identifies the skills and competencies they need to perform their role.

Several documents have been referred to in order to produce a robust process for development of ESP and nurse specialists. This framework builds on recommendations produced by the Royal College of Nursing (RCN 2010) and on the work produced by the British Association of Occupational Therapists and College of Occupational Therapists: Extended Scope Practice (Briefing14 - 2009). It also based on the work produced by the Extended Scope Physiotherapy Clinical Interest Group: the resource Manual and Competences for Extended Musculoskeletal Physiotherapy Roles (2009).This document aligns with a comprehensive development document initially adopted by WASH and Surrey PCT in 2009 and in 2011 by Sussex Community Trust for the development of Extended Scope Physiotherapists.

This document has been adopted byBrighton and SussexUniversityHospital (BSUH)[CL2] Fracture care and demonstrates an integrated approach to the training and development of health professionals in musculoskeletal care.

The document will need to be reviewed within two years to establish any feedback from users.

4 The Extended Scope role

ESP’s have the power to make clinical decisions and act on them, and by doing so, take responsibility for them. Power to act is given by BSUH[CL3], within the fracture care setting, and agreement to the role entitles the ESP’s to vicarious liability cover. This cover remains in place, providing the ESP’s can demonstrate that they are competent to perform their role.

Whilst many of the extended roles and responsibilities undertaken by ESP’ss have now come within the scope of physiotherapy, osteopathy, OT and nurse practice, the people in these roles are still potentially more vulnerable. The key to reducing the levels of vulnerability lay in the ESP’s knowing

  • The extent of their autonomy
  • The level of accountability for their actions
  • The boundaries of their knowledge

It is important that there are clear standards of competency for these roles, both for those in post, and those aspiring to them. This should help to reduce the vulnerability of those in post, and make it clear to all concerned what is involved in the role. There are numerous ways that the vulnerability of the ESP’s can be reduced:

  • Education- this must be tailored to the individual role where possible, to focus on any specific skills needed for a particular post. Examples might include education on the local protocols for radiological interventions, protocols / guidelines for listing for surgery etc. There will also be generic training that is also required, and these skills will be transferable between roles/posts. Example might include IRMER training, interpretation of investigations such as X-rays, scans or blood tests, common clinical pathologies, red flags etc.
  • Practice- it is essential that ESP’s are regularly assessed on their practice, and regularly assess their own practice. This might be through a number of means, such as peer review sessions or reflective statements on critical incidents.
  • Good record keeping- as well as keeping concise and relevant records, it is important that ESP’s are able to demonstrate that their records are accurate and comply with the legal requirements. Regular audits of the note keeping is advised
  • Self -assessment and Critical appraisal with colleagues- this is an ongoing process that links in to continuous practice. The ESP’s should have a network of peer support and support from clinical/managerial mentors who are able to facilitate the appraisal process with them. This process should be separate from, but link in to the (KSF/)PDP.

4.1 Developing the role

When a therapists/nurse wants to be an ESP or specialist nurse he/she needs to be developed in to these roles. A defined training programme needs to be in place that provides a clear structure and pathway for all involved. Five levels of supervision are suggested

1.Observe clinics with the consultant (medical, nurse, physiotherapist) /ESP/ clinical specialist

2.Be observed in clinics by one of the above, or see the patients together

3.See the patients independently, but discuss every case, slowly developing into a variety of cases with the consultant / ESP / specialist

4.See the patient independently and discuss only random or difficult cases

5.See the patient independently. Review at peer review sessions. Continuation of learning and competency including ongoing sessions in specialty consultant clinic.

Throughout this development process, the ESP’s should keep a portfolio of case studies, reflective statements, and a record of feedback from clinical mentors and colleagues. Before progressing from one stage to the next, both the ESP’s and the mentor must be happy that they have achieved the relevant experience. This will be decided by mutual consent, and is dependent on the ESP’s demonstrating, and providing evidence of the fact that they are ready to progress to the next level. The attached sheets within the appendix should be used in this process.

The ESP’s should familiarise themselves with the referral criteria for the clinic they work in, the threshold documents and primary care pathways, and the indications for any investigations, or surgery/further treatment that they may be requesting. It is the role of the ESP’s to identify any further training needs and to highlight these to the clinical mentor/line manager. The training needs form will help to facilitate this.

The induction process is designed to equip a developing ESP’s with the necessary extra skills and knowledge to extend their scope of practice.

The attached reflective practice proformas, and checklists should be used by all staff developing towards an extended scope role and for maintaining competency (Appendices I-XI).

For those developing into an extended scope role, the forms should be signed by the trainer and trainee and dated. Some training or evidence of peer review to ensure competency will be repeated annually to ensure skills remain updated, with relevance documentation completed. Throughout the induction, specific training needs should be identified and addressed, and a personal development plan written and agreed with the mentor/trainer. This should include a time frame and should be reviewed regularly.

