SHARED LEARNING OPPORTUNITIES PROJECT

Gary Morgan, Project Manager A partnership between the acute hospitals of Coventry and Warwickshire and Warwickshire Ambulance Service NHS Trust Supported by the Coventry and Warwickshire Workforce Development Confederation

SHARED LEARNING OPPORTUNITIES PROJECT

Contents 1.

Introduction

2.

Training Routes 2.1 2.2

Registered General Nurse State Registered Paramedic

3.

Shared Learning

4.

Nursing Syllabus Analysis

5.

Paramedic Syllabus Analysis

6.

Comparative Analysis of Skills and Knowledge (Coventry University)

7.

Problems Encountered with the Initial Analysis of Skills and Knowledge

8.

Assessment of Common and Unique Knowledge 8.1 8.2

Coventry University De Montfort University

9.

Range of skills gained post-qualification

10.

Delphi Study to Ascertain Future Educational Requirements 10.1 10.2 10.3

11.

Modular Approach to Developing Education 11.1 11.2

12

Background Progress Results

Models for Existing Staff - Paramedics Models for Existing Staff - Accident and Emergency Nurses

The Outcomes of Shared Learning 12.1 12.2

Skills based Academic based

13.

The Practitioner in Emergency Care (PEC)

14.

Conclusions

15.

Recommendations

16.

Appendices

17.

References

SHARED LEARNING OPPORTUNITIES PROJECT

1

Introduction

This is the working document of the Shared Learning Opportunities Project, and therefore represents progress over the six- month period from April 2001. Specific indepth syllabus information has been excluded from this version of the report for reasons of confidentiality. The project (funded by the Coventry and Warwickshire Workforce Confederation) had the following aims: 1. Undertake benchmarking to identify the opportunities for future shared learning between: Accident & emergency nurses, paramedics, operating department practitioners and renal technicians. 2. To assess the feasibility of developing the role of Practitioner in Emergency Care. To achieve these aims, the following objectives have been set: Ø Identify the training routes for Accident and Emergency Nurses and Paramedics. Ø Hence establish common and unique areas of knowledge and skills (in relation to competencies and academic levels) in both groups. Ø Subsequently identify the need and benefits of shared learning between the professions. Ø Identify current national progress towards practitioner roles. Ø From the above research develop a pathway to shared learning that could evolve to encompass the practitioner role in emergency care. Ø If time allows, extend the work to other professional areas (e.g. operating department practitioners and renal technicians). To achieve these aims and objectives, an action plan has been devised (Appendix 1), with a related time frame (Appendix 2). These are combined to form a Project Management Chart (Appendix 3). This will enable concurrent tasks to be visualised, together with allowing new tasks to be added easily. Further information on this work can be obtained from the project manager on: [email protected]

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SHARED LEARNING OPPORTUNITIES PROJECT

2

Training Routes

2.1 Registered General Nurse Pre-Registration All nursing training is undertaken at Institutes of Higher Education (colleges or universities). As can be seen in figure 1, students can study at either Diploma or Degree Level as follows:

Diploma of Higher Education in Nursing (Dip HE Nursing) Consists of a three-year course (2 year course available for students holding a health related degree). Comprises an 18- month Common Foundation Programme (CFP) followed by an 18- month branch programme (in this case Adult Nursing). This is currently being revised into a CFP of one year followed by a two-year branch programme.

Degree in Nursing (BA Hons, BN Hons, BSc in Nursing Studies) Three or four year course (according to number of study weeks per year), spilt into CFP and branch programmes as above.

Post-Registration There are various avenues open to nurses post-registration relevant to the accident and emergency role. This is either locally (in-hospital) or nationally (ENB) accredited.

Local A & E Training This is normally provided by the employing trust and so is variable in nature and not nationally recognised. Examples include wound management, venepuncture, IV drug administration, cannulation, etc.

National A & E Training This is externally accredited by the ENB. 199

Accident and Emergency Nursing

Minimum of 24-week course. To enable suitably qualified nurses to become competent to assess, plan, deliver and evaluate the specialised nursing care of patients of all ages in the Accident and Emergency Department and to give support to relatives and staff. A88

Nursing Care of the Child in Accident and Emergency

Block release and study days over 24 weeks. Enables Paediatric Nurses to acquire paediatric knowledge and skills in the area of Accident and Emergency Nursing. 2

SHARED LEARNING OPPORTUNITIES PROJECT N03

Short Programme in Accident & Emergency Nursing

20 day course to enable nurses working in Accident and Emergency areas to develop further knowledge, skill and understanding in caring for patients. N52

Advanced Trauma Care

5 day (37 hour) programme to promote competent holistic, professional and research based care for patients with acute and life threatening traumatic conditions, utilising a systematic approach. To ensure accessibility to trauma training for all practitioners, including those external to the NHS. R35

Specialist Clinical Examination

120 hours part-time module which aims to facilitate the personal and professional development of an individual who is analytical, reflective and who is able to integrate theory and practice to fulfil and contribute to a 'diagnostic' nursing role. R69

Practising Autonomously in Minor Injuries Nursing

75 hours theory followed by 5 days supervised work in A & E department. The aim of the programme is to prepare experienced nurses towards autonomous practice for clients with minor injuries. It will provide practitioners with the opportunity to critique this developing role, develop and practice new skills and evaluate new approaches to care. A33

Autonomous Practice

A minimum 40 days, this programme is intended to help practitioners to develop their autonomy within their role. This is currently being developed by Coventry University to a Diploma in Autonomous Practice (leading to BSc (Hons) Nursing Practice).

SPECIALIST PRACTITIONER PROGRAMME (DEGREE) S199 Accident & Emergency Normally no less than 1 academic year (32 Weeks) Full- time, or Part-Time equivalent. They may be completed in a shorter period of time where credit is given for prior learning or experience. The specialist practitioner programmes comprise of 50% Theory and 50% Practice and concentrate on four broad areas: 1. Clinical Nursing Practice 2. Care and Programme Management 3. Clinical Practice Development 4. Clinical Practice Leadership

Summary For this research it is envisaged that courses 199 and the A33 will be relevant (possibly A88 and S199). Some modules from the pre-registration course (particularly CFP) may also be applicable. 3

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 1:

PRE-ENTRY CRITERIA 2 A LEVELS (4 PTS) (MINIMUM STATUTORY)

Training Routes for Registered General Nurse

UNIVERSITY APPROVED BY ENB BA Hons, BN Hons, BSc NURSING STUDIES 3 or 4 YRS CFP + BRANCH PROGRAMME

POST REGISTRATION LOCAL TRAINING

ACCIDENT AND EMERGENCY DEPT (E.G. CPR, MOVING AND HANDLING, WOUND MANAGEMENT/CLOSURE, PLASTERING, GLUCOMETER, ENTONOX, TRIAGE, PAED RESUS, ECGS, VENEPUNCTURE, IV DRUG ADMINISTRATION, CANNULATION, X RAY REQUESTING, PLASTERING, PALS)

PATIENT GROUP DIRECTIONS FOR DRUGS

EXTERNALLY ACCREDITED (NON ENB) COURSES ALS, PALS (RESUSCITATION COUNCIL), APLS, ATLS (RCS) PRE-ENTRY CRITERIA 5 GCSES (GRADE C) (MINIMUM STATUTORY)

HEALTH RELATED DEGREE

COLLEGE OR UNIVERSITY APPROVED BY ENB (Dip HE NURSING) 3YRS CFP + BRANCH PROGRAMME

199 A88 POST REGISTRATION NATIONAL A & E TRAINING (CERTIFICATE, DEGREE OR DIPLOMA)

COLLEGE OR UNIVERSITY APPROVED BY ENB (Dip HE NURSING) 2YRS ACCELERATED PROGRAMME FOR GRADUATES CFP + BRANCH PROGRAMME

N03 N52 R35 R69 A33

ACCIDENT & EMERGENCY NURSING NURSING CARE OF THE CHILD IN ACCIDENT & EMERGENCY ACCIDENT & EMERGENCY NURSING ADVANCED TRAUMA CARE SPECIALIST CLINICAL EXAMINATION PRACTISING AUTONOMOUSLY IN MINOR INJURIES NURSING AUTONOMOUS PRACTICE

SPECIALIST PRACTITIONER PROGRAMME (DEGREE) S199 ACCIDENT & EMERGENCY NURSING (ADULT AND CHILDREN)

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2.2 State Registered Paramedic All paramedics are required to be registered with the CPSM (The Council For Professions Supplementary to Medicine). The requirement for registration is the holding (and re-certification) of the IHCD paramedic certificate (or equivalent). There are two routes into gaining this qualification.

Pre-registration “Traditional” training route The traditional method of gaining employment as a paramedic is through joining a NHS Ambulance Service Trust. This can be at outpatient transport level or direct as a trainee ambulance technician. Technician training would then need to be achieved at a recognised ambulance training centre/college (via 6 week ambulance aid and 3 week driving courses). Within this training route it is a requirement of entry to paramedic training courses that applicants are IHCD qualified technicians. Following the residential course, trainee technicians would therefore have to produce a portfolio showing evidence that the required competencies have been met (typically taking 1 year-18 months). IHCD qualified technicians are then eligible to undertake paramedic training following a pre-entry exam. This course is modular based and has just been revised as follows: 6 weeks

Residential course (includes PHTLS and PALS elements)

4 weeks

In- hospital training

Following the initial training, paramedics are then able to practice under supervision and again produce a competence based portfolio (taking 6-18 months) When this has been completed and accredited, the paramedic is then able to practice independently following registration with the CPSM.

BSc (Hons) Paramedic Science A new training route for paramedics is now starting to emerge. This is based on providing education via an academic institution. The only current course available that provides an IHCD paramedic award is the BSc (Hons) Paramedic Science at the University of Hertfordshire. This incorporates all the training and education mentioned above and also work placements with London Ambulance Service to achieve competence based evidence. The Paramedical Science Degree, previously available at the University of Sheffield has now been discontinued.

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Post-Registration Once qualified, paramedics have yearly updates and three yearly re-qualification in order to maintain their status. There are further options for training that are generally locally organised and also several courses in development. PHTLS and PALS courses Paramedics who trained under the old syllabus are increasingly learning additional skills, generally through PHTLS or PALS courses (recognised by the CPSM). Diploma in Immediate Medical Care (RCS) This qualification offered under the Royal College of Surgeons, consists of a theoretical and practical examination. There are preparatory courses that appear to reinforce academic knowledge but offer little extra in practical skills (particularly over PHTLS). BSc (Hons) & Diploma Pre -Hospital Care, University of Wales This course is mainly designed for paramedics, but the application information states it would also be of benefit to nurses with a specific pre-hospital interest. The degree incorporates key skills and the relevant underpinning knowledge and assessment to equip paramedics and nurses working in this field with the necessary education to further enhance their role Certificate/Diploma/Degree program in Pre Hospital Emergency Care, Oxford Brookes University This program in Pre Hospital Emergency Care has now been validated and is due to start in September 2001 (initially on a part-time basis for existing paramedics). The full time route will encompass a minimum three-year pathway during which the technician and paramedic qualification will be incorporated (on similar lines to the University of Hertfordshire degree). The School of Health Care is also seeking approval for developing a Practitioner in Emergency Care course.

Summary For the purposes of this research it is envisaged that the core IHCD paramedic syllabus will be most relevant with possible contributions from extra material contained within the degree courses.

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Figure 2:

Training Routes for State Registered Paramedic BSc HONOURS PRE-HOSPITAL CARE UNIVERSITY OF WALES

PRE-ENTRY CRITERIA 18-22 POINTS A LEVEL OR EQUIVALENT

PARAMEDIC TRAINING COURSE (AMBULANCE COLLEGE)

BSc HONOURS PARAMEDIC SCIENCE UNIVERSITY OF HERTFORDSHIRE

COMPETENCE BASED ASSESSMENT

DIPLOMA IN IMMEDIATE CARE – RCS PROFESSIONAL QUALIFICATION

IHCD PARAMEDIC AWARD AND CPSM REGISTRATION

ADDITIONAL SKILLS, PHTLS, PALS & LOCAL TRAINING CRYCOTHYROIDOTOMY EXTERNAL JUGULAR VEIN CANNULATION NEEDLE THORACOCENTESIS INTRA-OSSEOUS CANNULATION AND INFUSION ENDOTRACHEAL INTUBATION & DRUG ADMINISTRATION (PAEDS & NEONATES)

PARAMEDIC PRE ENTRY EXAM

PART-TIME ROUTE POST REGISTRATION QUALIFIED TECHNICIAN (COMPETENCE BASED ASSESSMENT)

CERTIFICATE/DIPLOMA/DEGREE PRE-HOSPITAL CARE OXFORD BROOKES UNIVERSITY (WILL BE AVAILABLE AS FULL TIME ROUTE FOR PRE-TECHNICIAN ENTRY)

IHCD TECHNICIAN TRAINING (AMBULANCE COLLEGE)

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3

Shared Learning

Opportunities for shared learning between A & E nurses and paramedics are limited at present and one objective of this research is to identify opportunities that may exist in the future. The pathway to identify shared learning opportunities is shown in figure 3. It is envisaged that the way to achieve this is to establish common and unique skills and knowledge from the syllabi of courses identified as being relevant from the training routes discussed previously.

Current Progress There are several academic institutions showing interest in or developing postregistration courses that may be accessible to paramedics and A & E nurses. BSc (Hons) & Diploma Pre -Hospital Care, University of Wales As discussed previously, although aimed at paramedics, this course does allow entry for nurses with at least one year A & E experience and a Diploma in Nursing with 120 CATS points at level 2. BSc (Hons) Emergency Care, University of Plymouth This is a 2- year-part-time degree programme in Emergency Care introduced in September 2000. It has been developed for experienced paramedics and A&E nurses who need to be of diploma standard (level 2) on entry. The aim is to produce an interprofessional group of practitioners in emergency care. Year 2 of the first course starts in September 2001. Course in Practitioner in Emergency Care, St Martins College, Carlisle Part –time degree course for paramedics in operation from September 2001, development alongside Nurse Practitioner course. Practitioner in Emergency Care Degree, University of Hertfordshire Developing course for those graduating from their paramedic degree course. Practitioner in Emergency Care Degree, Oxford Brookes University Seeking internal approval to develop a Practitioner in Emergency Care course.

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Figure 3:

Pathway to Shared Learning

PARAMEDIC ACCREDITATION IHCD

ST MARTINS COLLEGE, BSc (HONS) EMERGENCY PRACTITIONER 2.5 TO 4 YEAR PART TIME DEGREE (SEPT 2001) OPEN TO EXISTING PARAMEDICS

UNIVERSITY (DEGREE) SYLLABUS (ACADEMIC LEVEL) IHCD PARAMEDIC TRAINING COURSE (AMBULANCE COLLEGE)

UNIQUE SKILLS & KNOWLEDGE PATHWAY TO SHARED LEARNING

PRACTITIONER IN EMERGENCY CARE

COMMON SKILLS & KNOWLEDGE

UNIVERSITY (DEGREE) POST REGISTRATION TRAINING (DIPLOMA OR DEGREE)

SYLLABUS (ACADEMIC LEVEL)

UNIVERSITY (DIPLOMA)

UNIVERSITY OF PLYMOUTH BSc (HONS) EMERGENCY CARE 2-YEAR PART TIME DEGREE (SEPT 2000) OPEN TO EXPERIENCED PARAMEDICS AND A/E NURSES

ACCREDITATION ENB

NURSE 9

SHARED LEARNING OPPORTUNITIES PROJECT

4

Nursing Syllabus Analysis

The majority of the post-registration course information (figures 4 to 7) is provided by Coventry University). The syllabus information is divided into modules, each contributing 150 hours of study (double modules 300 hours). Modules of study are given a certain number of CATS points at either level 1, 2 or 3. Academic awards through gathering CATS points are as follows: Certificate of Higher Education Diploma of Higher Education Bachelor degree

120 points at level 1 240 points (e.g. 120 points at level 1 and 2) 360 points (e.g. 120 points at level 1, 2 and 3)

For example, Coventry University offers the Diploma of Professional Studies in Nursing (Emergency Care) with 8 modules at 15 points each, a total of 120 points at level 2. The ENB199 is part of this diploma (4 modules). The Diploma in Autonomous Emergency Practice is offered to those already holding 120 points at level 2, and to achieve the diploma, students must pass four modules at level 3. To achieve the degree, 4 further modules must be achieved (e.g. a total of 120 points). The module descriptors for each course will be examined and will provide summary information on the following areas: • • •

Learning objectives Practice outcomes Indicative content.

There is no further specific information available, as this would comprise of the lesson plans that tutors devise individually to meet the requirements of these areas. It is envisaged that this may cause problems mapping out and comparing skills and knowledge with the paramedic syllabus. Figure 8 shows similar information obtained for a comparison with De Montfort University, Leicester. Diploma students attain a Diploma (Higher Education) Health Care Practice, incorporating the ENB 199 and ENB 998. Degree students attain a BSc. (Hons) Health Care Practice, (incorporating ENB 199, Specialist Practitioner Qualification and ENB 998).

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Figure 4:

ENB 199 (ACCIDENT AND EMERGENCY NURSING)

LEVEL 2

PRINCIPLES AND CONCEPTS OF ACCIDENT AND EMERGENCY NURSING 209 AN

APPLICATION OF PRINCIPLES AND CONCEPTS OF ACCIDENT AND EMERGENCY NURSING 210 AN

SIGNIFICANCE OF RESEARCH 215 HS

PROFESSIONAL ISSUES AND MANAGEMENT 216 HS

Forms part of the Diploma of Professional Studies in Nursing (Emergency Care), which requires a total of eight modules.

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Figure 5:

ENB 199 (ACCIDENT AND EMERGENCY NURSING)

LEVEL 3

EMERGENCY NURSING CARE 353 AN (DOUBLE MODULE)

RESEARCH METHODS AND STATISTICS 315 NS

CURRENT ISSUES IN NURSING 301 NS

Forms part of the Degree in Nursing Practice (Emergency Care), which requires a total of 8 modules

OPTION MODULE 1

DISSERTATION 317 NS (DOUBLE MODULE)

OPTION MODULE 2

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Figure 6:

BSc. [or BSc (Hons.)] SPECIALIST NURSING PRACTICE/ ENB 199:EMERGENCY CARE

LEVEL 3

EMERGENCY SPECIALIST NURSING 305 AN (DOUBLE MODULE)

CLINICAL SUPERVISION 307

CLINICAL PRACTICE DEVELOPMENT 308

CLINICAL CARE & PROGRAMME MANAGEMENT 309

DISSERTATION 317 NS (DOUBLE MODULE)

13

CLINICAL PRACTICE MANAGEMENT & LEADERSHIP 310

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 7:

DIPLOMA IN AUTONOMOUS EMERGENCY PRACTICE ENB A33 (AUTONOMOUS PRACTICE)

LEVEL 3

PRINCIPLES AND CONCEPTS OF AUTONOMOUS PRACTICE

CARE AND MANAGEMENT OF MINOR ILLNESS

CARE AND MANAGEMENT OF MINOR INJURIES

EMERGENCY CARE PRACTICE

Leading to the Degree in Nursing Practice (Autonomous Emergency Practice), which requires a total of 8 modules:

RESEARCH METHODS AND STATISTICS 315 NS

DISSERTATION 317 NS (DOUBLE MODULE)

CURRENT ISSUES IN MANAGEMENT 301 NS

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Figure 8:

ENB 199 (ACCIDENT AND EMERGENCY NURSING), DE MONTFORT UNIVERSITY

LEVEL 2

IMMEDIATE CARE OF THE TRAUMA PATIENT IN ACCIDENT AND EMERGENCY PHCP 2013

IMMEDIATE CARE OF THE NON-TRAUMA PATIENT IN ACCIDENT AND EMERGENCY PHCP 2014

EXPLORING CURRENT INITIATIVES IN ACCIDENT AND EMERGENCY NURSING PHCP 2015

IMMEDIATE CARE OF PATIENTS WITH MUSCULO-SKELETAL TRAUMA PHCP 2016

Forms part of the Diploma (Higher Education) in Health Care Practice. This also incorporates the ENB 998 and requires a total of eight modules.

