The following guidance, developed and supported by Royal College of Nursing, outlines the clinical governance procedures for working with children with complex health needs,who require invasive care procedures. It explains which tasks can be carried out by non clinical staff following appropriate training and looks at delegation and competency issues. This guidance is updated regularly. http://www.rcn.org.uk/__data/assets/pdf_file/0013/254200/Clinical_proceduresfinal083.pdf
Managing children with health care needs: delegation of clinical procedures, training and accountability issues
Background In 2004 the Council for Disabled Children published ‘the Dignity of Risk’ 1 which contained an advisory list of procedures previously produced by the Royal College of Nursing in 1999, highlighting those clinical procedures which could be safely taught and delegated to non-health qualified staff. This list was subsequently updated for ‘Including Me’ in 2005 2 . Further revisions have since been made to reflect some of the queries which have arisen, clarifying pointers as needed. This document will continue to be updated at periodic intervals.
Clinical procedures which might be undertaken by non-health qualified staff Administration of medication or invasive clinical procedures should only be undertaken by staff or carers when prescribed by a qualified nurse * , qualified medical practitioner or qualified dentist. Staff and carers should only agree to undertake these tasks if they feel competent and confident to do so.
In order to safely and effectively support the care needs of children requiring these procedures comprehensive training needs to be in place and delivered by appropriately qualified nursing staff.
Underpinning principles - The training programme must be designed to enable carers to
* In respect of medications – only nurses who have completed the required training as a non-medical prescriber can prescribe medications † Routine tracheostomy changes provide an opportunity for a registered practitioner to assess carer competency while also undertaking an assessment of the tracheostomy site ‡ The first time replacement must be undertaken by an appropriately qualified nurse or qualified medical practitioner. § This is usually an appropriately qualified nurse such as a Community Children’s Nurse NB. If the child becomes unwell they need to be seen by appropriate clinical staff and cared for by appropriately qualified staff (Registered nursing care may be required at such times). - Non-health qualified staff should be trained to deliver care according to set protocols and guidelines and would not be expected to make independent decisions about a child’s care, but refer these to either a parent or health professional.
The permitted tasks for non-health qualified staff and focus of training for these tasks must be on the care as it applies to a named child. The individual carer will require specific training and assessment in order to participate in the care of a second or third child.
The following advisory list of procedures may be safely taught and delegated to non-health qualified staff following a child-specific assessment of clinical risk:
The following tasks should not be undertaken by non-health qualified carers:
Delegation and accountability Nursing involves complex tasks and procedures and even though health care support staff may have been trained to provide certain aspects of care to specific children, they may not necessarily be competent in all circumstances to do so. The NMC code states:
When delegating any aspect of care the NMC states that each child should be clinically assessed and the most appropriate person appointed to deliver any subsequent care. If this is a health care support worker then the registered nurse delegating the care should ensure they are competent to undertake the task being requested of them. The NMC advises that if a registrant feels they have been asked to delegate care to a health care support worker who they believe does not have the required competency or it is an inappropriate delegation, then they should refuse the instruction. This should then be raised formally with their employers including the justification for taking such a decision. Clause 8.2 and 8.3 of the Code supports this:
When a registered nurse assesses a member of health care support staff to carry out an aspect of care, then that must also include all aspects of the task including recording activities completed in the child’s record. The best interests of the child are paramount. It is important that in order to promote this registrants must ensure that they provide appropriate support and supervision to health care support staff when performing delegated care delivery.
Any delegation of clinical tasks to non-health qualified staff must be undertaken within a robust governance framework which encompasses:
Training non health qualified staff The aim of a training programme should be to provide information and learning about both theoretical and practical aspects of the carers role. Opportunities must be provided for supervised practice before an assessment of competence by a suitably qualified person § . This process should take into account the views of the child or young person, parents and the views of the person being assessed.
Training should take place at two levels:
Key elements of a training programme are suggested as follows
In the same way as information is shared on a need-to-know basis, training should be arranged on a general level for all staff working with a particular child and specific training for staff who will be supporting a child on a one-to-one basis.
The trainee must be assessed as competent to undertake the task and documentation signed by the health care professional to indicate this. At the time of assessment of competence the monitoring and date of training update will be agreed and recorded.
An example of general and specific training around complex health needs including core competencies for training that can then be used locally with necessary adaptations alongside standardising policies and procedures will be added in due course.
Updated by: Fiona Smith, David Widdas, Mary Lewis, Liz Bray and Linda Maynard Date: January 2008
Enquiries to: Fiona Smith, Adviser in Children and Young People’s Nursing Nursing Department, Royal College of Nursing
References 1 Council for Disabled Children, Shared Care Network and National Children’s Bureau (2004) The Dignity of Risk, London: National Children’s Bureau, Council for Disabled Children and Shared Care Network 2 Council for Disabled Children, Department for Education and Skills (2005) Including Me, London: Council for Disabled Children 3 Noyes, J and Lewis, M (2005) From Hospital to Home. Guidance on the discharge management and community support for children using long-term ventilation, Essex, Barnardos. 4. NMC (2007) Advice on delegation for NMC registrants, London: NMC
|