On completion of the induction programme, an appropriate specialist should sign off the competencies with the trainee. This may be a medical Consultant, Nurse or Physiotherapy Consultant or an established Extended Scope Practitioner.

4.2Induction programme & Ongoing Competency

4.2.1Induction program

Outlined below is the step-by-step process required for staff training to become extended scope practitioners. It is based on the levels of supervision previously mentioned.

Level 1- Observe a clinical session with the consultant/ESP/specialist

The trainee will be expected to sit in on appropriate clinics for the service that they are working in. They will be required to fill in a clinic attendance sheet (Appendix I & II) for each clinic, and to discuss this with their supervisor.

The trainee will have completed or have a date set to complete IRMER training at this stage.

The trainee will ensure that they are recognised as signatories for requesting X-rays, following their IRMER training and appropriate training in interpreting X-rays is provided. This may include time set aside for radiology training and discussions with colleagues.

The trainee will familiarise themselves with the referral protocols for radiological investigations.

The trainee will ensure they have the relevant training to be able to request appropriate blood tests.

The trainee will ensure that they are recognised as signatories for requesting blood tests.

For the trainee to progress to level 2, the supervisor and trainee need to agree that the trainee is ready to take this step, and this needs to be signed off and dated using the Training Programme Proforma (Appendix VII).

Level 2- Be observed in a clinical session by one of the above, or see the patients together

The trainee will be observed in the clinical session that they will be working in, for a minimum of 3 clinics, where they will take the lead in the examination of the patient and planning of treatment, but will work with the supervisor to come to an agreed plan.

The trainee will be required to complete a clinic attendance form following each of these sessions.

It is also recommended that the supervisor complete a reflective statement (appendix VIII) for each of these clinics, as part of their own development and that of the trainee, and as evidence for their PDP.

Before progressing to level 3, both parties must agree that the trainee is ready, and sign off the Levels of Supervision Checklist (Appendix VII).

The trainee should complete a minimum of 5 Radiological Interpretation Proformas (Appendix V) before progressing to level 3.

Level 3- See the patients independently, but discuss every case, slowly developing into a variety cases with the consultant/ESP/specialist

At this stage, the trainee is working independently in clinical sessions. This is a significant step to take, and it is important that the trainee has continuing support at this stage.

Where possible, an experienced ESP/Consultant/specialist colleague should be available during the clinic for any immediate issues that arise.

The trainee must discuss all patients seen in the clinical sessions at this stage, for at least 5 clinics.

Any differences of opinion must be fully discussed and highlighted in the Case Study Proforma (Appendix VI).

The Trainee will be expected to complete a minimum of 5 Case Study Proformas at this stage.

These must be completed and signed off by the supervisor before the trainee moves to level 4.

The trainee will be expected to complete a further 5 Radiological Interpretation Proformas (Appendix V) before moving on to level 4.

Before progressing to level 4, both parties must agree that the trainee is ready, and sign off the Training Programme Proforma (Appendix VII).

Level 4- See the patient independently and discuss only selected or difficult cases

The trainee is expected to discuss difficult cases with their supervisor or senior colleague at this stage, and to document a summary of the discussions using the Case Study Proforma (Appendix VI).

A minimum of 5 of these forms need to be completed before the trainee can progress to level 5.

A further 5 Radiological Interpretation Proformas (Appendix V) before moving on to level 5.

Before progressing to level 5, both parties must agree that the trainee is ready, and sign off the Training Programme Proforma (Appendix VII).

Level 5- See the patient independently. Review at peer review sessions

The trainee is working independently at this stage. It is expected that the trainee will maintain their competencies, using the proformas attached as evidence.

The trainee is expected to complete radiological interpretation proformas (Appendix IV).

The trainee is expected to complete case studies (Appendix VI).

Other proformas attached include:

1.patient reviews

2.problems patients with informal discussions which can provide evidence of ongoing competency (Appendix X-XI)

They are also expected to show evidence of maintaining evidence based treatment and intervention.

Participation in regular audit of the work undertaken in their ESP role, and to present and disseminate this in relevant format, should be pursued.

The extended scope practitioner's competency can be measured by the knowledge and skills that have been acquired through learning and experience. He/she needs to demonstrate they have achieved the required level of competence to confidently and safely practice in the role. The level of competence should be viewed with respect to their stage of development.
Clinical competence is achieved when the individual can demonstrate the following:

Knowledge of common pathologies seen in clinics

History and physical presentation of those pathologies

Knowledge of "masqueraders"

Pathways for investigation and management options or resources within the local health service

Application of appropriate investigations relating to the pathology and its diagnosis and management (indications, process, risk, interpretation)

Appendix IV contains all the examples per service of the knowledge and skills required to be competent. The scoring system will allow the ESP’s to determine which level he/she is at. Where necessary knowledge gaps will be identified and targeted learning / ongoing training will be required and submitted with CPD folder.