FOUNDATIONS OF PRACTICE AND EDUCATION PHCP 2001 (DOUBLE MODULE)

FOUNDATIONS IN TEACHING & ASSESSING IN CLINICAL PRACTICE PHCP 2002

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RESEARCH METHODS IN HEALTH HEST 2106

SHARED LEARNING OPPORTUNITIES PROJECT

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Paramedic Syllabus Analysis

General Information Figures 9 and 10 show the breakdown of technician and paramedic training into syllabus modules. Each module contributes 80 hours of study (double modules 160), with the exception of the driving modules, which combined account for 120 hours. Detailed syllabus information is provided by the IHCD, and so is followed by colleges providing training for paramedics. The modules are divided into units (B to I), which are further subdivided into numbered elements. For each element the syllabus describes • • •

What the student should be able to do (outcomes) Underpinning knowledge and key learning points Related skills and use of equipment.

Therefore there is fairly extensive content information available from this syllabus for the purposes of comparative work with the nursing courses. The figures show the course layout as well as the indicative content for each module. It is noticeable that some essential parts of the paramedics roles are missing, for example record keeping, cope of practice etc. Furthermore the hospital training stage is also not included, but is available in the old edition of the paramedic manual.

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Figure 9: DRIVING I B

B: 1 DRIVING

IHCD CORE SYLLABUS – TECHNICIAN DRIVING II C

C: 1 ADVANCED DRIVING

TECHNICIAN D

TECHNICIAN E

TECHNICIAN F

D: 1 INTRODUCTION TO THE BODY

E: 1 NERVOUS SYSTEM

F: 1 DIGESTIVE SYSTEM

D: 2 LIFTING, HANDLING

E: 2 NERVOUS DISORDERS

F: 2 DIABETES AND GLUCAGON

D: 3 RESPIRATORY SYSTEM

E: 3 SKELETAL SYSTEM

F: 3 LAW AND AMBULANCE STAFF

D: 4 CIRCULATORY SYSTEM

E: 4 MUSCULOSKELETAL TRAUMA

F: 4 MAJOR INCIDENTS

D: 5 CARDIAC MONITORING

E: 5 WOUNDS AND BLEEDING

F: 5 POISONING

E: 6 INFECTIOUS DISEASES

F: 6 EXTREMES OF BODY TEMPERATURE

E: 7 INFANTS AND CHILDREN

F: 7 MATERNITY

AND EQUIPMENT

D: 6 AIRWAY MANAGEMENT & RESUSCITATION D: 7 EXAMINATION AND ASSESSMENT

D: 8 ASSISTING THE PARAMEDIC

F: 8 HAEMODIALYSIS

D: 9 INFANTS AND CHILDREN

F: 9 ACUTE ABDOMINAL PROBLEMS

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Figure 10:

PARAMEDIC G

IHCD CORE SYLLABUS – PARAMEDIC

PARAMEDIC H

PARAMEDIC I

IN-HOSPITAL PLACEMENT (DOUBLE MODULE)

G: 1 RESPIRATORY SYSTEM

H: 1 TRAUMA CARE

I: 1 PAEDIATRIC CARE

40 HRS CCU

G: 2 CARDIOVASCULAR SYSTEM

H: 2 THERMAL INJURIES

I: 2 OBSTETRICS AND GYNAECOLOGY

120 HOURS THEATRES (OR SPLIT 80/40 THEATRES/A & E)

G: 3 NERVOUS SYSTEM/ OBSERVATION AND ASSESSMENT

H: 3 MEDICAL CONDITIONS

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6

Comparative Analysis of Skills and Knowledge (Coventry University)

This relates to whether the indicative content of the various modules described are covered by the paramedic syllabus. Bulleted lists refer to specific timetable information. Due to the information provided, the areas of commonalties can only be applied to breadth of knowledge, not depth. In the case of Coventry University the lectures delivered (i.e. timetables) are identical at both level 2 and 3, but it is the method of assessment that differentiates between the two. Therefore the combined analysis of these two modules will also apply to 353AN, Emergency Nursing Care.

Principles and Concepts of Accident and Emergency Nursing (Module 209AN) Areas of Common Knowledge

Paramedic

(Italics indicate possible commonalties)

Syllabus Ref.

Anatomy and physiology of major organs 1 • Respiratory physiology • Conduction system and electro physiology Applied physiology of multi-systems trauma

G3.1; G3.2 G1.1; G1.2 G2.1; G2.2 H1.4

Effects of injury/sudden illness • Abdominal Injuries • Aetiology of Thoracic Trauma • Spinal Injuries • Head Injuries/Neurological Emergencies • Principles of Major Trauma Management • Principles of Soft Tissue Injury Management • Diabetic Emergencies • Sudden Death • Practical Airway Management & Ventilation • Trauma Care • Arrhythmia workshop • Respiratory Emergencies Concepts of shock • Pathophysiology of Shock • Introduction to Trauma Care

H1.4.3 H1.4.2 H1.4.4 G3.3; H1.4.1 H1.3 E5.1 H3.1 F3.2 G1.4 H1.3 G2.4 G1.3

D4.4; G2.3 H1.3

Altered Consciousness

E1.1; G3.2

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SHARED LEARNING OPPORTUNITIES PROJECT Areas of Common Knowledge

Paramedic

(Italics indicate possible commonalties)

Syllabus Ref.

Application of ethical and legal issues, e.g. Patients charter/Children’s Act/Named Nurse 2

F3.1; GP1

Consent 2 Accountability 2

Areas of Unique Knowledge Effects of injury/sudden illness • Principles of Soft Tissue Injury Management • Sudden Death (relating to A & E Department procedures/issues) Application of ethical and legal issues, e.g. (Children’s Act/Named Nurse) Community Care Act Consent • Organ and Tissue Donation Discharge Accountability Advocacy Quality Standards

Notes 1. In general it is not known to what level/depth of knowledge this is to. It is also not specifically mentioned if the nervous system is covered. 2. Overlap in type of knowledge, but will be specific to own role. In paramedic training parts are covered briefly within technician course and will be developed locally.

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Application of Principles and Concepts of Accident and Emergency Nursing (Module 210AN)

Areas of Common Knowledge (Italics indicate possible commonalties)

Paramedic Syllabus Ref.

Nursing care 1 and clinical skills 2 , related to specific patient groups within the emergency department including: Children • Recognising the sick child • Child Protection Issues in Emergency Care Major and minor physically ill/injured • Abdominal Injuries • Aetiology of Thoracic Trauma • Spinal Injuries • Head Injuries/Neurological Emergencies • Principles of Major Trauma Management • Principles of Soft Tissue Injury Management • Diabetic Emergencies • Sudden Death • Practical Airway Management & Ventilation • Trauma Care • Arrhythmia workshop • Respiratory Emergencies

I1.2 F7.1

H1.4.3 H1.4.2 H1.4.4 G3.3; H1.4.1 H1.3 E5.1 H3.1 F3.2 G1.4 H1.3 G2.4 G1.3

Self harm and psychiatric illness3

F3.4

Acute psychiatric emergencies3 • Mental Health Related Issues in Emergency Care

F3.4

Administration and documentation 4 Application of ethical and legal issues 5

F3.1; GP1

Disaster planning 6

F4.1; F4.3

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Areas of Unique Knowledge Nursing care and clinical skills, related to specific patient groups (as above) • Child Protection Issues in Emergency Care • High Dependency Care • Pain Management and Related Pharmacology • Application of Blood Gas Analysis to Respiratory Emergencies Management skills, skill mix, organisation and workload Caring for patients with psychological reactions to traumatic experiences, strategies to employ • Psychological Aspects of Emergency Care Acute psychiatric emergencies Administration and documentation Teaching patients and staff Application of ethical and legal issues Disaster planning

Notes 1. Non-specific, may be some elements of nursing care that are covered by paramedic syllabus. 2. Clinical skills should be covered by at paramedic level, but not specific. 3. Covered in technician syllabus (not likely to be same depth). 4. Normally covered by induction/local training. Overlap in type of knowledge, but will be specific to own role. 5. Covered briefly by technician course. Likely to be role specific. 6. Major incidents covered in technician course (specific to profession).

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SIGNIFICANCE OF RESEARCH (Module 215HS) Areas of Unique Knowledge 1 Sources of knowledge, tradition, trial & error, sciences Examine rituals in professional practice Emergence of research in professional practice Stages in the research process Use of reflection to identify (research) knowledge base for practice Literature reviewing Research design, methodological issues Data collection method Validity and reliability Ethical issues Data analysis methods Introduction to statistics Critiquing skills

Notes 1. This is the significance of research module and as such it is not covered by the paramedic syllabus. Paramedics may have covered this by other learning (e.g. degrees, management courses).

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PROFESSIONAL ISSUES AND MANAGEMENT (Module 216HS) Areas of Common Knowledge (Italics indicate possible commonalties)

Paramedic Syllabus Ref.

Professionalism and professional codes applied to own sphere of practice Policy initiatives and their implications for clinical practice 2 Legal and ethical issues, Privacy, Confidentiality, Data Collection, and Data 3

F3.1; GP1

Standards of Record Keeping applied to care of the surgical patient 3 Accountability, professional boundaries, scope of professional practice within own sphere of practice 1

Areas of Unique Knowledge Professionalism and professional codes applied to own sphere of practice Policy initiatives and their implications for clinical practice Legal and ethical issues, Privacy, Confidentiality, Data Collection, and Data Protection Act, Advocacy, Informed Consent Standards of Record Keeping applied to care of the surgical patient Accountability, professional boundaries, scope of professional practice within own sphere of practice Management styles and roles applied to managing care 4 Leadership, managing change, problem solving 4 Creating a learning ethos within own field of practice 4 Quality assurance strategies within own sphere of nursing/midwifery practice 4 Resource Management 4

Notes 1. 2. 3. 4.

Is covered relating to own profession, further enhanced locally. Changes will be covered locally as and when they happen. Covered partly by technician syllabus (specific to own role), and enhanced locally. Not covered by syllabus, only likely to be achieved by study of management course. 24

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7

Problems Encountered with the Initial Analysis of Skills and Knowledge

The initial analysis of the syllabi could only compare skills and knowledge at a general level due to the way the module content of the nursing courses is described. The analysis could only be based on probable (and possible) areas of common knowledge. It was slightly easier to identify unique areas as these were often found to be completely absent from the paramedic training. A comparison was made with descriptors provided for the 199 elements of courses provided by UCE and De Montfort University and the A33 course provided by Coventry University. These were found to be generally the same format, although some areas were described in more detail. On further investigation, the ENB validation process does not take place at a detailed level (in terms of content) and so is not likely to be a source of specific information. This was confirmed following discussions with Coventry University. Further enquiries are also ongoing with the RCN, this has pointed in the direction of the Faculty of Emergency Nursing (see below). In order to carry out this comparison it will be necessary to obtain more specific information, the plan being to identify: •

Whether this exists for all parts of the course

•

If this is reasonably consistent year by year

•

Current research related to 199 courses nationally

•

If there is a drive to standardise competences nationally

Identify whether specific information exists for all parts of the course Meetings were arranged with Module leaders for the 199 courses at Coventry and De Montfort Universities to ascertain if this information is ava ilable. This would involve obtaining information down to timetable and lesson plan level.

Coventry University Not all lesson plans are available for the 199, but module guides have now been obtained with further timetable information. The course leader will send out a letter to visiting lecturers (with a guide to objectives) but on short-term basis. With differences in 199 course nationally and the variability of courses to map (e.g. paramedic training, paramedic degree in various guises, various nursing postregistration) it may be better to map at module level and then assess feasibility.

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SHARED LEARNING OPPORTUNITIES PROJECT

De Montfort University Module descriptors are more specific, although lesson plans are not available. Some more specific information is available in the form of learning guidelines and a meeting with the course leader gained more detailed information on content. The course differs substantially from Coventry in terms of structure and content.

Identify if this information is reasonably consistent year by year The module leader at Coventry has only been organising the course since May and previously there was a void of 18 months. Given the nature of the course provision, it is unlikely that it will be completely consistent. However this does not mean it will not meet the ENB requirements for outcomes and content, given that they are only general in nature. De Montfort information appears consistent, only being updated for new developments in field etc.

Identify any current research related to 199 courses nationally There has been recent work relating to ENB 199 courses (Scholes et al. 2000). This is essentially a specific part of research commissioned by the ENB entitled “A documentary analysis and literature review of critical care nursing” (Scholes et al. 1999). The authors conclude that there was diversity in the 199 courses in terms of the • • • •

Level at which they were set Academic credits awarded Theoretical and practice assessment strategies Amount of student effort

There are further conclusions as to why this diversity has arisen and it is suggested that national comparability of the course will remain an illusion until consensus over the purpose of the course is agreed. This further compounds the analysis part of the project in that the initial assumption was that a comparison of skills/knowledge with the locally run courses would be a reasonable benchmark nationally. The differences between the Coventry and De Montfort courses would seem to support the findings that this is not the case.

Identify if there is a drive to standardise competences nationally I am in contact with the authors of the above report who are currently examining the effectiveness of critical care education. This includes the generation of core competencies for the ENB 100, 124, 199, 183/176 and 415 (going out for national consultation at the beginning of June).

26

SHARED LEARNING OPPORTUNITIES PROJECT The researchers have asked if I will contribute to the consultation process with regard to the 199 element. This was distributed on the 4th June and allows access to the proposed core competencies. However, it is unlikely the consultation will be finished in time to make an accurate contribution to this project, although it will provide a useful insight into the future direction of accident and emergency nurse education.

Faculty of Emergency Nursing Following a lead from the RCN, contact has been made with Rob Crouch, chair of the Pilot Project Management Group. The aims of the faculty are to (RCN, 2000): •

define standards of competence for emergency nurses which in turn will form the building blocks for people working in this field

•

develop a core educational curriculum to be used as a template by education providers when devising their own programmes and courses

•

focus on 'continuing professional development' for emergency nurses and develop ways in which individuals and A&E departments can be accredited for their achievements

It seems that only general information is available (Endacott et al, 1999 and Crouch et al, 1997) as this is only in the pilot stages. It has been suggested that the originators of the idea envisage core educational curriculum being a replacement for the ENB 199 course.

Amendment to Project Plan Given the problems discussed in this section, a change to the plan has been agreed. It has been demonstrated that the comparison of knowledge cannot be achieved in detail. Therefore the comparison will be made in breadth, not depth and supplemented by skills/competences gained within sampled Accident and Emergency Departments. From this a modular system will be devised to build an academic approach to bringing the two professions to a similar base of knowledge and skills. This may well then link into the extension of education to encompass the Practitioner in Emergency Care role.

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8

Assessment of Common and Unique Knowledge

8.1 Coventry University Areas of Shared Knowledge (breadth not depth) Anatomy and Physiology Respiratory system (structure and mechanism) Cardiovascular system (structure and mechanism)

Medical conditions Normal/abnormal conditions of the respiratory system Treatment/management of conditions of the respiratory system Normal/abnormal conditions of the cardiovascular system Observation and assessment relating to the nervous system Treatment and management of disorders of the nervous system Shock Diabetes mellitus Self harm, psychiatric illness and emergencies

Trauma Principles of trauma management Management of the trauma patient: • Head trauma • Thoracic trauma • Abdominal / pelvic trauma • Spinal trauma • Multi-systems trauma Soft tissue injury management

Paediatrics Paediatric assessment, examination and recognition of the seriously ill or deteriorating child Child Protection

Others Sudden death

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SHARED LEARNING OPPORTUNITIES PROJECT

Areas of Unique Knowledge (Paramedics) Anatomy and Physiology Structure of the nervous system

Medical conditions Treatment/management of conditions of the respiratory system Treatment/management of conditions of the cardiovascular system Drug overdoses/poisoning Convulsion/fits

Trauma Mechanisms of trauma Assessment and examination of trauma Extremities trauma Trauma in pregnancy Recognition and management of thermal injuries

Paediatrics Anatomical and physiological differences between adults and children Management of the sick child (and parents) Paediatric trauma and thermal injuries Management of cardiac arrest in neonates, infants and children Resuscitation of the baby at birth

Professional Issues Ethical and legal issues Consent Administration and documentation Privacy, confidentiality, data collection Standards of record keeping Accountability, professional boundaries, scope of professional practice Professionalism and professional codes (within own sphere of practice) Policy initiatives and their implications for clinical practice

Obstetrics General and local organisation of domiciliary, obstetric and gynaecology services Anatomical, physiological and pathological changes during pregnancy Assessment and examination of the pregnant woman Normal labour Abnormalities in pregnancy and labour Resuscitation in pregnancy

Others Major incident planning Sudden death procedures within the pre-hospital environment

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SHARED LEARNING OPPORTUNITIES PROJECT

Areas of Unique Knowledge (Nurses) Medical Conditions Nursing care High dependency care Pain management and related pharmacology Application of blood gas analysis to respiratory emergencies Acute psychiatric emergencies Mental health related issues in emergency care

Trauma Soft tissue injury management

Paediatrics Child protection within the hospital environment

Professional issues Discharge Accountability Community Care Act Teaching patients and staff Ethical and legal issues Advocacy, informed consent (including organ and tissue donation) Administration and documentation Privacy, confidentiality, data collection, and Data Protection Act Standards of record keeping Accountability, professional boundaries, scope of professional practice (within own sphere of practice) Professionalism and professional codes (applied to own sphere of practice) Policy initiatives and their implications for clinical practice

Research Sources of knowledge, tradition, trial & error, sciences Examine rituals in professional practice Emergence of research in professional practice Stages in the research process Use of reflection to identify (research) knowledge base for practice Literature reviewing Research design, methodological issues Data collection method Validity and reliability Ethical issues Data analysis methods Introduction to statistics Critiquing skills

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SHARED LEARNING OPPORTUNITIES PROJECT

Management Management skills (including skill mix, organisation and workload) Management styles and roles applied to managing care Leadership, managing change, problem solving Creating a learning ethos within own field of practice Quality assurance strategies within own sphere of nursing/midwifery practice Resource management

Others Caring for patients with psycholo gical reactions to traumatic experiences Disaster planning Sudden death procedures within the hospital environment

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8.2

De Montfort University

This analysis was compiled following a meeting with the module leader, as again comprehensive detailed information is not available to a deep enough level. There is additional information to that of the Coventry syllabus in terms of skills/procedures. It can be seen that the research, management and professional issues are not listed. Whilst they might be covered in the overall diploma/degree, they are not modules designated as part of the ENB 199.

Areas of Shared Knowledge (breadth not depth) Anatomy and Physiology Head and neck (nervous system content almost identical) Abdominal and pelvic cavity Thoracic cavity Musculoskeletal system Cardiovascular and respiratory systems (structure and mechanism)

Medical conditions Normal/abnormal conditions of the respiratory system Treatment/management of conditions of the respiratory system Normal/abnormal conditions of the cardiovascular system Observation and assessment relating to the nervous system Treatment and management of disorders of the nervous system Diabetes mellitus Self-poisoning Introduction to psychiatric emergencies Shock Near drowning and barotraumas (pre- hospital) Hypothermia (pre- hospital)

Trauma Mechanism of trauma Assessment and examination of trauma Principles of trauma management Parenteral analgesia in the trauma patient Management of the trauma patient: • Head injury • Thoracic trauma • Abdominal/pelvic trauma • Spinal trauma • Extremities trauma Multidisciplinary management of major trauma Recognition and management of thermal injuries Basic immediate care of the ophthalmic emergency

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Paediatrics Recognition of the abused or non-accidentally injured child Recognition of the sick child, assessment and the immediate care Child centred trauma care

Diagnostics and procedures Airway management (use of oral/nasal airways) Assisting with ET intubation Assisting with emergency cricothyroidotomy Assisted ventilation (e.g. bag and mask) Fluid resuscitation (all apart from cannulation) Three and twelve lead ECG recording Use of entonox Splinting and immobilising Patient monitoring equipment

Others Concept of trauma centres and minor injury units Transport of the seriously ill or injure patient Inter-disciplinary collaboration in the pre-hospital care of the injured patient Management of major incidents

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SHARED LEARNING OPPORTUNITIES PROJECT

Areas of Unique Knowledge (Paramedics) Anatomy and Physiology Structure of the nervous system: • Spinal cord • Reflexes and spinal nerves • Action of neurotransmitters

Medical Conditions Management of specific respiratory conditions: • Acute respiratory obstruction • COAD • Pneumonia • Pulmonary emboli and oedema Treatment/management of conditions of the cardiovascular system Convulsions/fits

Trauma Trauma in pregnancy

Paediatrics Anatomical and physiological differences between adults and children Management of the sick child (and parents) Paediatric trauma and thermal injuries Management of cardiac arrest in neonates, infants and children Resuscitation of the baby at birth

Diagnostics and procedures Airway management (ET intubation) Performing emergency cricothyroidotomy (locally variable) Venous cannulation Manual defibrillation and autonomous drug administration

Professional Issues Professionalism and professional codes in relation to own sphere of practice

Obstetrics General and local organisation of domiciliary, obstetric and gynaecology services Anatomical, physiological and pathological changes during pregnancy Assessment and exa mination of the pregnant woman Normal labour Abnormalities in pregnancy and labour Resuscitation in pregnancy

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SHARED LEARNING OPPORTUNITIES PROJECT

Areas of Unique Knowledge (Nurses) Anatomy and Physiology Abdominal and pelvic cavity: • Cullen’s sign, Grey Turner’s sign • Delayed splenic rupture • Oesophageal varices • Mesenteric injuries • Renal/urinary tract injury • Bladder related injury Specific anatomy of the lower and upper limbs (carpal tunnel, tendons, and ligaments)

Medical Conditions Follow up of psychiatric emergencies and the role of the Liaison Psychiatric Service Near drowning and barotraumas (management in A&E) Hypothermia (management in A&E) Assessment and multi-disciplinary management of the acute surgical emergency

Trauma Wound care in thermal injuries Types and management of the ophthalmic emergency Oral and parenteral analgesia and sedation in the trauma patient Local and regional anaesthetic blocks during procedures Use of general anaesthesia

Paediatrics Immediate multi-disciplinary management of the abused or non-accidentally injured child

Diagnostics and procedures Assisting with tracheostomy Preparation of chest drain equipment Role in peritoneal lavage Introduction to interpretation of chest X-rays Interpretation of x-rays following trauma Tetanus prophylaxis Triage in A&E care Interpretation of CVP monitoring

Professional Issues Role of the nurse in relation to “Guidelines for Professional Practice” and “Standards for the administration of Medicines”

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SHARED LEARNING OPPORTUNITIES PROJECT

Others Care of the bereaved in Accident and Emergency Initial management of sudden loss The role of the Coroner and the Coroners inquest Concept of the Nurse Practitioner in A&E nursing Role of the A&E nurse in pre- hospital trauma care (e.g. flying squads) Management of major incidents (hospital) Health promotion and accident prevention Organ donation and retrieval Safe discharge of patient

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9

Range of skills gained post-qualification

This section focuses on the skills gained by Accident and Emergency Nurses postqualification. Whilst many paramedics gain skills post-qualification, the majority of these would be in areas such as PHTLS and PALS (or parts of these locally licensed). These have already been included in the study as they are now incorporated in the new paramedic syllabus.

Post-Registration Skills In order to carry out this analysis, a snapshot is needed of the various skills gained by nurses in a typical Accident and Emergency Department. This information was obtained at the George Eliot Hospital by introducing a training database (Appendix 4). This allowed easy aggrega tion of the information (which was previously available from a spreadsheet and personal files and hence difficult to extract). The data for the department is shown in Appendix 5, and illustrated in figures 11, 12 and 13. From the data it can be reasonably assumed that high percentages are likely to indicate skills or qualifications deemed necessary or useful by the department. One cautionary note to this is that some skills may be important, but it is only necessary for a small number of staff to have these skills. If the data is viewed in descending order of percentage the following qualifications are held by at least 40% of the department: Basic life support Glucometer use Intravenous drug administration Paediatric resuscitation Venepuncture Ward information system Wound management

Cannulation Health and Safety Moving and handling Triage Violence and Aggression (dealing with) Wound closure X-ray requesting

There are also significant numbers (>60%) of experienced nurses (E, F and G grade) who have: Advanced life support Teaching and assessing TNCC (trauma nursing) Qualification to minimum diploma level

Male catheterisation Communication Infection control

On comparison with the skills held by paramedics, it can be seen that there already exists a potential for shared knowledge of skills in: • • • •

Advanced life support Basic life support Cannulation Glucometer use

37

SHARED LEARNING OPPORTUNITIES PROJECT • • • • •

Intravenous drug administration Moving and handling Paediatric resuscitation Trauma knowledge and treatment Venepuncture

There are also 5 areas of possible shared knowledge, (where limited numbers in either profession are trained): • • • • •

Appraisal training Entonox (use and administration) PALS skills 12 lead ECG recording 12 lead ECG recognition

In summary a total of 14 (out of 44) skill areas overlap to some extent, i.e. 33% are practiced by paramedics. The remaining areas should also therefore be considered when looking at potential areas of learning for paramedics to be able to function in an alternative role in an Accident and Emergency department: • • • • • • • • • • • •

Communication Infection control Male catheterisation Qualification to minimum diploma level Teaching and assessing Triage Venepuncture (refresher as normally only achieved in initial training)) Violence and Aggression (dealing with) Ward information system Wound closure Wound management X-ray requesting

Further analysis of the skills held by paramedics will allow a similar picture to be built up in order for nurses to work in the pre-hospital environment. These will obviously be in addition to those mentioned in the shared learning list above: • • • • • • • • •

Advanced Paediatric Life Support Autonomous drug therapy Crycothyroidotomy* ECG recording and interpretation (12 lead) Endotracheal intubation and extubation (if not covered by ALS) External jugular vein cannulation* Immobilisation techniques (pre-hospital) Intra-osseous cannulation and infusion* Laryngeal mask

38

SHARED LEARNING OPPORTUNITIES PROJECT • • •

Manual defibrillation (if not covered by ALS) Needle thoracocentesis Obstetric/neonatal related skills

* Dependant on local service procedures. Due to the varied nature of nursing training, this is likely to be specific to the individual concerned. For example, figure 13 shows comparison of the nursing skills with the paramedic skill set (i.e. reversing the approach of the previous figures). It can be seen that many of the skills selected have significant overlaps with nursing, however the variations in the percentages of the nurses trained supports the individual nature of the profession. It can be seen that all of the nurses in the department had been trained in 27% of the skills (12/44) and half of the nurses had been trained in 43% (19/44) of the skills. These findings are obviously unique to the hospital and ambulance service considered. The specific overlap in the knowledge and skills will depend on competencies/learning outcomes of each qualification, which would need to be investigated further. It is hoped that the Delphi study (section 10) will also provide similar findings in terms of potential overlaps.

39

60.0

50.0

40.0 Percentage

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 11: George Eliot Qualified A/E Nurse Training Breakdown 100.0

80.0

PARAMEDIC (FOR COMPARISON)

70.0

EMERGENCY WD CENTRE COUNSELLING CERT XRAY INTERPRETATION NVQ ASS/D32/D33 DEGREE A33 APPRAISAL TRAINING SIDs SALT SCREEN OTHER (IN HOUSE ENP) FIRE SAFETY ENB MODULES ECG RECORDING (12 LEAD) ECG RECOGNITION (12 LEAD) CONFERENCE CHILD PROTECTION 199 LEVEL 2 RECORD KEEPING PALS INFECTION CONTROL TNCC (PHTLS FOR PARA)

40

BEREAVEMENT ENTONOX DIPLOMA COMMUNICATION 998 OR 730 CATHETERISATION (MALE) PLASTERING ALS XRAY REQUESTING V & AGGRESION HEALTH & SAFETY WARD INFO SYSTEM PAED RESUS CANNULATION MOVING & HANDLING BLS I.V. DRUGS GLUCOMETER VENEPUNCTURE WOUND MANAGEMENT WOUND CLOSURE TRIAGE

Qualification/Skill

QUALIFIED A&E NURSES Target for paramedics 2001/2002

90.0

30.0

20.0

10.0

0.0

60.0

50.0

40.0

Percentage

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 12: George Eliot Qualified A&E Nurse Training Breakdown 100.0

90.0

80.0

EMERGENCY WD CENTRE COUNSELLING CERT XRAY INTERPRETATION NVQ ASS/D32/D33 DEGREE A33 APPRAISAL TRAINING SIDs SALT SCREEN OTHER (IN HOUSE ENP) FIRE SAFETY ENB MODULES ECG RECORDING (12 LEAD) ECG RECOGNITION (12 LEAD) CONFERENCE CHILD PROTECTION 199 LEVEL 2 RECORD KEEPING PALS INFECTION CONTROL

41

TNCC (PHTLS FOR PARA) BEREAVEMENT ENTONOX DIPLOMA COMMUNICATION 998 OR 730 CATHETERISATION (MALE) PLASTERING ALS XRAY REQUESTING V & AGGRESION HEALTH & SAFETY WARD INFO SYSTEM PAED RESUS CANNULATION MOVING & HANDLING BLS I.V. DRUGS GLUCOMETER VENEPUNCTURE WOUND MANAGEMENT WOUND CLOSURE TRIAGE

Qualification/Skill

G F E D 70.0

30.0

20.0

10.0

0.0

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 13: Comparison of Nurse with Paramedic Skill Set

100.0

A/E Nurse Paramedic (100% if not shown) 90.0

80.0

70.0

60.0

50.0

40.0

30.0

20.0

10.0

0.0

Intraosseous Cannulation & Infusion PHTLS (TNCC) Laryngeal Mask Manual Defibrillation (Paediatric) Autonomous Drug Adminstration Interpretation of pulse oximeters Emergency Driving 12 lead ECG recording 3 lead ECG recording Blood Glucose Measurement Entonox Adminstration Fluid administration Rectal drugs Buccal drugs ET drugs IM drugs Cannulation Extubation Intubation (Paediatric) Intubation (Adult) Suction Adult Basic Life Support

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10

Delphi Study to Ascertain Future Educational Requirements

10.1 Background (Dr. M. Cooke) In order to define the educational pathways for accident and emergency nurses and ambulance paramedics we need to be certain of the end point to this educational pathway. Therefore we need to define the skills, experience and professional attitudes of these two groups. I would suggest it is most appropriate to look at this in the five to ten year time frame. I would propose undertaking a Delphi study in order to determine the appropriate attributes of each group as envisaged by experts in the appropriate field.

Delphi Study This type of study is a proven way of achieving reliable consensus from a group of experts. It uses a technique of three rounds of questions to the experts in order to achieve consensus. In round one of this study, the experts are asked open questions so as to obtain their views, unbiased by either the other experts or by the investigators. For round two all the responses achieved in round one are collated into appropriate groups. The experts are then asked to give their opinion of the importance of each of these factors. They are asked to score this on a five point Likeart scale where one represents not required and five represents essential requirement. In round three all the results are collated and the same questions are sent out again. The difference with the third round is that each person is able to see how many people scored each point on the scale and is reminded of their own scale. In this way they are given the opportunity to revise their score with knowledge of the other experts opinion. The results of this third round then form the consensus opinion. Analysis is then undertaken by creating a total score for each of the factors.

Relevance of this Delphi study to the larger study I believe that by knowing the factors which experts consider to be important for each of the training groups we can then assess how experts view the commonality of skills and training required for the two roles in the next five to ten years. This information can then be combined with the analysis of present training to reach the overall goal of the study.

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10.2 Progress Initially the majority of work was in identifying appropriate participants. To make the study valid, each group of participants had to contain a minimum of ten people. Therefore a total of 26 people were identified on both the nursing and paramedic side to allow for any reduction in responses as the study progressed. On the nursing side the two groups were defined as: •

NAE: Accident and Emergency Nurse Managers. Sample taken from hospitals offering acute Accident and Emergency services in the local area (e.g. West Midlands, Trent regions).

•

NHE: Nurse involved in Higher Education (e.g. senior lecturers). Sample taken from list of institutions providing ENB approved courses relating to acute care.

On the paramedic side the two groups were defined as: •

POM: Senior Operational Managers of Ambulance Services (e.g. Director of Operations). Sample taken from West Midlands and Trent regions, with additional from other regions to make up required numbers.

•

PMA: Medical Advisors to Ambulance Services & Course leaders involved in Paramedic Related Higher Education. Due to the very limited number of institutions involved in paramedic related higher education, this group was enhanced by medical directors of ambulance services. Sample was again mainly taken from the West Midlands and Trent regions.

The initial round of questions are illustrated in figure 14.

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SHARED LEARNING OPPORTUNITIES PROJECT

Figure 14: Round One Questions

Paramedic Groups 1.

What do you see as the skills required by a paramedic practitioner *?

2.

What do you see as the experience required for someone to take up the post as a paramedic practitioner (please be as specific as possible)?

3.

What specific training do you believe a paramedic practitioner should have achieved since their initial qualification?

* We envisage the role of a paramedic practitioner of the future as being in dealing with the seriously ill and injured, treating minor conditions at the scene, deciding on the further health care needs of the patient to a variety of health care sources and the ability to discharge patients from the scene.

Nursing Groups 1.

What do you see as the skills required by an experienced nurse working in an accident and emergency department?

2.

What do you see as the experience required for someone to take up the post as this nurse in the accident and emergency department (please be as specific as possible)?

3.

What specific training do you believe an experienced nurse in accident and emergency should have achieved since qualification?

These questions were sent out by email on the 9th May. Participants were asked to return the study by 23rd May with the collation date set at 31st May. Reminders were sent out on the 24th May to those participants who had not replied. The main initial problem identified was the non-delivery of some emails (particularly to those using an older system via the NHSnet). This was compounded by the fact that the sender was not aware of this as non-delivery messages were not returned. To counter this, a webbased address was then used (already set up in case of problems developing). Collation of round 1 took place on the 21st May. The main problem initially apparent was the overlap of answer areas over the three questions. This was in part due to the general nature of the questions. This was resolved in round 2 (see Appendix 6) 45

SHARED LEARNING OPPORTUNITIES PROJECT following the categorisation of the answers into each question area. Round 2 was collated and Round 3 sent out on the 13th August.

10.3 Results The results from Round 3 are shown in Appendix 7. They are shown in question order, with the columns representing the results from each participant group. A mean score is given for each answer, together with the standard deviation (sdev) and the number of replies for that answer (n=). A high level of agreement with the statement is indicated where the mean score is 4 or above. A score of 2 or below indicates a high level of disagreement with the stated answer. In question 2, the participants were also asked to grade the time required where they thought the item was essential.

Accident and Emergency Nurses Question one illustrates the wide range of skills that the participants expected the experienced accident and emergency nurse to possess. As would be expected, many of the current skills utilised are reinforced by the study. The essentials of patient assessment are highlighted, particularly in the areas of history taking, questioning, observation and triage. Consensus was found in the areas of using underpinning theoretical knowledge in clinical decision making across all categories. In the area of management, important skills were considered to be leading teams, risk assessment and managing of disaster. It is possible that a more autonomous role is being proposed, as organising and managing caseloads achieved a high consensus. Finally, managing your own stress scored highly, a factor often given a high priority. A relatively high consensus was found in all areas of teaching/evidence based practice. Communication skills (written and verbal) scored highly, with an emphasis also on good communication with other professionals and patients. A very high consensus was found in the areas of care of the bereaved and defusing violent situations. As would be expected, many clinical skills (for example basic life support, vital signs, wound care, splinting and plastering) were found to be essential. The study again showed in this section a move towards more autonomous practice, for example in 12lead ECG interpretation. In terms of advanced life support, there was consensus in the areas of defibrillation and drug administration. Opinion was divided over the more advanced skills in trauma and paediatrics. Infection control, hygiene/continence care and moving/handling were considered essential. Consensus was also found in the areas of venepuncture, cannulation, catheterisation and spinal immobilisation. The autonomous practice section revealed areas (often beyond current scope of practice without additional qualifications) that the participants believed to be important. There was consensus towards the decision to initiate treatment and administration of:

46

SHARED LEARNING OPPORTUNITIES PROJECT • • • • • • • • • • • • • • • • • • •

Activated charcoal Anti-emetic (e.g. Metoclopramide) Aspirin Atropine (3mg in cardiac arrest) Atropine (for bradycardia) Entonox Epinephrine (1:10,000) Glucagon Glyceryl Trinitrate (GTN) Hartmanns Lidocaine (local anaesthesia) Naloxone Hydrochloride Oral antibiotics (selected) Oral painkillers (selected) Oxygen Paracetamol Elixir (Calpol) Salbutamol (Ventolin) Sodium Chloride (0.9%) Tetanus Toxoid

The degree of consensus was varied (differences can be seen in the mean and standard deviations), indicating that the role of the nurse is probably undecided and may be likely to change in the future. This was reinforced by the consensus towards other autonomous practice areas. Question 2 revealed the previous experience the participant’s thought the experienced nurse should possess. As can be seen from the results, the only factor that gained positive agreement was that the nurse should have previous experience in an accident and emergency department. General comments alongside the answers were that no one route was definable, and that many areas would be useful as an addition. Question 3 indicated the level of theoretical training required. The minimum previous academic qualification was at GCSE (or O- level). Opinions were divided over exactly what further education qualification would be appropriate. However, 75% of respondents thought a minimum of diploma level was appropriate. There was consensus towards additional specific courses that would be beneficial (e.g. ATNC/TNCC, PALS/APLS and ALS). Teaching/assessing, Manchester triage and the ENB 199 courses also scored highly (although with variations in opinion).

Accident and Emergency Nurses – Summary The results from the nursing study indicated that currently practised skills are generally in line with future expectations. The exceptions were found to be in the areas of autonomous practice, where in many areas an increase in current scope and role was apparent.

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Paramedics As would be expected, many of the currently practised skills were identified as still being relevant. The high scores in current patient assessment skills implied the continued importance of this area in the future. Palpation (probably currently underused) and mobility assessment were also considered important. The high scores attributed to decision- making based on underpinning theoretical knowledge would indicate that future training needs will need to be reassessed. This appears particularly important in the areas of minor illness, injury and mental health, which are not currently covered. Furthermore enhanced education may also be required in anatomy and physiology, obstetrics and management of the sick child. The management section produced different opinions within and between the groups. Areas of risk assessment and awareness of the scope of other agencies were considered important. No consensus was reached on teaching and assessment skills, and the importance of critical appraisal of research was divided. Communication skills were found to be important in all areas. Care of the bereaved and defusing violent/aggressive situations were interesting additions to the current portfolio of training. Again, the current range of clinical skills was emphasised. In addition consensus was reached in 12- lead ECG interpretation and the use of temperature in diagnosis. As well as the underpinning knowledge in minor injuries mentioned previously, there was also high consensus in the field of wound care skills. This encompassed aseptic, dressing and wound closure techniques (including suturing and glueing) and infiltration of local anaesthetic. Infection control was also deemed to be important. Additional areas (that are currently being introduced) in advanced life support were highlighted, including needle cricothyroidotomy and thoracocentesis. Other skills where there was consensus, but to a lesser degree were intubation with rapid sequence induction and male catheterisation. The current* range of drug administration was supported with additional consensus in: • • • • • • • • • • • •

Benzyl Penicillin Chlorpheniramine (for anaphylaxis) Hydrocortisone Lidocaine (in local anaesthesia) Morphine Sulphate Oral antibiotics (selected) Oral painkillers (selected) Paracetamol Elixir (Calpol) Prednisolone Tetanus toxoid Tenectaplase Thrombolytics (other than streptokinase)

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SHARED LEARNING OPPORTUNITIES PROJECT

* Some examples are already in use in ambulance services. Those illustrated in bold are already part of JRCALC guidelines. Again the consensus varied according to group. Other drugs only reaching consensus with one group included: • • • • •

Activated charcoal Amiodarone Ketamine Lorazepam Propofol

Finally, other areas of autonomous practice were agreed to be important, with again wound management and minor trauma scoring highly. Discharge of patients requiring advice and resolved emergencies were other areas of increased autonomy. Additional skills proposed included the ability to refer directly to other agencies and the initiation of blood tests. In question 2, consensus was reached on the experience required for this role in the following areas: • • • • • • • • •

Accident and emergency departments Anaesthetics/theatres Coronary care units Mental Health Minor injury units Obstetrics and gynaecology Orthopaedics Paediatrics Primary care

The degree of consensus was varied between groups. There are significant additional areas above the current paramedic training. The analysis of results to question three indicates variation in the academic level required (other than the IHCD paramedic award). 75% of respondents agreed that a minimum diploma level was appropriate. This implies that the actual requirement above this level is at present undecided. Aside from this, additional specific courses highlighted PHTLS and PALS as a very high consensus. MIMMS was also considered important. Interestingly the A33 (Developing Autonomous Practice), a nursing qualification, was highlighted by the operational managers.

Paramedics – Summary The results from the paramedic study indicate that both underpinning knowledge and skills will increase as the role develops. The study particularly highlighted the areas of:

49

SHARED LEARNING OPPORTUNITIES PROJECT • • • • • •

Minor illness Minor injury (particularly wound management) Mental health Additional drug administration Discharge of patients and resolved emergencies Direct referral routes

Additional areas of training to enable the appropriate experience to be gained were also highlighted.

50

SHARED LEARNING OPPORTUNITIES PROJECT

11

Modular Approach to Developing Education

The problems encountered in mapping skills and knowledge between the two professions have already been discussed (in terms of the different approaches to education). One way to resolve this is to use the academic modular basis for education to build a model of a paramedic degree. This will enhance paramedic training to a similar knowledge base to that of nursing. This method will have further benefits in that it will then lead into defining areas of shared learning, and can then be built on further to develop the idea of a paramedic practitioner or practitioner in emergency care (PEC). The Delphi study will also feed into this part of the project as it focuses “experts” views on the education and skills required in each profession. The modular approach could then be reversed to examine the areas required to enhance accident and emergency nurse training to a similar level to that of paramedics. The skills and competences gained by nurses within the hospital environment will feed into this part of the study. Hence a true route forward into shared learning will be established with differing outcomes depending on the model used. The essential part of the educational development of paramedics and nurses will be to produce an end produc t with standardised competences/outcomes nationally. A national agreement of the purpose of such a course will be essential (for example developing the concept of the PEC according to ASA and JRCALC, 2000). The dangers of not doing so have already been encountered in nursing and supported by the findings of this project (as section 7):

“There are further conclusions as to why this diversity has arisen and it is suggested that national comparability of the course will remain an illusion until consensus over the purpose of the course is agreed.” Figure 15 shows the current model of healthcare education. It can be seen that nurse education involves the local university, with ongoing training also provided inhospital. Paramedic education is traditionally carried out without university involvement. There are areas of education and development that overlap but not currently exploited. Figure 16 shows a future vision of how this model could change if the ideas of shared learning are progressed. Paramedic education has now moved into an academic arena, with ongoing training and development still accessed externally. Because of this movement there are now areas of shared learning that could be addressed within the university. This could be then be advanced into further education, development and working between the professions outside of the academic environment. Appendix 8 shows possible full time models that could be developed in the future. Some models utilise the existing framework at Coventry University to illustrate where shared learning can take place (specific module numbers shown in brackets).

51

SHARED LEARNING OPPORTUNITIES PROJECT Feasibility of models will need to be discussed and developed in conjunction with the University and titles of courses are for illustration only. Appendix 9 shows the models currently available nationally (discussed in sections 2 and 3). Figure 17 illustrates in more detail where staff could share learning at various points in their careers (using existing courses at Coventry University). Specific routes for existing staff are then described in more detail. As shown in Appendix 8, it would be possible for ambulance staff wishing to become technicians to access aspects of the nursing common foundation programme alongside their traditional training. Student nurses and technicians could then complete their training in branch specific areas in the traditional way. Qualified technicians could then access parts of the ENB 199 course alongside paramedic training. As has been shown there are overlaps in learning and so these could be incorporated into a combined emergency care course for paramedics and nurses. Branch specific elements could then be developed in order to produce emergency care workers with their own expertise in the pre-hospital or nursing environments. Entry point three is therefore for these new breed of healthcare workers who although are still working in their own fields, have already shared learning where there is overlap in knowledge. Both sets of professionals now have minimum of level 2 education (dip loma) and so can now access level 3 education. In this case the A33 (Autonomous Emergency Practice) is used as an example. These two groups (tentatively named practitioners) now have level 3 education in the form of a BSc. or BSc. (Hons.). Whilst they may have many additional skills and knowledge, this may not equate to a PEC (JRCALC/ASA, 2000) in it’s proposed form (the outcomes of these professionals are discussed more thoroughly following the specific routes for existing staff). Instead we have now produced a nurse or paramedic with extensive background education to back up their practical skills. They will no doubt have extended skills (particularly in this case in autonomous management of minor injures/illness). For example there may now be potential for the paramedic to work in a minor injuries or accident and emergency unit. However the final transition to a PEC would depend on: •

Absolute clarification of the definition and role. This will be dependant on exactly where the PEC would be expected to rotate in acute units. Would they be expected to focus on Accident and Emergency Departments/Minor Injury Units? Alternatively, they could develop specialist knowledge and rotate in other areas of expertise (e.g. CCU, Primary Care, paediatrics etc).

•

Final conversion (including hospital, primary care placements etc) to address the above issues.

52

SHARED LEARNING OPPORTUNITIES PROJECT There are therefore two options: 1. Including the appropriate branch specific elements in previous training (or final conversion) to produce a truly multi-skilled professional. 2. Acknowledge that these practitioners are not 100% multi- skilled but do bring their own skills and expertise to many areas in each other’s field. The routes illustrated will however produce considerable areas of overlap.

53

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 15:

Current model of Healthcare Education

LOCAL AREA

UNIVERSITY NURSE EDUCATION

UNIVERSITY

NURSE EDUCATION & DEVELOPMENT

TRAINING AND DEVELOPMENT (EXTERNAL AND IN-SERVICE)

PARAMEDIC EDUCATION & DEVELOPMENT

 Shared Learning Project 8/2001 54

IN-HOSPITAL & EXTERNAL DEVELOPMENT

POTENTIAL FOR SHARED DEVELOPMENT & WORKING

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 16:

Future Vision of Healthcare Education (based on a national template/curriculum)

LOCAL or REGIONAL AREA UNIVERSITY NURSE EDUCATION

UNIVERSITY PARAMEDIC EDUCATION UNIVERSITY

PROPOSED SHARED LEARNING

PARAMEDIC * EDUCATION & DEVELOPMENT

NURSE * EDUCATION & DEVELOPMENT

IN-SERVICE & EXTERNAL DEVELOPMENT

* Could be extended to other healthcare professionals

IN-HOSPITAL & EXTERNAL DEVELOPMENT

POSSIBLE SHARED DEVELOPMENT & WORKING

 Shared Learning Project 8/2001 55

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 17: Career Entry points in Shared Learning Entry Point 1 Student Technician

Student Nurse

Shared Elements from Common Foundation Programme

Branch Specific

Branch Specific

Entry Point 2 Qualified Technician

Registered Nurse

Shared Elements from ENB 199 and Paramedic Courses

Branch Specific

Branch Specific

Diploma in Emergency Care (Pre-Hospital or Nursing)

56

SHARED LEARNING OPPORTUNITIES PROJECT

Entry Point 3

Qualified Paramedic

Registered A & E Nurse

ENB A33

Degree in Autonomous Emergency Care (Practice) (Pre-Hospital or Nursing)

Entry Point 4 Paramedic Practitioner

Nurse Practitioner

Final conversion, hospital placements etc.

Practitioner in Emergency Care (PEC)

57

SHARED LEARNING OPPORTUNITIES PROJECT

11.1 Models for existing staff - Paramedics It is important to recognise that paramedics have achieved a great deal of knowledge through their technician, paramedic and post-qualification training and also experienced gained in the working environment. The former is easier to analyse but bears no formal academic accreditation. The latter is difficult to assess in either a quantitative or qualitative nature, however this could be achieved by examining the portfolio produced. The aim of these three models is to: •

Acknowledge prior training and experience.

•

Enable paramedics to access higher education.

•

Improve those areas of knowledge gained as part of their training.

•

Add additional relevant areas (highlighted from studies of the nursing education, particularly at ENB 199 level 2).

•

Enable paramedics to access relevant Level 3 modules (i.e. A33 autonomous practitioner).

The models and outcomes are illustrated in figures 18-20. The following information may be useful to explain abbreviations used. APL

Accreditation of prior learning (i.e. credit for existing qualifications)

APEL

Accreditation of prior experiential learning (credit for experience if student is able to demonstrate skills and knowledge)

AP(E)L

Either (or both) of the above

A33

Autonomous Emergency Practice (diploma or part of degree), Coventry University.

(216HS)

Example of module already in existence for Nurses at Coventry University which could at least in part be shared.

BSc.

Degree

BSc. (Hons.) Honours degree

58

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 18: Paramedics (option 1) Prerequisite for entry: (or AP(E)L) Study Skills, and Portfolio Develop. (102NS)

Previous accredited study Paramedic Training, including Hospital Placement (390 hours)

Year 1 Anatomy, physiology & pharmacology

Practice Portfolio (minimum 6 months) (To be assessed at level 2)

(six months) Patient Assessment and Differential Diagnosis

Professional issues and management (216 HS)

Significance of Research (215HS)

Diploma in Paramedical Science Year 2

Accessing A33 (could be two years part time)

Principles/concepts of autonomous practice

Care and management of minor illness

Research methods and statistics (315 NS)

Current issues in NHS/Ambulance (301 NS)

Care and management of minor injuries

Emergency care practice

Dissertation

BSc (or BSc Hons) Advanced Paramedic Practitioner (with Diploma in Autonomous Practice)

Black box = Level 1

Red box = 59

Level 2

Green box = Level 3

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 19: Paramedics (option 2) Prerequisite for entry: (or AP(E)L) Study Skills, and Portfolio Develop. (102NS)

Previous accredited study Paramedic Training, including Hospital Placement (390 hours)

Year 1 Anatomy, physiology and pharmacology

Medical conditions (including mental health)

Patient Assessment and Differential Diagnosis

Professional issues and management (216 HS)

Significance of Research (215HS)

Diploma in Paramedical Science Year 2

Accessing A33 (could be two years part time)

Principles/concepts of autonomous practice

Care and management of minor illness

Research methods and statistics (315 NS)

Current issues in NHS/Ambulance (301 NS)

Care and management of minor injuries

Emergency care practice

Dissertation

BSc (or BSc Hons) Advanced Paramedic Practitioner (with Diploma in Autonomous Practice) Black box = Level 1

Red box = 60

Level 2

Green box = Level 3

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 20: Paramedics (option 3) Prerequisite for entry: (or AP(E)L) Study Skills, and Portfolio Develop. (102NS)

Previous accredited study Paramedic Training, including Hospital Placement (390 hours)

Year 1 Anatomy, physiology and pharmacology

Medical conditions (including mental health)

Patient Assessment and Differential Diagnosis

Optional (from list*)

Professional issues and management (216 HS)

Significance of Research (215HS)

Diploma in Paramedical Science Year 2

Accessing A33 (could be two years part time)

Principles/concepts of autonomous practice

Care and management of minor illness

Research methods and statistics (315 NS)

Current issues in NHS/Ambulance (301 NS)

Care and management of minor injuries

Emergency care practice

Dissertation

BSc (or BSc Hons) Advanced Paramedic Practitioner (with Diploma in Autonomous Practice) Black box = Level 1

Red box = 61

Level 2

Green box = Level 3

SHARED LEARNING OPPORTUNITIES PROJECT

* Optional modules

Evidence Based Practice Medical Equipment Design and Technology Advanced procedures Teaching/assessing Psychology Disaster Management and Bereavement

62

SHARED LEARNING OPPORTUNITIES PROJECT

Notes Whilst acknowledging the prior experience gained by paramedics through their work, it must be recognised that they have a great variety of previous educational experiences. This could range from O- levels/GCSES (or equivalent) to various certificate/diploma studies or even degrees. Some may have evidence of recent study, others may not have studied for many years. It will therefore be important to enable access to the proposed models. If the education routes are established, it is likely that a varied workforce will be produced with education to differing levels according to their ability. For example, there may be a third at certificate level (probably technicians), a third at diploma level (paramedics), a third at degree level (paramedics/practitioners). In this section we are concentrating on existing paramedics and therefore make the assumption that this group would benefit from education to minimum diploma level. Given the above discussion, students should prior to entry be able to demonstrate that they have the necessary skills to access education at this level. This would be by AP(E)L or by accessing an appropriate study skills course (may be level 1 or 2). For those not experienced in producing portfolios this could also be included although may of more use to staff entering education pre-technician level. All three options address the areas identified as being missing from paramedic training when compared to post-registration nursing (in this case ENB 199). Hence the models include study in: • • •

Professional issues Research Management

All three models also include the proposed background education necessary for paramedics: • •

Anatomy, physiology and pharmacology Patient Assessment and Differential Diagnosis

In all models it is assumed that paramedics can enter at level 2, i.e. that they have enough A(P)EL covering technician training, portfolios and work experience to cover level 1. It is also assumed that existing training will be accreditable at level 2. In practice much of paramedic training may only be assessed at level 1 although the depth of knowledge in some areas is great, but taught intensively (e.g. anatomy and physiology). Alternatively a comprehensive paramedic portfolio could be assessed at level 2, with the preceding training and experience at level 1. Hence either the existing training is assessed for AP(E)L at level 2 or the paramedic may have to produce evidence of understanding at level 2. This would be down to the individual University to decide.

63

SHARED LEARNING OPPORTUNITIES PROJECT Finally the model is produced on a theoretical 8 module per year course. This leaves approximately 15 weeks for working as a paramedic if studied full- time. The differences between the models are in the areas of previous credit and content as follows.

Option 1 The main difference with this model compared to the others is in the amount of accreditation given. Included in the accreditation is a practice portfolio (as in the A33 course). This relates to the paramedics in Warwickshire who produce a portfolio of patient care illustrating their competence in various paramedic skills. This is normally achieved over a minimum period of 6 months and is a true competence based method of education. The portfolio should include reflection on individual cases to enhance information provided by patient report forms. To be included satisfactorily to the University, this reflection and hence assessment should be at level 2. It may be unrealistic to expect that Universities will accept both the portfolio and training evidence as this high proportion of accreditation at level 2 (i.e. half of the diploma or 60 CATs points). If this model is acceptable the diploma could be completed in 6 months (or alternatively 12 months part time). Access is then possible into the A33 course. This would be supplemented by two modules (in this case, 315 NS and 301NS used as examples with again some content shared with nurses). These modules could be adapted to suit the requirements of the degree (for example possible alternatives are illustrated in Appendix 6). Finally a dissertation would follow for those willing and able to complete an Honours degree.

Option 2 This is similar in nature, but accepts that the portfolio would not be accessible for prior accreditation. This may be more realistic as many services may not use this method for assessment. The anatomy, physiology and pharmacology module has been increased in size. This may be more suitable to provide the amount of education required in these areas. An additional module has been proposed to complete the diploma. This is provisionally titled “Medical Conditions”. It is included to acknowledge the fact that whilst paramedics have particularly good treatment skills in some areas (for example trauma), other areas are either not covered or not in enough depth. Examples are in the increasing care of chest pain patients (i.e. thrombolysis) and assessment and care of abdominal medical problems (taking every abdominal pain to hospital!). The remainder of the model is the same as option 1.

Option 3 Accreditation is the same as in Option 2. However, there is a minor difference in content in that Anatomy, physiology and pharmacology is now reduced to the original single module. A new optional module is introduced enabling students to study areas 64

SHARED LEARNING OPPORTUNITIES PROJECT that they are interested in, giving diversity to the diploma. The numbers of students would presumably have to be high in order to make this option feasible.

Summary Options two and three appear most feasible, and differ only in minor parts of the content of the course. If paramedic training was not accreditable at level 2, this could either be: • •

Replaced with an assessed portfolio at level 2 Substituted with two additional modules (which may APL anyway according to previous study)

Comparative Training Routes Figure 21 shows a comparison between a specific training route of and accident and emergency nurse and a paramedic. The paramedic completes their training and accesses 6 modules to achieve a diploma at level 2. This is given that the University gives them enough advance standing via A(P)EL as a paramedic and technician (and/or includes an assessed portfolio). Alternatively it may be possible, depending on their previous education, that a minimum of 4 modules may only be required to proceed to level 3. The registered nurse completes 4 modules to gain the ENB 199, with 4 further modules to complete the Professional Diploma in Nursing (Emergency Care). Alternatively, if they wish to access level 3 courses, they would only need to complete 4 modules at level 2 (given that they have advance standing at level 1 and 2 from preregistration training). However, it has already been demonstrated that there is considerable overlap between the paramedic training and the Principles (and Application of Principles) of Accident and Emergency Nursing modules. Therefore these could be combined to become Principles (and Application of Principles) of Emergency Care, with parts of the timetable devoted to the appropriate branch specific areas (as in figure 22). The implication of this would be that the current paramedic training would have to be moved within the University remit. This is discussed further on page 68 and is particularly relevant to options 2 and 3 in Section 13 (page 78). In summary, it can be seen that there is potential for two separate educational pathways, but with multi-professional modules embracing the ethos of shared learning. The future challenge is to define exactly the requirements of a paramedic degree (in terms of learning outcomes) and clarify the future of accident and emergency nurse education. From these templates, a shared model of education could then be developed.

65

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 21: Comparative Routes following Separate Pathways Paramedic

Multi-professional route

Nursing

Level 2 (dashed line indicates shared modules)

Paramedic Training, including Hospital Placement

Anatomy, physiology and pharmacology

Medical conditions (including mental health)

Patient Assessment and Differential Diagnosis

Professional issues and management (216 HS)

Significance of Research (215HS)

Diploma in Emergency Care (Pre-Hospital)

Additional Module

Additional Module

Additional Module

Additional Module

Principles & Concepts of A&E Nursing (209AN)

Application of Principles & Concepts of A&E Nursing (210 AN)

Diploma of Professional Studies in Nursing (Emergency Care) Level 3

Principles/concepts of autonomous practice

Care and management of minor illness

Research methods and statistics

Current issues in Nursing (or Prehospital) Practice

BSc (or BSc Hons) in Emergency Care (with Diploma in Autonomous Practice)

Care and management of minor injuries

Emergency care practice

Dissertation

66

BSc (or BSc Hons) in Nursing Practice (Autonomous Emergency Practice)

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 22: Comparative Routes with Integrated Pathway Paramedic

Multi-professional routes

Nursing

Level 2 (dashed line indicates shared modules)

Paramedic Skills

Anatomy, physiology and pharmacology

Professional issues and management (216 HS)

Significance of Research (215HS)

Additional Module

Additional Module

Medical conditions (including mental health)

Patient Assessment and Differential Diagnosis

Principles & Concepts of Emergency Care (A/E nursing or pre-hospital)

Application of Principles & Concepts of Emergency Care (A/E nursing or pre-hospital)

Additional Module

Additional Module

Diploma of Professional Studies in Nursing (Emergency Care)

Diploma in Emergency Care (Pre-Hospital) Level 3 Principles/concepts of autonomous practice

Care and management of minor illness

Research methods and statistics

Current issues in Nursing (or Prehospital) Practice

BSc (or BSc Hons) in Emergency Care (with Diploma in Autonomous Practice)

Care and management of minor injuries

Emergency care practice

Dissertation

67

BSc (or BSc Hons) in Nursing Practice (Autonomous Emergency Practice)

SHARED LEARNING OPPORTUNITIES PROJECT

11.2 Models for existing staff - Accident and Emergency Nurses It is difficult to define exactly what areas of training would be required to allow an accident and emergency nurse to be able to work alongside paramedics in the prehospital environment. This is because: •

Nurses can access many different courses post registration

•

Identical qualifications contain different content and produce different outcomes

•

Further skills can be obtained in the department and this will obviously vary from hospital to hospital.

•

Technician and paramedic training are currently only available as a complete course (i.e. you cannot access parts of it).

To overcome this, a standard set of skills and knowledge would have to be established with the nurse able to AP(E)L out of the required areas. This may involve a radical change to the paramedic training in that the course modules may have to be redefined, of which the relevant ones could be accessed. This is illustrated in blue in figure 23. It is difficult to envisage this happening in the current training college set up. However the vision for the future could include a training centre being part of (or linked into) the University providing paramedic education. The paramedic (and technician) training could then be taught in specific modular areas (for example separate anatomy and physiology, specific skills training etc). It would then be possible for the nurse to AP(E)L out of the relevant areas. The remaining reinforcement of knowledge could be built up by experience (carefully monitored/mentored). Other healthcare professionals could also use this training centre, particularly where shared areas of skills are apparent, hence building towards a multi-skilled NHS workforce working across organisational boundaries. This type of change in training provision is already being pioneered in Hertfordshire where there is a satellite training centre operated by the University that concentrates on the skills aspects of the ambulance training courses.

68

SHARED LEARNING OPPORTUNITIES PROJECT Based on this work, areas where nurses could be expected to obtain APL would be those covered by the following courses or skills: ENB 199 course (Illustrated specific to Coventry University) • • • • •

Certain areas of anatomy and physiology Normal and abnormal conditions of the body systems Treatment and management of these abnormal conditions Trauma care Basic paediatric assessment and care

Advanced Life Support (ALS) Pre-Hospital Trauma Life Support (PHTLS or ATNC/TNCC ) Paediatric Advanced Life Support (PALS or APLS/PHPLS) Other skills obtained in-hospital • • • • • •

Basic life support Cannulation ECG recording and recognitio n (12 lead) Entonox administration Intravenous drug administration techniques Paediatric resuscitation

69

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 23: Accident and Emergency Nurses (Defining areas for study and AP(E)L)

Paramedic Training (240 hours)

Respiratory Cardiovasc. System System

Nervous System

Trauma Care

Thermal Injuries

Medical Conditions

Paediatric Care

Obstetrics & Gynae.

Re-define Anatomy & Physiology

Normal & Abnormal Conditions

Treatment & Mgmt of Conditions

Related skills and use of equipment

Hospital Placement (160 hours)

A&E

CCU

Underpinning Knowledge

Portfolio Development (6 months)

Blue box = separated and re-defined into areas for AP(E)L – size of box not related to time

Theatres

70

SHARED LEARNING OPPORTUNITIES PROJECT

Pathways to Pre-Hospital Care It has been acknowledged that the Accident and Emergency Nurse will have accrued a great deal of knowledge and skills through their initial training, post-registration courses and in- hospital training. Therefore the initial orientation to pre-hospital care would encompass two areas: • •

Additional skills related to the pre- hospital environment Adapting skills and knowledge to autonomous practice in this environment.

The initial part of the proposed model is shown below:

Local orientation Including Technician Skills* (or Technician course)

Advanced Driving (120 hours)

* Specific Technician skills as required, for example: Lifting, handling and equipment (D2) Immobilisation and support (E4:3,6) Infectious diseases (E6) Law and Ambulance Staff (F3) Administration of technician drugs Major incidents (F4) Maternity (F7)

There would need to be a local orientation (including required technician skills) and completion of the advanced driving course. As stated because of the varied backgrounds in education and development of nurses, the skills element could be either tailored to suit the students (having assessed prior knowledge) or consist of attendance of a technician course. To enhance this to paramedic level, various routes are possible given the varied nature of previous education, experience and development. Three possible routes are shown in figure 24. In all routes there would be considerable scope for shared learning.

71

SHARED LEARNING OPPORTUNITIES PROJECT

Figure 24: Accident and Emergency Nurses – Possible Pathways to Pre-Hospital Care •

ENB 199 (A & E nursing) qualification

•

Additional skills gained inhouse

•

No ENB 199 qualification

•

No ENB 199 qualification

•

Additional skills gained inhouse

•

No additional skills gained in- house

Underpinning knowledge 1 in:

Underpinning knowledge 2 in:

Anatomy and physiology (selected) Medical Conditions (selected) Medical conditions Paediatrics Professional issues (pre-hospital) Obstetrics Autonomous drug administration

Respiratory, cardiovascular, nervous systems Trauma care, thermal injuries Medical conditions and Paediatric care Obstetrics and gynaecology Autonomous drug administration

Skills not already achieved through: Advanced Life Support (ALS) Pre-Hospital Trauma Life Support (PHTLS or ATNC/TNCC) Paediatric Advanced Life Support (PALS or APLS/PHPLS) In- house training: Basic life support Cannulation ECG recording and recognitio n (12 lead) Entonox administration Intravenous drug administration techniques Paediatric resuscitation 72

Paramedic training course to gain underpinning knowledge and skills

Portfolio development and mentorship (through supervised working)

1. See section 8.1 for more detail. 1. & 2. May also be demonstrated through APEL.

SHARED LEARNING OPPORTUNITIES PROJECT

12

The Outcomes of Shared Learning

The project has looked at shared learning at various levels, from local skills to regional shared academic courses (with the obvious potential for development nationally). The major changes and developments in terms of outcomes will obvious ly be most pronounced at an academic level. However, consideration is first given to the local skills option.

12.1 Skills based Section 9 focussed on skills gained by nurses post registration. A comparison showed there were many commonalties with those skills practiced by paramedics. Furthermore it provided an indication of which skills would be relevant to professionals operating in each other’s field of practice. The common ground in skills has implications for future training. There would be inherent adva ntages in different healthcare professionals undertaking joint training in these skills: • • • • •

Understanding of other healthcare professionals roles Breaking down barriers between professional groups Standardising competences amongst professionals - developing best practice Utilising best sources of education/training available Sharing of cost of training

An example of this is the current sharing of the PALS course which paramedics access at the George Eliot Hospital. These factors will also be relevant where skills are included within the academic basis for shared learning, as below.

12.2 Academic based Type of Professional and Scope of work Taking the comparative training routes (figures 21 and 22), the main scope of work for nursing would be similar to the current situation (i.e. accident and emergency or minor injury units). If they follow the pathway through to pre- hospital care (figure 24), it is envisaged they could achieve a paramedic qualification and therefore work as such. This would allow significant autonomy in their fields of practice and would also bring additional skills and knowledge to the pre- hospital arena. If a paramedic diploma/degree was developed along the lines of figures 18 to 20, the main benefit will be increased background clinical knowledge, and hence a greater competence in making clinical decisions. Furthermore as in nursing, the professionals produced at this post-registration level will have both management and critical 73

SHARED LEARNING OPPORTUNITIES PROJECT research skills. As well as being the line and senior managers of the future, they will also be in a better position to contribute to the latest evidence based pre- hospital health care. It is likely that there will also be a considerable increase in skills and knowledge in the minor injury and illness fields. Therefore the scope of work could extend particularly into minor injury units (and minor injury areas of accident and emergency departments). There could also be scope for bringing their current areas of expertise into new roles (e.g. into resuscitation areas). Depending on the content of the education (including placements), there may also be roles in primary care, intermediate care or in coronary care units. Hence these professionals will ideally placed to challenge (and therefore work across) organisational boundaries to improve communication and working in many areas. In both groups of professionals, the increase in minor injury and illness education could lead to extended treatment of patients at home. Together with utilising alternative referral routes (available through joint working and challenging traditional practice) this should reduce the number of inappropriate transport and admission of patients to acute hospital units. Whatever the scope of work, the increase in autonomous practice will undoubtedly be beneficial to patient care.

Costs There will be significant cost involved in developing a new degree/diploma course for paramedics. This is difficult to calculate, as it would depend on the exact nature and length of the course. However, this work has shown there to be potential areas of shared learning that could be exploited through to degree level. Hence there could be significant savings if this were pursued. The costs will have to be weighed against the benefits of shared (and enhanced) training and education.

Benefits There are likely to be benefits of shared learning both locally and to the wider NHS picture. The local advantages of sharing skill-based training have already been discussed in section 12.1, and are further enhanced by including a shared academic element in the following areas. Standard core syllabus (shared between professions) •

Improved quality of care (utilising best sources of education in both professions, thereby improving practice) • Inter-profession collaboration (bringing together those who currently work separately and breaking down barriers that may currently exist) • Understanding of other healthcare professionals roles • Flexible career direction • National development of “standard” competences and outcomes

74

SHARED LEARNING OPPORTUNITIES PROJECT Extended and improved roles •

New techniques and challenges - Job satisfaction - Blurring boundaries with and challenging roles of other professionals (e.g. senior house officers) to bring relevant experience and improvements to patient care - Embracing NHS policy of lifelong learning

•

Treating more patients at home - Improving patient care at source - Particularly cost-effective in remote and rural communities - Reduced number of patients seen in accident and emergency - Less hospital admissions - Alleviating hospital bed pressures

•

Alternative admission possibilities - More appropriate (and fast-tracked) patient care - Reduce drain on A & E - Alleviate acute hospital bed pressures

Staffing problems in the NHS •

Multi-skilled staff could reduce problems particularly at times of high or unexpected demand due to - Sickness - General employment pressures - Major incident or disaster

Continuity of Care •

Improve link between pre-hospital and acute emergency care - Avoid repeated triage and assessment - Improve patient care by targeted and relevant admission routes

75

SHARED LEARNING OPPORTUNITIES PROJECT

13

The Practitioner in Emergency Care (PEC)

The concept of practitioner in emergency care (PEC) was proposed in 2000 by ASANCEP, a subcommittee of ASA and JRCALC in a paper titled The Future Role and Education of Paramedic Ambulance Service Personnel (Emerging Concepts). It is also mentioned in a review of options for the future of ambulance services carried out on behalf of the ASA (2001). The model for the education of the PEC is outlined below.

Figure 25: ASA/JRCALC PEC Model Year 1 This will be integrated into the new core education for the nursing profession (12 months). It will provide underpinning knowledge that is needed by entrants into the nursing and paramedical professions and will be delivered predominantly by members of the nursing profession.

Years 2 and 3 These will be directed primarily towards pre- hospital care, but will be modular, with some modules having wider applicability. The modules should include: •

Continued theoretical learning with medical, nursing, managerial, and ethical components as well as background knowledge of the history, ethos, and aspirations of all the emergency services.

•

Practical training and hospital experience (as appropriate) in Accident and Emergency Units, Intensive Care Units, Cardiac care Units, Paediatric Intensive Care Units, Anaesthetic and recovery Rooms, other High Dependency areas and Obstetric Units;

•

Brief observational experience in operating theatres and other relevant specialist units.

•

Observational and practical experience within primary care, in liaison with general practitioner units, midwives, health visitors, and the psychiatric and general social services.

•

Practical training and experience within the ambulance service, with all the components (including driving, radio, and telemetry skills) that will be appropriate for the future needs of PEC's.

76

SHARED LEARNING OPPORTUNITIES PROJECT An alternative model is shown below (figure 26), relevant to access via a pre-hospital environment. As with all the models developed in this work, there is no reason why it could not be shared with current nurse training by utilising existing courses.

Figure 26: Alternative PEC model (Pre-hospital access) Year 1 Certificate level:

30 weeks plus technician training. Could be shared common foundation programme.

Year 2 Practice Portfolio:

Optional step off year (consolidation as trainee technician)

Year 3 Diploma level:

30 weeks plus paramedic qualification/placement.

Year 4 Degree level:

30 weeks plus placement/paramedic qualification (or second year foundation degree)

Year 5 Practice Portfolio:

6-month trainee paramedic plus optional 6 months further consolidation/further modules?

Year 6 Degree level:

PEC degree (or half year 5 to year 6)

Outcomes This six-year program combines academic and vocational experience. It addresses problems in gaining enough experience in three years with a direct undergraduate entrant from school (i.e. a 21 year old PEC). Technician equivalent qualification is achievable in year 1, paramedic in years 2-4, and PEC in year 6. Shared learning exists in year 1 (with parts of common foundation programme) and possibilities (but mainly branch specific) in later years.

77

SHARED LEARNING OPPORTUNITIES PROJECT

General Notes It is likely to take approximately two years to develop a PEC degree in full. Existing staff could access selected pre-existing modules before then on a pilot basis and then gain accreditation later (particularly if specialising in one area, e.g. minor injuries). Many PEC attributes could (and probably would) be incorporated into earlier years of degree programs (i.e. minor injuries/illness treatment, Category C patient discharge). It will be important to define and clarify the PEC before embarking on degree developments. For example: •

Is it realistic to have PECs truly multi-skilled and functioning in many roles? This would require large knowledge base and easily lead to erosion of skills.

•

Would narrowing of or specialising in roles be more appropriate (e.g. minor injuries)? Further discussion has already been published on this (Wood, 2000). Shared learning could still take place.

•

Driving force should be improving education, workforce and patient care, not finding a substitute for nurses etc. (although multi- skilled working could help relieve pressures in times of high demand).

•

It will be important to develop the PEC properly and not cut corners, i.e. quickly adapting existing nurse practitioner degree and calling this a PEC.

•

Further national lead/research on these issues needs to be undertaken (ASA or CPSM/derivative).

•

Strategy for interface between academic and professional bodies (i.e. future of existing training accreditor (IHCD) needs to be established): 1. Modules “franchised” out to training centres (i.e. existing paramedic/technician courses). 2. Universities with own training centres accredited by IHCD (e.g. Hertfordshire). Advantage is that theory component can be taken out of module and taught separately allowing module to concentrate on skills. Collaborative approach. 3. Universities take full control of training (presumably qualification accredited by CPSM or derivative).

However whilst further work is required to develop the PEC degree, a paramedic degree or diploma could be developed and then enhanced with a post- graduate course to cover any additional areas.

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SHARED LEARNING OPPORTUNITIES PROJECT

14

Conclusions

This project has looked at many areas related to education and development of accident and emergency nurses and paramedics. As well as the conclusions drawn from this work (discussed below), there were also additional benefits and outcomes not directly related to the project (as shown in Appendix 10).

Nurse Education and Development There are a wide variety of post-registration courses open to nurses who wish to continue their education. These vary from short courses to degree level study and are generally recognised externa lly (and are accredited as such). These are further complemented by local “in- house” training in various skills and competences. The main sources of information for this project were the Accident and Emergency (ENB 199) and Autonomous Practice (ENB A33) courses at Coventry University. There was also some analytical contribution from the ENB 199 course at De Montfort University. There is no shared element (between paramedics and nurses) in these courses, but the A33 has been developed with access by paramedics in mind. The courses are described in terms of learning objectives, practice outcomes and indicative content, but not in specific detail. The ENB 199 is also offered at levels 2 and 3, with differing assessment strategies. This caused problems in mapping with the paramedic training as discussed later. An associated factor that transpired during this project was the diversity of postregistration nursing courses regionally. This is confirmed by previous research that concluded there was diversity in the ENB 199 courses nationally in terms of: • • • •

Level at which they were set Academic credits awarded Theoretical and practice assessment strategies Amount of student effort

There is now further work progressing on the future education of accident and emerge ncy nurses, both via consultation on core competencies and the Faculty of Nursing competences and educational curriculum. A further assessment of skills and knowledge was undertaken with the George Eliot Hospital, to assess how education is supplemented by local training. A database was designed and introduced into the accident and emergency department to obtain this information. The analysis showed a range of skills held by a majority of nurses, together with variations in skills held by grade. There were many areas of overlap, with almost a third of these skills being practiced by paramedics. Furthermore, the unique skills could then be identified as being most valuable if working was to take place in the other professionals’ field of practice.

79

SHARED LEARNING OPPORTUNITIES PROJECT Finally, a Delphi study was carried out to define the skills, experience and training required in accident and emergency nursing. As well as giving a useful picture of “experts” views of the profession, it was combined with a similar study for paramedics to view the envisaged commonality of skills and training in the future.

Paramedic Education and Development Paramedics follow a more specific training route that results in a paramedic award and registration. This is not recognisable outside of the ambulance service. Initially they must qualify as a technician (8 weeks), followed by period of portfolio development whilst a trainee. The paramedic training is then concentrated into 6 weeks, but will be complemented by experiential learning in the workplace. In Warwickshire, paramedics then work under supervision, producing a competence based portfolio. In total the whole training process takes 2-3 years. In the past, paramedics have extended their training by attending various post registration training (e.g. PHTLS, PALS), but this has now been incorporated into the new training syllabus. The paramedic syllabus is described in terms of outcomes, underpinning knowledge, and related skills, and is quite detailed in nature. The difference in the description between the education methods (i.e. academic language and traditional training course) caused problems in mapping out and comparing skills and knowledge between the two. The paramedic skill set was shown to compare with the additional “in- house” nursing skills in the department. The distribution is inherently different as there are few extra skills gained by paramedics post-registration. Those that are (and that can be used, for example in PHTLS) are now incorporated into the new paramedic syllabus anyway. However, the results showed that all of the nurses in the department had been trained in 27% of these skills. Half the nurses had been trained in 43% of the total skill set.

Shared Learning and Development There are a few examples of post-registration education that have at least an element of shared learning. The shared learning generally takes place between postregistration nurses and paramedics, and the courses are often adapted from an existing nurse qualification. At time of writing, the only current undergraduate program is at the University of Hertfordshire, where paramedics and nurses shared parts of the existing common foundation programme in year 1. A comparative analysis was undertaken between the ENB 199 and the paramedic syllabi. There were areas of significant overlap between the two education routes, notably in some or all of the following areas: • •

Anatomy and physiology Medical conditions and their treatment 80

SHARED LEARNING OPPORTUNITIES PROJECT • •

Trauma aetiology and management Paediatrics

There were also areas of unique knowledge specific to the professions. For example, paramedics had unique knowledge in some areas of: • • • • •

Anatomy and physiology (e.g. nervous system in depth) Specific medical conditions (e.g. autonomous management of) Trauma Paediatrics Obstetrics

Accident and emergency nurses were found to have unique knowledge in: • • • • •

Specific medical conditions (e.g. mental health) Minor injury/wound management Child protection Research skills and methodology Management skills and methodology

Hence this work has illustrated that there is significant potential for shared learning following a multi-professional academic pathway. Apart from the current areas of overlap in knowledge, there are also potential benefits in sharing each other’s unique areas of knowledge. A modular approach to shared learning was developed to illustrate the feasibility of shared learning within Coventry and Warwickshire. It was shown how a paramedic diploma/degree could be developed sharing integral parts of current post-registration nursing courses. Both professional groups could then access an autonomous practitioner course to enhance their education and scope of practice. These models could then be extended to develop a new undergraduate program for aspiring paramedics, again with possibilities of sharing learning back to the common foundation programme. This type of shared learning with multi-professional pathways fits in with the future vision of integrated education on a regional (or sub-regional) basis. The important feature of this development should be the identification of a national “template” of competences (as is being developed in nursing) so that a national standard of paramedic and nurse education can be established. The work has also illustrated the potential of developing shared local skills based training. There was significant overlap in the skills practiced within the accident and emergency and pre-hospital arenas. This potential has already started to be developed with the sharing of a PALS course (in the George Eliot Hospital) between nursing staff and paramedics.

The outcomes of shared learning have been discussed in terms of a local skills basis and a local or regional academic basis. There is obvious potential to then extend this nationally. The academic based sharing of learning would improve paramedic

81

SHARED LEARNING OPPORTUNITIES PROJECT training by enhancing background clinical knowledge and thus competence in clinical decision- making. New areas of knowledge would be introduced in management and critical research skills, with the possibility of extending into minor injuries and illness. There would therefore be scope for working in (or rotating around) new areas of practice (e.g. minor injury and accident and emergency departments) and challenging organisational boundaries to improve joint working. It would also be feasible to develop pathways for nurses (including those from specialties other than accident and emergency) to orientate to pre-hospital care. Finally, there are likely to be significant financial implications involved in developing new academic programmes, even if offset against a reduction in shared training cost. This needs to be seen in the context of the following perceived benefits: • • • • • • •

Improved quality of patient care Developing inter-professional working and collaboration Flexible career direction Introducing new techniques and challenges Treating more patients at home (and reducing hospital admissions) Reducing impact of staffing problems in the NHS Improve link between pre-hospital and acute emergency care

The Practitioner in Emergency Care (PEC) The idea of the PEC was introduced and an alternative model was described (based on a paramedic degree). There was limited shared learning in this model. The majority of the previous discussions in shared learning are however relevant to the feasibility of the PEC. Rather than a starting point of developing a completely new educational programme (and realistically a new professional) an alternative approach has become apparent. This is building on the ethos of shared learning to develop new educational programmes based on existing nurse education. These new diploma and degree courses in emergency care would have branch specific elements for paramedics and accident and emergency nurses, but with a significant shared element. These emergency care workers could then progress to autonomous practitioner degree level courses, again with some branch specific areas. The professionals produced will have extensive background education to back up their practical skills. They will also have extended skills that would allow them to work in new fields. Any further requirements in education would depend on the final definition of the PEC: • • • •

Clarification of the extent of the multi-skilled nature and function Possible narrowing of or specialising in roles Timescale of developing education Future of the interface between the academic and professional bodies

In order to take the PEC forward, there needs to be a strong national lead and further research on the issue. This should take place alongside developing education for paramedics (and sharing this with nursing).

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SHARED LEARNING OPPORTUNITIES PROJECT

15

Recommendations

This project has looked at many areas and makes the following recommendations (specific initiatives are numbered).

Instigating Shared Learning The project has identified many opportunities for shared learning that should be pursued and developed in the following areas. Skills On a local basis healthcare organisations should consider where they could share learning to utilise the best resources and promulgate best practice. 1. An operational working party should be established to pilot the sharing of skills training. This should initially consist of representatives from the Ambulance Service and the acute hospitals of Coventry and Warwickshire, and concentrate in the first instance on skills within the Accident and Emergency Department. This pilot would then be extended to: • • • •

Other specialities of nursing within hospitals. Additional healthcare professionals within hospitals. Nurses and healthcare professionals within acute, pre-hospit al and community trusts within Coventry and Warwickshire. Gain accreditation for the training across all organisations.

Academic routes The proposed integration of paramedic training with existing nurse education should be further researched with the aim of producing a paramedic degree/diploma (probably based on existing nurse education). This should be taken forward on a subregional (or regional) basis as a pilot scheme. 2. An academic working party should be established to develop, test and implement a new education route for paramedic education. This should consist of representatives from the Ambulance Service, the IHCD, and the local education provider (Coventry University). The aim will be to develop the education pathway in stages: • • • •

Build paramedic training to diploma/degree level (pilot early access for paramedics to appropriate existing courses at a local level). Integration of paramedic training with existing nurse education (to be developed on a modular basis). Further development to an integrated Practitioner in Emergency Care (PEC) degree. Liase with other academic institutions and relevant parties to produce a “template” for national paramedic education. National work needs to progress quickly to standardise the courses available for accident and emergency nurses. The same should be undertaken if paramedic degrees or diplomas are to be developed in order that the same situation that exists in nursing does not develop. 83

SHARED LEARNING OPPORTUNITIES PROJECT Academic Routes and Skills It would be sensible to combine both areas in order to maximise the potential of shared learning. The locally based skills options will be more easily achieved if the academic routes option progresses. Therefore the two initiatives will be best achieved if they run in parallel, eventually producing a flexible workforce working across organisational boundaries. The ultimate goal will be for the organisations to have shared training polices and accreditation.

Testing joint working In order to test how the professions work together, further joint working should be undertaken. This will also highlight particular areas of shared and unique knowledge. 3. The Accident and Emergency Department is where the closest relationship exists between the two groups. Therefore a trial of paramedics working in differing roles within the department should be undertaken to assess the feasibility and benefits of using their autonomous skills. This could be combined with access to modular areas of education (in 2, above) in order to equip the paramedics with sufficient skills to perform in a new role. This could then be further extended to encompass other areas (e.g. minor injury and coronary care units, primary care) following further evaluation and feasibility studies. 4. In order to examine the impact of joint working in pre-hospital care, a trial should be instigated in the community. This could involve a nurse practitioner working alongside paramedics to treat patients at home and develop alternative referral routes. As well as reducing unnecessary hospital admissions, this could indicate areas where new skills would be useful in the pre-hospital environment. This trial may also impact on the use of other healthcare professionals as ambulance “first responders”. Further work will be required with the IHCD to accredit nurses from any discipline with the appropriate technician or paramedic qualification, in order that they would not have to be supernumerary.

Funding for future research and development The above recommendations will have additional funding requirements, particula rly in the initial research and development stages. Therefore possible sources of funding will need to be identified and pursued before further progress can be made: 1

Sharing of skills training may be achieved on a low cost basis. Indeed, combining training may achieve a cost-neutral scenario, or produce savings that should be used to enhance training quality.

2, 3 and 4.

Financial support will be required in the following areas: o Development of paramedic degree o Replacement salary costs for paramedics and nurses testing new roles. Funding for these professionals to access required training. Possible sources of funding include: o Coventry and Warwickshire Workforce Development Confederation § Funding for accessing courses and for replacement salaries § Future cost of post-registration degree programmes. 84

SHARED LEARNING OPPORTUNITIES PROJECT

16

Appendices

Appendix 1:

Initial Action Plan

1. Identify paramedic degree courses available; obtain information on syllabus and competencies/skills. IHCD regional training centre (Chippenham) to provide information on traditional training routes, obtain information on local syllabus and competencies/skills. Utilise IHCD central office for national syllabus. 2. Identify nurse-training courses available (focussing on post-registration); obtain information on syllabus and competencies/skills. Use local training provider (Coventry University) and NHS careers/ENB to source information. 3. Comparative analysis of skills and knowledge gained through training from 1 & 2 above. Consider how to identify differences in knowledge levels? Differences in skills and subjects should be apparent? 4. Identify shared and unique skills (and knowledge). 5. Further assess skills, knowledge and competencies in working environment. Consider any extra skills gained after initial training. •

• •

A/E departments of hospitals. Contact nurses (visit or letter/questionnaire) responsible for CPD in George Eliot, Coventry and Warwickshire, Warwick and St Cross Hospitals. Widen scope to other hospitals? Obtain aims or objectives. Is this competence based or through study days etc? Training Department, Warwickshire Ambulance Service (contact other ambulance services to ascertain if similar picture nationally?) Contact those involved in Cumbria study.

6. Identify overlaps (from 4 & 5) that could form the basis of shared learning. Consider how differences in skills and knowledge could be addressed to further complement shared learning: • • •

Standardisation of skills and knowledge base Additional modules to extend or diversify knowledge Additional modules to develop the practitioner in emergency care.

7. Undertake feasibility study of extending shared learning to other specialities (e.g. Operating Department Practitioners and junior medical staff).

85

SHARED LEARNING OPPORTUNITIES PROJECT

Appendix 2:

Time Frame for Project Development

Date 9th April Completion of action plan and initial familiarisation and research. 23rd April

(1 month)

Completion of research into academic routes (1 & 2) 26 June

(3 months)

Comparative analysis of skills and knowledge, identification of shared and unique skills (3 & 4). Completion of working environment skills/knowledge (5). 26th July

(4 months)

Plan for shared learning (6). 10th September

(5.5 months)

Feasibility of extending shared learning to other specialities and to the development of the emergency practitioner role (7). 25 September

(6 months, project end)

Completion of written report based on the research project.

86

SHARED LEARNING OPPORTUNITIES PROJECT

Appendix 3:

Project Management Chart

ACTION PLAN NO

Key Stage Description 26 2

APRIL 9 16 23 30

MAY 7 14 21 28 4

WEEK NUMBER JUNE JULY 11 18 25 2 9 16 23 30

AUGUST SEPT 6 13 20 27 3 10 17

INITIAL FAMILIARISATION/ACTION PLANNING 1

IDENTIFY PARAMEDIC TRAINING PATHWAY OBTAIN SYLLABUS INFO FROM CHIPPENHAM OBTAIN SYLLABUS INFO FROM IHCD

2

IDENTIFY NURSE TRAINING PATHWAY OBTAIN APPROPRIATE NURSE SYLLABUS INFO

3

COMPARATIVE ANALYSIS OF SKILLS & KNOWLEDGE

4

IDENTIFY SHARED AND UNIQUE SKILLS AND KNOWLEDGE

5

INVESTIGATE FURTHER SKILLS GAINED POST QUALIFICATION

6

IDENTIFY OVERLAPS THAT COULD FORM BASIS OF SHARED LEARNING AND/OR APL DELPHI STUDY TO ASSESS FUTURE REQD ATTRIBUTES OF A&E NURSE/PARAMEDIC

1

3

5

6

8

9

11 12

ASSESS FEASIBILITY & BUILD FOUNDATION FOR PEC PROGRAMME 7

UNDERTAKE FEASIBILITY STUDY OF EXTENDING LEARNING TO OTHER GROUPS KEY

PROJECT MEETING CRITICAL PATH

87

STEERING GROUP NON-CRITICAL PATH

MILESTONE SLACK

SHARED LEARNING OPPORTUNITIES PROJECT

Appendix 4:

A & E Training Database

A)

Start Menu

B)

General Reports Menu

C)

Individual Reports Menu

88

SHARED LEARNING OPPORTUNITIES PROJECT

Appendix 5:

Qualified Nurse Training, George Eliot Accident and Emergency Department

QUALIFICATION TRIAGE WOUND CLOSURE WOUND MANAGEMENT VENEPUNCTURE GLUCOMETER I.V. DRUGS BLS MOVING & HANDLING CANNULATION PAED RESUS WARD INFO SYSTEM HEALTH & SAFETY V & AGGRESION XRAY REQUESTING ALS PLASTERING CATHETERISATION (MALE) 998 OR 730 COMMUNICATION DIPLOMA ENTONOX BEREAVEMENT TNCC (PHTLS FOR PARA) INFECTION CONTROL PALS RECORD KEEPING 199 LEVEL 2 CHILD PROTECTION CONFERENCE ECG RECOGNITION (12 LEAD) ECG RECORDING (12 LEAD) ENB MODULES FIRE SAFETY OTHER (IN HOUSE ENP) SALT SCREEN SIDs APPRAISAL TRAINING A33 DEGREE NVQ ASS/D32/D33 XRAY INTERPRETATION COUNSELLING CERT EMERGENCY WD CENTRE

D 11 11 10 8 8 7 10 10 4 5 2 7 7 3 2 6 5 2 1 1 5 2 1 2 1 1 5 3 2

NUMBER EACH GRADE E F 14 6 14 5 14 5 10 5 8 6 9 4 5 5 6 3 5 6 7 4 6 5 2 5 6 1 9 3 5 3 6 2 1 4 2 2 3 3 1 2 2 1 2 1 2 2 1 1 2 1 1 1 1 1 2 1

2 1 1

1

1 1 2 1

1

1

TOTAL G 6 6 6 5 5 6 4 3 6 3 6 4 3 2 5 2 5 3 5 1 3 4 4 2 3 4 1 1 3 4 1 3 3 2 2 2 1 2 1

37 36 35 28 27 26 24 22 21 19 19 18 17 17 15 14 12 11 10 9 9 8 8 7 7 6 5 5 5 5 5 4 4 4 4 4 3 2 2 2 2 1 1

D 73 73 67 53 53 47 67 67 27 33 13 47 47 20 13 40 33 13 7 7 33 13 0 7 13 7 0 7 33 20 13 0 0 0 7 7 0 0 0 7 0 0 7 89

% EACH GRADE % OF E F QUALIFIED G A&E NURSES 88 100 100 86.0 88 83 100 83.7 88 83 100 81.4 63 83 83 65.1 50 100 83 62.8 56 67 100 60.5 31 83 67 55.8 38 50 50 51.2 31 100 100 48.8 44 67 50 44.2 38 83 100 44.2 13 83 67 41.9 38 17 50 39.5 56 50 33 39.5 31 50 83 34.9 38 33 0 32.6 6 67 33 27.9 13 33 83 25.6 19 50 50 23.3 6 33 83 20.9 13 17 17 20.9 13 17 50 18.6 13 33 67 18.6 6 17 67 16.3 13 17 33 16.3 6 17 50 14.0 0 17 67 11.6 6 33 17 11.6 0 0 0 11.6 6 0 17 11.6 0 0 50 11.6 0 0 67 9.3 13 17 17 9.3 0 17 50 9.3 6 33 0 9.3 0 0 50 9.3 0 17 33 7.0 0 0 33 4.7 0 0 33 4.7 0 0 17 4.7 0 0 33 4.7 0 0 17 2.3 0 0 0 2.3

% EACH GRADE OUT OF TOTAL D E F G 25.6 32.6 14.0 14.0 25.6 32.6 11.6 14.0 23.3 32.6 11.6 14.0 18.6 23.3 11.6 11.6 18.6 18.6 14.0 11.6 16.3 20.9 9.3 14.0 23.3 11.6 11.6 9.3 23.3 14.0 7.0 7.0 9.3 11.6 14.0 14.0 11.6 16.3 9.3 7.0 4.7 14.0 11.6 14.0 16.3 4.7 11.6 9.3 16.3 14.0 2.3 7.0 7.0 20.9 7.0 4.7 4.7 11.6 7.0 11.6 14.0 14.0 4.7 0.0 11.6 2.3 9.3 4.7 4.7 4.7 4.7 11.6 2.3 7.0 7.0 7.0 2.3 2.3 4.7 11.6 11.6 4.7 2.3 2.3 4.7 4.7 2.3 7.0 0.0 4.7 4.7 9.3 2.3 2.3 2.3 9.3 4.7 4.7 2.3 4.7 2.3 2.3 2.3 7.0 0.0 0.0 2.3 9.3 2.3 2.3 4.7 2.3 11.6 0.0 0.0 0.0 7.0 2.3 0.0 2.3 4.7 0.0 0.0 7.0 0.0 0.0 0.0 9.3 0.0 4.7 2.3 2.3 0.0 0.0 2.3 7.0 2.3 2.3 4.7 0.0 2.3 0.0 0.0 7.0 0.0 0.0 2.3 4.7 0.0 0.0 0.0 4.7 0.0 0.0 0.0 4.7 2.3 0.0 0.0 2.3 0.0 0.0 0.0 4.7 0.0 0.0 0.0 2.3 2.3 0.0 0.0 0.0

SHARED LEARNING OPPORTUNITIES PROJECT

Appendix 6: 1.

Delphi Study Round 2 Questions

What do you see as the skills required by a paramedic practitioner*?

GRADE SKILL

Not reqd 1 2

PATIENT ASSESSMENT History taking Mechanism of injury assessment Questioning & information collection techniques Observation Palpation Mobility assessment Visual Acuity Complete ABCD assessment Triage/prioritisation techniques Use of auroscope Use of ophthalmoscope CLINICAL JUDGEMENT Decision making based on underpinning theoretical knowledge in: − Anatomy and physiology − Emergency and life threatening conditions − Minor injury − Minor illness − Mental health − Obstetrics and gynaecology − Management of the sick child Interpretation of information collected from patient assessment Demonstration of “critical thinking” MANAGEMENT Organise own caseload/time management Managing patient caseload Direct and supervise the work of others Team leadership/builder Risk assessment Departmental/service procedures Management of the major incident/disaster Managing own stress Awareness of scope of other health and social care agencies TEACHING/EVIDENCE BASED PRACTICE Patient education skills Clinical teaching skills Small group tutorial skills 90

3

Essential 4 5

COMMENT

SHARED LEARNING OPPORTUNITIES PROJECT

GRADE SKILL

Not reqd 1 2

Mentoring and assessment Critical appraisal of research COMMUNICATION SKILLS Written communication in clear, accurate and structured manner Proficiency in completing documentation Confidentiality Adaptable verbal communication skills Appropriate communication with: − Wide range of healthcare professionals − Non health care colleagues − Professionals from other agencies − Patients and relatives (age appropriate) Care of bereaved/counselling Defusing violent/aggressive situations Radio procedures Computer literate Use of clinical decision support software Health promotion Accident prevention CLINICAL SKILLS Vital signs (pulse, BP, respiratory rate) Peak expiratory flow rate (PEFR) Blood glucose ECG monitoring 12 lead ECG interpretation External pacing Urinalysis Use of syringe drivers Temperature X-ray requesting X-ray interpretation Wound care skills: − Aseptic technique − Dressing technique − Wound closure techniques (including suturing and glueing) − Infiltration of local anaesthetic − Selection of appropriate product Selection and use of walking aids Fracture/dislocation management: − Splinting − Plastering − Manipulation Airway care Adult basic life support 91

3

Essential 4 5

COMMENT

SHARED LEARNING OPPORTUNITIES PROJECT

GRADE SKILL

Not reqd 1 2

Paediatric basic life support Advanced life support: − Defibrillation − Drug administration − Intubation − Intubation with rapid sequence induction − Needle cricothyroidotomy − Needle thoracocentesis − Use of laryngeal mask − All skills of PHTLS/ATNC/TNCC − Obstetric and neonatal resuscitation − All skills of PALS/APLS/PHPLS − Chest tube insertion Infection control Pressure area care Hygiene and continence care Venepuncture Venous cannulation Arterial blood gas sampling IV fluid administration Lifting/moving and handling Male catheterisation Female catheterisation Spinal immobilisation Removal of spinal immobilisation AUTONOMOUS PRACTICE Decision to initiate treatment & administration of: − Activated charcoal − Aspirin − Atropine (3mg in cardiac arrest) − Atropine (for bradycardia) − Benzyl Penicillin − Chlorpheniramine (for anaphylaxis) − Diazepam − Diazemuls − Entonox (Nitronox) − Epinephrine (Adrenaline) 1:10,000 − Epinephrine (Adrenaline) 1:1,000 − Frusemide − Glucagon (Glucagen) − Glucose 10 % − Glyceryl Trinitrate (GTN) − Hartmanns (Ringers Lactate) − Hydrocortisone − Hypostop − Ketamine 92

3

Essential 4 5

COMMENT

SHARED LEARNING OPPORTUNITIES PROJECT

GRADE SKILL − − − − − − − − − − − − − − − − − − −

Not reqd 1 2

Lidocaine (Lignocaine) (local anaesthesia) Lidocaine (Lignocaine) (cardiac conditions) Lorazepam Morphine Sulphate Nalbuphine Hydrochloride (Nubain) Naloxone Hydrochloride (Narcan) Oral antibiotics (selected) Oral painkillers (selected) Oxygen Paracetamol Elixir (Calpol) Prednisolone Propofol/Midazolam (in R.S.I.) Salbutamol (Ventolin) Sodium Chloride 0.9% Streptokinase Syntometrine Tetanus toxoid Thrombolytics (other than Streptokinase) Additional (please state):

Other autonomous practice: − Wound management − Other minor trauma − Discharge of patients only requiring advice and/or reassurance − Resolved diabetic emergencies − Resolved epileptic emergencies − Resolved asthmatic emergencies − Minor head injury treatment/advice − Ability to refer directly to alternative agencies − Initiation of blood tests

93

3

Essential 4 5

COMMENT

SHARED LEARNING OPPORTUNITIES PROJECT 2.

What do you see as the experience required for someone to take up the post as a paramedic practitioner (since their initial paramedic qualification)?

GRADE EXPERIENCE

Not reqd 1 2

3

Essent ial 4 5

TIME REQD *

COMMENT

PREVIOUS IN Accident and Emergency ITU/HDU CCU General Medicine General Surgery Mental Health Obstetrics and gynaecology Orthopaedics Paediatrics Pre-hospital care: − Working as a paramedic − Working as a technician − Control room/operations centre Primary care Ophthalmology Anaesthetics/theatres Oncology NHS direct Minor Injury Units Critical care transfer

* Please insert the time you feel would be required in each field (unless you grade it as not required). For example; 6w (6 weeks), 3m (3 months), 2y (2 years).

94

SHARED LEARNING OPPORTUNITIES PROJECT 3.

What level of theoretical training do you believe a paramedic practitioner should have achieved?

GRADE TRAINING

Not reqd 1 2

ACADEMIC LEVELS GCSE/O- level A levels (or equivalent) IHCD paramedic award University diploma University degree (BSc) University Honours degree (BSc Hons) University Masters degree (MSc) SPECIFIC COURSES Basic life support (adult) Basic life support (paediatric) ATNC/TNCC/PHTLS PALS/APLS/PHPLS MIMMS City and Guild/NVQ assessor (D32, D33) ALS City and Guilds 730 (Teachers certificate) ENB 998 (Teaching & Assessing) Manchester Triage ENB 199 (Accident & Emergency Nursing) ENB A33 (Developing Autonomous Practice) Management (Introductory level) Management (Certificate level) Management (Diploma level) Diploma in Immediate Care

95

3

Essential 4 5

COMMENT

SHARED LEARNING OPPORTUNITIES PROJECT

Appendix 7:

Delphi Study Round 3 Results POM

ID (NAE,NHE,POM,PMA)

PMA

NAE

NHE

mean sdev n= mean sdev n= mean sdev n= mean sdev n=

QUESTION 1 PATIENT ASSESSMENT History taking Mechanism of injury assessment Questioning & information collection techniques Observation Palpation Mobility assessment Visual Acuity Complete ABCD assessment Triage/prioritisation techniques Use of auroscope Use of ophthalmoscope

5.0 5.0

0.0 0.0

12 12

5.0 4.9

0.0 0.3

9 9

5.0 5.0

0.0 0.0

6 6

5.0 4.6

0.0 0.7

10 10

4.8 5.0 4.7 4.4 4.3 5.0 5.0 3.3 3.0

0.5 0.0 0.7 0.8 0.8 0.0 0.0 1.1 1.0

12 12 12 12 12 12 12 12 12

4.7 4.8 4.3 4.2 3.6 5.0 4.7 2.9 2.8

1.0 0.7 1.1 1.0 1.4 0.0 1.0 1.4 1.3

9 9 9 9 9 9 9 9 9

5.0 5.0 3.2 3.7 4.3 4.7 5.0 2.8 2.8

0.0 0.0 0.8 1.5 0.5 0.5 0.0 0.4 0.4

6 6 6 6 6 6 6 6 6

4.9 4.9 3.9 4.7 4.7 4.7 5.0 3.0 3.0

0.3 0.3 0.9 0.5 0.7 0.5 0.0 1.1 1.1

10 10 10 10 10 10 10 10 10

5.0

0.0

12

4.4

1.0

9

4.8

0.4

6

5.0

0.0

10

5.0 4.8 4.8 4.3 4.6 5.0

0.0 0.4 0.4 0.8 0.7 0.0

12 12 12 12 12 12

4.8 4.7 4.7 4.3 4.6 5.0

0.7 0.7 0.7 0.7 0.7 0.0

9 9 9 9 9 9

5.0 4.7 4.3 4.2 4.0 5.0

0.0 0.5 0.5 0.4 0.6 0.0

6 6 6 6 6 6

5.0 4.6 4.4 4.6 4.4 4.8

0.0 0.7 0.5 0.5 0.7 0.4

10 10 9 10 10 10

5.0 5.0

0.0 0.0

12 12

4.6 4.7

1.3 1.0

9 9

5.0 4.8

0.0 0.4

6 6

5.0 4.9

0.0 0.3

10 10

3.8 3.6 3.8 4.0 4.3 4.0

1.3 1.1 0.8 0.6 0.8 0.6

12 12 12 12 12 12

4.0 3.9 3.3 3.6 4.1 3.8

0.9 1.0 1.2 1.2 1.4 1.3

8 8 8 8 8 8

5.0 4.8 4.5 4.7 5.0 4.5

0.0 0.4 0.5 0.5 0.0 0.5

6 6 6 6 6 6

5.0 4.8 4.8 5.0 4.9 4.8

0.0 0.4 0.4 0.0 0.3 0.4

10 10 10 10 10 10

3.9 4.3

0.7 0.6

12 12

4.0 3.9

0.9 0.8

8 8

4.2 4.8

0.8 0.4

6 6

4.6 4.9

0.5 0.3

10 10

4.4

0.5

12

4.3

0.5

8

4.2

0.8

6

4.9

0.3

10

3.7 3.9 3.8 3.9 4.1

0.7 0.8 1.0 0.7 0.5

12 12 12 12 12

3.9 3.4 3.3 3.4 3.8

1.0 1.2 1.2 1.2 1.0

8 8 8 8 8

4.8 4.8 4.2 4.3 4.3

0.4 0.4 0.4 0.5 0.5

6 6 6 6 6

4.8 4.7 4.4 4.7 4.6

0.4 0.7 0.8 0.7 0.5

10 10 10 10 10

CLINICAL JUDGEMENT Decision making based on underpinning theoretical knowledge in: Anatomy and physiology Emergency and life threatening conditions Minor injury Minor illness Mental health Obstetrics and gynaecology Management of the sick child Interpretation of info. collected from patient assessment Demonstration of critical thinking

MANAGEMENT Organise own caseload/time mgt Managing patient caseload Direct and supervise the work of others Team leadership/builder Risk assessment Departmental/service procedures Management of the major incident/disaster Managing own stress Awareness of scope of other health and social care agencies

TEACHING/EVIDENCE BASED PRACTICE Patient education skills Clinical teaching skills Small group tutorial skills Mentoring and assessment Critical appraisal of research

96

SHARED LEARNING OPPORTUNITIES PROJECT

COMMUNICATION SKILLS Written communication in clear, accurate and structured manner

4.8

0.4

12

4.8

0.7

8

5.0

0.0

6

4.7

0.7

10

Proficiency in completing documentation Confidentiality Adaptable verbal communication skills Appropriate communication with: Wide range of healthcare professionals Non health care colleagues Professionals from other agencies Patients and relatives (age appropriate) Care of bereaved/counselling Defusing violent/aggressive situations Radio procedures Computer literate

4.9 5.0 4.8

0.3 0.0 0.4

12 12 12

4.5 5.0 4.3

1.4 0.0 1.4

8 8 8

5.0 5.0 5.0

0.0 0.0 0.0

6 6 6

4.9 5.0 4.8

0.3 0.0 0.4

10 10 10

4.8 4.4 4.5

0.5 0.7 0.7

12 12 11

4.8 4.3 4.1

0.5 1.2 1.4

8 8 8

4.8 4.8 4.7

0.4 0.4 0.5

6 6 6

4.9 4.8 4.7

0.3 0.4 0.5

10 10 10

4.8 4.4 4.7 4.2 4.0

0.5 0.5 0.5 0.9 0.6

12 12 12 12 12

4.8 4.4 4.6 4.4 4.3

0.5 1.1 0.7 1.4 0.7

8 8 8 8 8

5.0 5.0 5.0 3.2 3.8

0.0 0.0 0.0 0.8 0.4

6 6 6 6 6

5.0 4.9 4.9 3.0 3.8

0.0 0.3 0.3 0.5 0.8

10 9 10 8 10

Use of clinical decision support software Health promotion Accident prevention

3.8 3.6 3.3

0.7 0.7 0.7

12 12 12

4.2 3.4 3.4

1.0 1.2 1.2

9 8 8

3.7 4.3 3.8

0.5 0.5 1.0

6 6 6

3.3 4.2 4.1

0.9 0.8 0.7

9 10 10

5.0 4.9 4.9 5.0 4.8 3.7 3.8 3.6 4.9 3.9 3.3

0.0 0.3 0.3 0.0 0.4 1.0 0.6 1.0 0.3 1.2 1.2

12 12 12 12 12 12 12 12 11 12 12

5.0 5.0 4.5 5.0 5.0 4.2 4.3 3.3 4.6 3.9 3.1

0.0 0.0 1.4 0.0 0.0 1.3 0.7 1.1 0.7 1.3 1.5

8 8 8 8 8 9 9 9 9 9 9

5.0 5.0 5.0 5.0 4.8 3.7 5.0 5.0 5.0 4.0 3.5

0.0 0.0 0.0 0.0 0.4 1.0 0.0 0.0 0.0 0.9 0.8

6 6 6 6 6 6 6 6 6 6 6

5.0 5.0 5.0 5.0 4.7 4.0 5.0 4.6 5.0 4.3 4.0

0.0 0.0 0.0 0.0 0.7 0.8 0.0 0.5 0.0 0.8 1.2

10 10 10 10 10 10 10 10 10 10 9

4.8 4.9

0.4 0.3

12 12

4.9 4.8

0.3 0.7

9 9

5.0 5.0

0.0 0.0

6 6

5.0 5.0

0.0 0.0

10 10

4.8 4.6 4.7 2.8

0.6 1.0 0.7 0.6

12 12 12 12

4.8 4.8 4.9 2.9

0.4 0.4 0.3 1.1

9 9 9 9

4.8 4.7 4.8 4.3

0.4 0.5 0.4 1.6

6 6 6 6

5.0 4.7 4.9 4.7

0.0 0.7 0.3 0.7

10 10 10 10

4.8 2.9 3.8 5.0 5.0 5.0

0.5 1.2 1.1 0.0 0.0 0.0

12 12 12 12 12 12

4.9 2.9 3.6 5.0 5.0 5.0

0.3 1.5 1.3 0.0 0.0 0.0

9 9 9 9 9 9

5.0 5.0 3.2 5.0 5.0 5.0

0.0 0.0 0.8 0.0 0.0 0.0

6 6 6 6 6 6

5.0 4.8 3.0 5.0 5.0 4.9

0.0 0.4 0.9 0.0 0.0 0.3

10 10 10 10 10 10

CLINICAL SKILLS Vital signs (pulse, BP, respiratory rate) Peak expiratory flow rate (PEFR) Blood glucose ECG monitoring (3 lead) 12 lead ECG interpretation External pacing Urinalysis Use of syringe drivers Temperature X-ray requesting X-ray interpretation Wound care skills: Aseptic technique Dressing technique Wound closure techniques (including suturing and glueing) Infiltration of local anaesthetic Selection of appropriate product Selection and use of walking aids Fracture/dislocation management: Splinting Plastering Manipulation Airway care Adult basic life support Paediatric basic life support

97

SHARED LEARNING OPPORTUNITIES PROJECT Advanced life support: Defibrillation Drug administration Intubation Intubation with rapid sequence induction Needle cricothyroidotomy Needle thoracocentesis Use of laryngeal mask All skills of PHTLS/ATNC/TNCC Obstetric and neonatal resusc. All skills of PALS/APLS/PHPLS Chest tube insertion Infection control Pressure area care Hygiene and continence care Venepuncture Venous cannulation Arterial blood gas sampling IV fluid administration Lifting/moving and handling Male catheterisation Female catheterisation Spinal immobilisation Removal of spinal immobilisation AUTONOMOUS PRACTICE Decision to initiate treatment & administration of: Activated charcoal Aspirin Atropine (3mg in cardiac arrest) Atropine (for bradycardia) Benzyl Penicillin Chlorpheniramine (for anaphylaxis) Diazepam Diazemuls Entonox (Nitronox) Epinephrine (Adrenaline) 1:10,000 Epinephrine (Adrenaline) 1:1,000 Frusemide Glucagon (Glucagen) Glucose 10 % Glyceryl Trinitrate (GTN) Hartmanns (Ringers Lactate) Hydrocortisone Hypostop Ketamine Lidocaine (Lignocaine) (local anaesthesia) Lidocaine (Lignocaine) (cardiac conditions) Lorazepam Morphine Sulphate Nalbuphine Hydrochloride (Nubain)

5.0 5.0 4.9

0.0 0.0 0.3

12 12 12

5.0 5.0 4.8

0.0 0.0 0.7

9 9 9

5.0 4.8 3.5

0.0 0.4 1.4

6 6 6

4.8 4.7 3.7

0.4 0.5 1.1

10 10 10

4.3 4.6 4.8 4.6 4.9 4.9 5.0 3.7 4.6 3.6 3.4 5.0 4.9 2.7 5.0 4.8 4.0 3.8 5.0 4.9

0.8 0.5 0.4 0.7 0.3 0.3 0.0 0.8 0.7 0.8 1.0 0.0 0.3 1.2 0.0 0.6 1.1 1.1 0.0 0.3

12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12

4.0 4.8 5.0 5.0 4.8 4.8 4.9 2.9 4.4 3.8 3.4 4.9 4.9 2.9 5.0 4.9 4.0 3.4 5.0 3.8

1.2 0.4 0.0 0.0 0.4 0.4 0.3 1.6 0.9 1.2 1.3 0.3 0.3 1.5 0.0 0.3 1.3 1.5 0.0 1.6

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

2.7 2.7 2.8 3.8 4.8 4.3 4.5 3.0 5.0 4.8 5.0 5.0 5.0 3.5 5.0 5.0 4.7 4.8 5.0 5.0

1.4 1.0 1.0 0.8 0.4 0.8 0.8 1.1 0.0 0.4 0.0 0.0 0.0 0.5 0.0 0.0 0.5 0.4 0.0 0.0

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

3.1 2.8 3.0 4.1 3.9 4.1 3.8 2.5 5.0 5.0 5.0 4.7 4.7 3.6 4.8 5.0 4.5 4.6 5.0 4.4

1.1 1.4 1.4 0.6 0.9 1.2 1.1 1.0 0.0 0.0 0.0 0.5 0.5 1.3 0.4 0.0 0.5 0.5 0.0 1.1

10 9 9 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10

4.3 5.0 5.0 5.0 4.8 4.8 4.8 5.0 5.0 5.0 5.0 4.8 5.0 4.8 5.0 5.0 4.7 5.0 4.3

1.4 0.0 0.0 0.0 0.4 0.6 0.9 0.0 0.0 0.0 0.0 0.4 0.0 0.6 0.0 0.0 0.7 0.0 1.2

11 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12

3.7 5.0 5.0 5.0 5.0 4.6 4.5 4.8 5.0 5.0 5.0 4.7 5.0 5.0 5.0 5.0 4.5 5.0 3.8

1.5 0.0 0.0 0.0 0.0 0.7 1.1 0.4 0.0 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.8 0.0 1.2

9 9 9 9 9 8 8 9 9 9 9 9 9 9 9 9 8 9 9

4.8 5.0 4.7 4.3 4.0 4.7 3.8 3.7 4.7 4.5 3.8 3.8 4.3 3.5 4.7 4.3 4.2 4.7 2.7

0.4 0.0 0.8 0.8 1.3 0.8 1.2 1.2 0.8 0.8 1.0 1.0 1.0 1.5 0.8 1.0 1.0 0.8 1.0

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

4.2 4.7 4.2 4.3 3.8 3.9 3.0 3.8 5.0 4.3 4.2 3.6 4.3 4.3 4.8 4.2 3.2 3.7 3.0

1.3 0.5 1.3 1.0 1.3 1.5 1.6 1.5 0.0 0.9 1.1 1.0 0.9 1.1 0.4 1.1 1.6 1.3 1.5

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

4.8

0.9

12

4.6

1.0

9

4.8

0.4

6

4.7

0.7

9

4.7 3.9 5.0 4.7

1.2 1.3 0.0 0.9

12 12 12 12

4.7 4.6 4.3 3.8

0.7 0.7 1.3 1.6

9 8 9 9

4.0 3.2 4.8 2.2

1.0 1.8 0.5 1.1

5 5 4 5

3.1 2.4 3.6 1.8

1.7 1.3 1.0 0.8

9 9 9 9

98

SHARED LEARNING OPPORTUNITIES PROJECT

Naloxone Hydrochloride (Narcan) Oral antibiotics (selected) Oral painkillers (selected) Oxygen Paracetamol Elixir (Calpol) Prednisolone Propofol/Midazolam (in R.S.I.) Salbutamol (Ventolin) Sodium Chloride 0.9% Streptokinase Syntometrine Tetanus toxoid Thrombolytics (other than Streptokinase) Additional: Amiodarone Anti-emetic (e.g. Metoclopramide) Morning after pill Tevecteplase Tramadol Other autonomous practice: Wound management Other minor trauma Discharge of patients only requiring advice and/or reassurance Resolved diabetic emergencies Resolved epileptic emergencies Resolved asthmatic emergencies Minor head injury treatment/advice Ability to refer directly to alternative agencies Initiation of blood tests

5.0 4.6 4.8 5.0 4.9 4.3 4.2 5.0 5.0 3.5 4.6 4.3

0.0 1.2 0.6 0.0 0.3 1.2 1.1 0.0 0.0 1.7 0.7 1.2

12 12 12 12 12 12 12 12 12 12 12 12

5.0 4.2 4.7 5.0 5.0 4.9 3.8 5.0 5.0 3.9 4.2 4.3

0.0 1.2 0.7 0.0 0.0 0.4 1.3 0.0 0.0 1.7 1.4 1.3

9 9 9 9 9 8 9 9 9 9 9 9

4.3 4.7 5.0 5.0 5.0 3.2 2.0 4.8 4.7 4.0 2.3 5.0

1.6 0.8 0.0 0.0 0.0 2.0 1.0 0.4 0.8 1.7 1.0 0.0

6 6 6 6 5 5 5 6 6 5 6 6

4.6 4.2 4.7 5.0 4.9 2.6 2.6 4.7 4.4 3.6 2.2 4.9

1.0 1.0 0.5 0.0 0.3 1.6 1.2 0.5 1.0 1.5 1.0 0.3

9 9 9 9 9 9 9 9 9 9 9 9

4.8

0.4

12

4.8

0.7

9

3.6

1.7

5

3.3

1.4

9

4.4 4.9 3.3 4.9 3.3

0.5 0.4 1.6 0.4 1.4

6 9 7 7 6

3.2 4.5 3.2 4.6 2.4

1.8 1.2 1.6 0.5 1.9

6 6 6 5 5

3.0 4.2 4.2 2.5 2.3

2.0 1.6 1.0 1.9 1.5

5 6 6 4 4

3.4 4.0 3.8 2.0 2.2

1.3 1.3 1.6 0.9 1.6

7 7 6 6 6

4.9 4.9

0.3 0.3

12 12

4.8 4.8

0.7 0.7

9 9

5.0 4.8

0.0 0.4

6 6

4.9 4.6

0.3 0.5

10 10

4.8 4.9 4.9 4.9 4.9

0.6 0.3 0.3 0.3 0.3

12 12 12 12 12

4.9 5.0 5.0 5.0 5.0

0.3 0.0 0.0 0.0 0.0

9 9 9 9 9

5.0 4.7 4.7 4.7 5.0

0.0 0.8 0.8 0.8 0.0

6 6 6 6 6

4.7 4.3 4.3 4.3 4.3

0.5 0.9 0.9 0.9 0.9

10 10 10 10 10

4.8 4.5

0.6 1.2

12 12

4.9 4.6

0.3 1.1

9 8

5.0 5.0

0.0 0.0

6 6

4.6 4.8

0.7 0.4

10 10

99

SHARED LEARNING OPPORTUNITIES PROJECT

ID (NAE,NHE,POM,PMA)

POM (SCORE) mean sdev

n=

POM (WKS) mean sdev

PMA (SCORE)

n=

mean sdev

PMA (WKS)

n=

mean

sdev

n=

QUESTION 2 PREVIOUS IN (WKS) Accident and Emergency ITU/HDU CCU General Medicine General Surgery Mental Health Obstetrics and gynaecology Orthopaedics Paediatrics Pre-hospital care: Working as a paramedic Working as a technician Control room/operations centre Primary care Ophthalmology Anaesthetics/theatres Oncology NHS direct Minor Injury Units Critical care transfer

ID (NAE,NHE,POM,PMA)

4.8 4.2 4.8 4.2 3.8 4.0 4.3 4.2 4.8

0.6 0.9 0.4 0.8 1.2 1.3 1.0 0.9 0.5

12 12 12 12 12 12 12 12 12

12.0 4.4 3.8 3.9 2.6 2.3 3.4 1.9 3.9

15.5 4.4 2.2 2.1 1.7 1.8 2.0 1.7 2.0

9 7 9 8 7 7 8 8 8

5.0 3.8 4.7 3.8 3.7 4.1 4.3 4.0 4.6

0.0 0.8 0.7 1.3 1.2 1.1 0.7 1.0 0.7

9 9 9 9 9 9 9 9 9

29.2 3.2 5.0 4.0 1.5 4.3 3.8 2.3 4.4

37.9 1.1 2.0 2.8 0.7 2.9 2.7 1.5 2.2

6 5 4 2 2 4 5 3 5

5.0 3.8 2.9 4.4 2.9 4.6 3.0 3.4 4.2 3.4

0.0 1.7 1.2 0.7 1.2 0.7 1.0 0.9 0.8 1.0

12 12 12 12 11 12 12 12 12 12

98.2 86.7 13.3 7.1 2.2 3.4 1.7 1.0 2.3 1.6

17.3 26.9 12.5 8.6 1.9 1.6 2.1 0.6 1.2 0.5

9 6 3 8 6 8 6 6 8 5

5.0 4.3 4.0 4.7 2.8 4.2 2.2 3.7 4.6 3.7

0.0 1.4 1.4 0.5 1.2 1.1 1.2 1.5 0.5 1.3

9 9 9 9 9 9 9 9 8 9

72.4 39.0 11.4 7.2 2.5 6.7 0.7 0.5 6.0 3.0

41.0 22.5 9.0 3.4 2.1 5.4 0.4 5.6 1.7

7 3 5 6 2 5 1 3 4 3

NAE (SCORE) mean sdev n=

NAE (WKS) mean sdev n=

NHE (SCORE) mean sdev n=

NHE (WKS) mean sdev n=

QUESTION 2 PREVIOUS IN (WKS) Accident and Emergency ITU/HDU CCU General Medicine General Surgery Mental Health Obstetrics and gynaecology Orthopaedics Paediatrics Pre-hospital care: Working as a paramedic

5.0 3.0 3.0 3.0 2.8 2.2 1.8 2.4 2.6

0.0 1.2 1.2 1.4 1.3 0.8 0.8 0.9 1.5

6.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

1.7

1.0

6.0

-

Working as a technician

1.3

0.5

6.0

1.0 1.8 1.4 1.8 1.4 1.8 2.4 2.2

0.0 0.8 0.5 0.8 0.9 1.1 1.3 1.3

6.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

Control room/operations centre Primary care Ophthalmology Anaesthetics/theatres Oncology NHS direct Minor Injury Units Critical care transfer

115.6 65.3 6.0 6.0 26.0 0 26.0 0 6.0 6.0 6.0 6.0 -

5 1 1 2 2 1 1 1 1

4.9 3.0 3.1 2.9 2.9 3.1 2.5 3.1 3.0

0.3 1.2 1.2 1.5 1.5 1.6 1.4 1.2 1.3

9 9 9 9 9 8 8 9 8

150.5 57.3 40.0 13.0 13.0 15.0 1.0 17.3 8.5

73.6 85.6 55.7 15.6 7.5 6.4

8 3 3 1 1 2 1 3 2

-

0

2.0

1.2

7

54.0

70.7

2

-

-

0

1.4

0.8

7

-

-

0

6.0 6.0

-

0 0 0 1 0 0 0 1

1.3 2.6 2.1 2.0 1.5 2.3 2.6 3.0

0.7 1.4 0.8 0.8 0.8 1.2 1.2 1.1

8 7 8 8 8 8 8 8

0.6 1.0 0.1 29.0 1.0

0.6 32.5 -

0 0 2 1 0 1 2 1

100

SHARED LEARNING OPPORTUNITIES PROJECT

POM

ID (NAE,NHE,POM,PMA)

mean sdev

PMA n=

mean sdev

NAE n=

mean sdev

NHE n=

mean sdev

n=

QUESTION 3 ACADEMIC LEVELS GCSE/O-level A levels (or equivalent) IHCD paramedic award University diploma University degree (BSc) University Honours degree (BSc Hons) University Masters degree (MSc)

4.8 3.7 4.9 3.8 3.8 3.3 2.4

0.6 0.9 0.3 0.9 1.3 1.0 0.9

12 12 12 12 12 12 12

4.0 3.7 4.8 3.6 3.3 2.9 1.8

1.4 1.3 0.7 1.6 1.5 1.4 0.8

9 9 9 9 9 9 9

4.7 2.8 1.8 3.5 3.0 2.8 2.0

0.8 1.3 1.3 0.8 0.6 1.6 1.1

6 6 6 6 6 6 6

4.5 3.8 2.1 4.8 3.8 4.1 3.1

1.4 1.4 1.1 0.6 0.9 0.8 0.3

8 9 9 10 10 9 9

5.0 5.0 4.9 4.8 4.1 3.2 4.8 2.7 3.2 2.9 3.7 4.5 3.3 2.9 2.4 3.3

0.0 0.0 0.3 0.4 1.0 0.9 0.4 0.7 0.7 0.3 1.1 0.8 1.3 1.1 1.2 1.1

12 12 12 12 12 12 12 12 12 11 12 11 12 12 12 12

5.0 5.0 5.0 5.0 4.1 2.1 5.0 2.5 3.0 2.5 2.3 2.5 3.0 2.9 1.9 2.4

0.0 0.0 0.0 0.0 1.1 0.9 0.0 1.1 1.2 1.1 1.0 1.1 1.4 1.6 1.1 1.4

8 8 8 8 8 7 8 8 8 8 8 8 8 8 8 7

5.0 5.0 4.8 4.7 2.0 2.6 5.0 3.5 4.7 4.5 4.3 4.0 3.2 2.8 2.3 2.4

0.0 0.0 0.4 0.5 1.2 0.9 0.0 0.5 0.5 0.8 1.0 0.9 1.3 1.5 1.0 1.3

6 6 6 6 4 5 6 6 6 6 6 6 6 6 6 5

5.0 4.9 4.4 4.3 3.7 3.0 4.7 3.5 4.7 4.1 4.6 3.9 3.7 3.3 3.3 3.0

0.0 0.3 0.7 0.7 0.8 0.7 0.7 1.0 0.7 1.1 0.8 1.1 1.1 1.3 1.1 0.9

10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10

SPECIFIC COURSES Basic life support (adult) Basic life support (paediatric) ATNC/TNCC/PHTLS PALS/APLS/PHPLS MIMMS City and Guild/NVQ assessor (D32, D33) ALS City and Guilds 730 (Teachers certificate) ENB 998 (Teaching & Assessing) Manchester Triage ENB 199 (Accident & Emergency Nursing) ENB A33 (Developing Autonomous Practice) Management (Introductory level) Management (Certificate level) Management (Diploma level) Diploma in Immediate Care

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Appendix 8:

Possible Full-Time Models

Two year diploma format Year 1 Social Context of Health

Technician Training (240 hours)

Advanced Driving (120 hours)

Practice Portfolio

Community Issues E.g. Child Protection Mental Health

Study Skills, and Portfolio Develop.

Hospital or Community Placement

Certificate of Higher Education

Year 2 Anatomy, physiology & pharmacology

Medical Conditions (including Mental Health)

Paramedic Training, including Hospital Placement (390 hours)

Optional (from list*)

Patient Assessment and Differential Diagnosis

Professional issues and management

Significance of Research

Diploma in Paramedical Science

Key

(Academic Year 8 modules=1200 hours=30 weeks)

Half module (75 hrs)

1 ½ Module (225 hours)

Single Module (150 hrs)

Double Module (300 hours)

Black box = Level 1

Red box =

Level 2

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Green box = Level 3

SHARED LEARNING OPPORTUNITIES PROJECT

Two year diploma format (no practice portfolio) Year 1 Social Context of Health

Technician Training (240 hours)

Advanced Driving (120 hours)

Study Skills, and Portfolio Develop.

Personal and Interpersonal skills

Welfare, Health and Inequalities

Community Issues E.g. Child Protection Mental Health

Hospital or Community Placement

Certificate of Higher Education

Year 2 Anatomy, physiology, pharmacology

Medical Conditions (including Mental Health)

Patient Assessment and Differential Diagnosis

Paramedic Training, including Hospital Placement (390 hours)

Professional issues and management

Evidence Base Practice

Diploma in Paramedical Science

Year 3 (using A33 as example) Principles/concepts of autonomous practice

Care and management of minor illness

Research methods and statistics

Current issues in NHS/Ambulance

Care and management of minor injuries

Emergency care practice

Dissertation

BSc (or BSc Hons) Advanced Paramedic Practitioner (with Diploma in Autonomous Practice)

Black box = Level 1

Red box =

Level 2 103

Green box = Level 3

SHARED LEARNING OPPORTUNITIES PROJECT

Two year diploma format (link into A33 course) Year 1 Social Context of Health

Technician Training (240 hours)

Advanced Driving (120 hours)

Practice Portfolio

Community Issues E.g. Child Protection Mental Health

Study Skills, and Portfolio Develop.

Hospital or Community Placement

Certificate of Higher Education

Year 2 Anatomy, physiology, pharmacology

Medical Conditions (including Mental Health)

Patient Assessment and Differential Diagnosis

Paramedic Training, including Hospital Placement (390 hours)

Professional issues and management

Evidence Base Practice

Diploma in Paramedical Science

Year 3 Principles/concepts of autonomous practice

Care and management of minor illness

Research methods and statistics

Current issues in NHS/Ambulance

Care and management of minor injuries

Emergency care practice

Dissertation

BSc (or BSc Hons) Advanced Paramedic Practitioner (with Diploma in Autonomous Practice)

Black box = Level 1

Red box =

Level 2

104

Green box = Level 3

SHARED LEARNING OPPORTUNITIES PROJECT

Three year degree format (without A33) Year 1 Social Context of Health

Technician Training (240 hours)

Advanced Driving (120 hours)

Practice Portfolio

Community Issues E.g. Child Protection Mental Health

Study Skills, and Portfolio Develop.

Hospital or Community Placement

Certificate of Higher Education

Year 2 Anatomy, physiology, pharmacology

Medical Conditions (including Mental Health)

Patient Assessment and Differential Diagnosis

Paramedic Training, including Hospital Placement (390 hours)

Professional issues and management

Evidence Base Practice

Diploma in Paramedical Science

Year 3

Optional (from list*)

Optional (from list*)

Research methods and statistics

Current issues in NHS/Ambulance

Mental Health?

Advanced procedures (e.g. assisting BASICS)

Dissertation

BSc (or BSc Hons) Paramedical Science

Black box = Level 1

Red box =

Level 2

105

Green box = Level 3

SHARED LEARNING OPPORTUNITIES PROJECT

* Optional modules Evidence Based Practice Medical Equipment Design and Technology Teaching/assessing (level 2?) Management (level two or three) Psychology (level?) Clinical supervision Care and management of minor injuries Care and management of minor illness Mental Health Disaster/Major Incident Management Bereavement

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Appendix 9:

Existing Models Available Nationally (with references to websites - last accessed October 2001)

University of Hertfordshire BSc (Hons.) Paramedic Science with IHCD Paramedic Award Year one Semester One

Biosciences

Semester Two

Biosciences

Summer

Practice Placement (8 weeks)

Behavioural Sciences Behavioural Sciences

Professional Issues and Law Professional Issues and Law

Practice Placement Practice Placement & IHCD Driving Course

Behavioural Sciences Practice Placements Technician Award

Professional Issues and Law Practice Placements

Practice Placement Practice Placements

Patient Assessment Patient Assessment IHCD Paramedic Award

Practice Placements Practice Placements Practice: IHCD Stage 4

Year two Semester One

Biosciences

Semester Two

Biosciences

Summer

Practice Placement (8 weeks)

Year three Semester One Semester Two Summer

Research Project Medical Design and Technology Research Project Managerial Studies BSc (Hons) Paramedic Science

(http://www.herts.ac.uk/extrel/UGP2002/health/bsc_paramedic.html)

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SHARED LEARNING OPPORTUNITIES PROJECT

Oxford Brookes University Certificate/Diploma/BSc/BSc (Hons.) in Pre-Hospital Emergency Care Year 1 Health People and Society

Basic Ambulance Aid and Driver Training

Applying Ambulance Aid in Practice

Psychology of Healthcare

Physiology in Practice

Year 2 Hospital Practice

Paramedic Skills

Human Life Sciences

Understanding Research in Context of Healthcare

Developing Paramedic Skills in Pre-Hospital Practice

Independent Study

Year 3 Helicopter Procedures/Mental Health/River Rescue

Optional

Optional

Research in Practice

Theoretical & Ethical base for Workplace Learning

Assessment in the Workplace

Dissertation

(http://www.brookes.ac.uk/schools/hcs/)

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SHARED LEARNING OPPORTUNITIES PROJECT

University of Wales BSc (Hons.) Pre-Hospital Care Part time as six one-week blocks per year, over four academic years. The dissertation will take up much of Year 4 study. Alternatively, students may exit the course after two years and receive a Diploma in Pre-Hospital Care.

Years 1 and 2 (Level 2) Clinical Practice I Applied Behavioural Sciences Research Awareness and Methods Physiology and Pharmacology Health Care Law

30 credits 20 credits 20 credits 40 credits 10 credits

Years 3 and 4 (Level 3) Social Policy Clinical Practice II & Adult and Paediatric Trauma Disaster Management and Bereavement Ethics in Pre Hospital Care Management in Pre Hospital Care Dissertation

10 credits 20 credits 20 credits 10 credits 20 credits 40 credits

(http://www.healthscience.swan.ac.uk/courses/forprofessionals/Ne wpages/index.htm)

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SHARED LEARNING OPPORTUNITIES PROJECT

University of Plymouth BSc (Hons.) Emergency Care (maximum 2 years part-time) CHOICE OF OPTIONS

Evidence Based Practice & Clinical Effectiveness 20 credits

Assessing and Facilitating Clinical Skills Learning 20 credits

Core Concepts in Emergency Care 20 credits

Applied Skills in Emergency Care 20 credits

Leadership and Management in Emergency Care 20 credits

Contemporary Issues in Emergency Care 10 credits

Developing & Refining Practice in Emergency Care

(http://www.ihs.plymouth.ac.uk/ihs/courses/hsms/ihspro01.pdf)

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St Martins College, Carlisle BSc (Hons.) Emergency Practitioner (2.5 to 4 years)

Human Health and Disease Part 1 15 credits

Human Health and Disease Part 2 15 credits

Health Assessment Part 1 15 credits

Health Assessment Part 2 15 credits

Applied Pharmacology Part 1 15 credits

Applied Pharmacology Part 2 15 credits

Therapeutic Communication 15 credits

Scope of Paramedic Practice 15 credits

Practitioner Research 15 credits

Advanced Paramedic Practice 15 credits

Clinical Decision Making for Paramedics 30 credits

Teaching in Health Related Settings 15 credits

Theory & Practice of Adv. Resuscitation Skills 15 credits

Evidence Based Practice Development (Dissertation) 30 credits

(http://www.ucsm.ac.uk/courses/health/smc_cpd.pdf)

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Appendix 10: Additional Benefits from the Project As well as the specific work involved with the project, some additional benefits and work have resulted from it (either fully or partly) as follows. •

Introduction of comprehensive training database utility into A&E department: o o o o

•

Allowed current paper records to be checked Produced individual training records and other reports Aids the future planning of training and I.P.R. or appraisal Ongoing development into other departments and hospitals

Proposal for Nurse Practitioner secondment to Warwickshire Ambulance Service: o In conjunction with George Eliot Hospital and for consideration of the Intermediate Care Board o Aims to test joint working and education and reduce inappropriate admissions (by treatment at home and alternative referral methods)

•

Working across many organisational boundaries to develop links and improve relationships and communication: o o o o o

Intermediate care team (North Warwickshire) Bed management team (George Eliot Hospital) Coventry University Acute Hospitals of Coventry and Warwickshire Warwickshire Ambulance Service

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17

References

ASA/Medical Care Research Unit (2001): The Future of Ambulance Services in the United Kingdom. Medical Care Research Unit, Sheffield (ASA, London). Crouch R, Jones G. (1997): Towards a Faculty of Emergency Nursing: planning for the future. Emergency Nurse 5: 6, 12-15 Endacott R, Edwards B, Crouch R, Castille K, Dolan B, Hamilton C, Jones G, MacPhee D, Manley K, Windle J. (1999): Towards a Faculty of Emergency Nursing. Emergency Nurse. 7: 5, 10-16 JRCALC/ASA. (2000): The Future Role and Education of Paramedic Ambulance Service Personnel (Emerging concepts). Joint Royal Colleges and Ambulance Liaison Committee and the Ambulance Service Association, London. RCN (2000): Faculty Project. RCN Web address: http://www.rcn.org.uk/services/promote/faculty/faculty.htm2 Scholes J, Endacott R. & Chellel A. (1999): A Documentary Analysis and Literature Review of Critical Care Nursing. English National Board for Nursing Midwifery and Health Visiting, London. * Scholes J, Endacott R. & Chellel A. (2000): To Prime or to Consolidate Experience? Review of ENB 199 A & E Courses. Accident and Emergency Nursing 8, 34-41 Wood I. (2000): Practitioners in emergency care: generic workers or skilled professionals? Pre-Hospital Immediate Care 4, 132-135

* If you have access to the WISH/OVID database, this is available in similar form via the Internet as: Scholes J., Endacott R. & Chellel A. (2000) A Formula for Diversity: A review of Critical Care Curricula. Journal of Clinical Nursing 9 (3), 382-390.

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