4.2.2Radiology requesting

This extension to the therapist / nurse normal practice refers to suitably trained and authorised ESP’s referring patients for a limited range of radiological investigations which have been agreed in IRMER protocols with BSUH[CL4] radiology department.

There are also specific legal requirements outlined in the Ionising Radiation for Medical Exposure to Radiation (IRMER) guidelines, which must be covered in the training and are mandatory before the ESP’s is able to request.

This training should be updated every 3 years by all staff requesting radiological imaging.

Ongoing Evaluation:

The ESP’s should use the Radiology Interpretation Sheet (Appendix IV) to monitor their ongoing performance in X-ray interpretation, matching their interpretation of the films with that of the reporting Radiologist. This can again be used as an appropriate self-directed learning tool, providing evidence of development.

4.2.3Haematology / Biochemistry and Immunology requesting

This extension to the therapist / nurse normal practice refers to suitably trained and authorised ESP’s referring patients for a limited range of blood investigations. The ESP’s should demonstrate they attended a recognised "Interpretation of bloods" course or demonstrate able to interpret due to experience and previous training. If a formal course has not been attended then the ESP’s will need to attend one at the earliest opportunity.

4.2.4Ongoing competency

As proof of ongoing competence the ESP’s will be required to submit the following per year:

  1. Diagnostic imaging:
  2. IR(ME)R training certificate
  3. Formal training (TBA)
  4. Requesting according to protocol for 5 X-rays , MRI's & USS
  5. Interpretation of 5 X-rays and / or observed in clinic
  6. Interpretation of 5 MRI's and / or observed in clinic
  7. Interpretation of 5 CT's and / or observed in clinic
  8. Interpretation of 5 USS's and / or observed in clinic
  9. Requesting and Interpreting of blood tests:
  10. Attend recognised blood training course
  11. 5 case studies and/or observed in clinic
  1. Referral to secondary care: Demonstrate clinical reasoning
  2. 5 case studies and/or observed in clinic
  1. Pharmacology
  2. Basic knowledge of evidence in guidelines and over the counter medication - demonstrate knowledge via 5 case studies/ letters or observed in clinic
  1. Triage:
  2. Being aware of existing triage documents and threshold and making sure up to date version is being used when triaging
  3. Retriage will be undertaken by clinical lead and feedback will be given - any learning from this needs to be documented
  4. 360 degree feedback form - used for assessment of triage (see appendix XIII)
  5. Triage competency assessment document (see appendix XIV)
  1. Joint injections if applicable:
  2. Attended recognised injection training course or equivalent
  3. Keep log of all injections
  4. Submit 5 case studies
  1. Communication:
  2. Audit of 10 clinical letters by clinical lead and feedback will be given
  3. Contribute to MDT
  4. Observed in clinic
  1. Clinical reasoning and decision making
  2. Observed in clinic
  3. Discuss complex patient at MDT - 2 case presentation
  1. Ongoing sessions in specialty consultant clinic to foster good clinical governance, closer working, discussion of urgent problems and maintaining skills - depending on level of worked clinics once every 2 or 3 months - ESP’s to keep track of dates and report back to clinic lead at PDP/appraisal/
  2. Audit
  3. Monthly stats (triage rate, investigation rates, onward referral pattern, serious spinal pathology identified, ...) will be provided and any learning from this will be actioned and documented
  1. Research
  2. Involved in projects, literature searches, publications
  1. Education
  2. Demonstration of local, regional, national teaching (peers, GP's...)
  1. Participation in:
  2. MDT's -
  3. ESP team meeting - 3h every 3 months
  1. Supervision and appraisal:
  2. ESP’s will have 1 session every 3 months (to observe or being observed)
  3. PDP and appraisal - 3x per year for 1h
    Clinical lead to use Supervision Agreement and Record form (Appendix XII)
  1. Other:
  2. Attend SpR training programme
  3. Attending Conferences
  4. Postgraduate Extended Scope Practice modules offered by Universities
  5. External courses that target Extended Scope Practice issues
  6. Peer review: clinical reasoning is evaluated and discussed between peers
  7. Watch surgery

Appendix I - Clinics Attended

Clinic attended / Date / Lead clinician / Patients seen / Reflective statement produced y/n
ESP Acute knee clinic
ESP Shoulder clinic
Orthopaedic generic fracture clinic
Orthopaedic F&A clinic
Orthopaedic Knee clinic
Orthopaedic shoulder clinic
Rheumatology
Pain clinic
Clinics Attended

Appendix II - Competency Clinical session sheet

Competency Clinical session sheet

Name: Date: