New framework launched to clarify the knowledge and skills emergency nurses need
The RCN Emergency Care Association has launched the National Curriculum and Competency Framework for Emergency Nursing in response to demands for clarity about the knowledge and skills nurses require to work in emergency settings.
In June, the RCN Emergency Care Association (ECA) launched the National Curriculum and Competency Framework for Emergency Nursing in response to demands for clarity about the knowledge and skills nurses require to work in emergency settings at various levels.
The framework is shown below. The ‘good nursing practice’ competencies, which are integral to everyday practice, are aligned to the Nursing and Midwifery Council Code, and are intended to promote professional behaviour, teamwork, education, leadership and practice development. There are eight cross-cutting themes that form substantial elements of emergency nursing, which are relevant to patients of all ages with all types of presentations:
- Patient assessment.
- Pain assessment and management.
- Medicines management.
- Moving and handling.
- Infection prevention and control.
- Safeguarding children and adults.
- Documentation and record keeping.
- Preventing and controlling violence and aggression.
Seven clinical domains (with the absence of trauma) outline the specific knowledge and skills required to work with patients of different ages with a variety of presenting complaints and acuity. There are no specific competencies for nurses who work with trauma patients because the National Major Trauma Nursing Group (NMTNG) has already published competencies for trauma nurses (NMTNG 2016). The clinical domains in the RCN framework are:
- Caring for acutely ill adults. This section is organised by biological system, for example cardiovascular problems, gastrointestinal problems.
- Caring for adults requiring resuscitation. This section covers topics such as airway and ventilation management, and patients with anaphylaxis and/or who are fitting. Topics are generally those that can be attributed to multiple biological systems, such as sepsis.
- Caring for adults with minor injury and illness.
- Caring for children and young people.
- Caring for people with mental health needs.
- Caring for older people.
- Emergency planning and disaster management.
Level 1 and level 2 competencies
There are level 1 and level 2 competencies for the three categories of the framework – good nursing practice, the cross-cutting themes and the clinical domains. This in line with the NMTNG trauma competencies. Level 1 is intended for newly qualified nurses or those new to emergency care, while level 2 is aimed at nurses wishing to progress beyond fundamental emergency nursing.
Existing emergency nurses, many of whom have years of experience, will rightly start with level 2 competencies. However, many of the level 1 competencies are duplicated in level 2 as they are relevant to senior practitioners. Other competencies require progression from level 1 or are unique to level 2.
Those who wish to progress along the ‘advancing clinical practice’ part of the career development pathway, beyond level 2 competencies, should access the Royal College of Emergency Medicine/Health Education England curriculum for emergency care advanced clinical practitioners.
The competencies are assessed using Benner’s (1984) stages of clinical competence, the novice to expert continuum. This model is widely known and the definitions are easy to apply.
The competency tables in the framework begin with a self-assessment column to help practitioners identify their learning needs:
- Novice: ‘I have some awareness, but little knowledge or skill in this competency.’
- Advanced beginner: ‘I have basic knowledge or skill in this competency and need supervision.’
- Competent: ‘I have the knowledge and skills relevant for the competency and could complete without supervision.’
- Proficient: ‘I am experienced in the knowledge and skills relevant for the competency and could supervise or teach others.’
- Expert: ‘I am leading developments in this competency.’
Each competency has set minimum achievement criteria for successful completion.
For the framework to be implemented successfully, nurses should each be allocated a mentor or clinical supervisor. For foundation staff nurses this should be an emergency nurse who has completed level 1 at a minimum, and who has had training in the supervision and assessment of others. Supervisors for emergency nurses should have completed level 2 or beyond, and are likely to be emergency charge nurses or practice educators.
When emergency care settings start to use this framework there are unlikely to be sufficient nurses who have achieved level 1 and 2 competencies to supervise the development of foundation staff nurses and emergency nurses. Therefore, until all established nurses have completed the appropriate level, a pragmatic approach should be taken and senior nurses should be allowed to supervise others in line with their role.
Self-assessment helps to direct learning, supports development and provides a baseline for subsequent assessments. However, objective formal assessment of competence should be undertaken for quality assurance and should include individual feedback. Assessment should be based on objective evidence, but due to the diverse nature of the competencies no single type of evidence can meet all the statements. Therefore, a variety of methods should be used to demonstrate that practitioners have gained the relevant knowledge, skills and behaviours. Appropriate evidence may include, but is not be limited to:
- Direct observation of practice.
- Case-based discussion.
- Reflective report.
- Question and answer.
- Anonymised clinical case notes.
- Feedback from colleagues and/or patients.
- Nationally recognised courses.
Regular reviews are essential to identify and resolve any difficulties in achieving or maintaining competence and to support nurses to reach their potential without being restricted by traditional time-bound progression limits. It would be overwhelming for anyone to try to address all the competencies simultaneously, so realistic developmental goals should be set at each one-to-one meeting with a mentor or clinical supervisor, and should be regularly reviewed.
In year two, meetings could be held at six-month intervals, with yearly appraisals and development planning thereafter. There should be agreement at each meeting about which competencies have been achieved or maintained and which need to be gained before the next meeting.
Transferrable knowledge and skills
Some competencies may not be applicable to the environment where practitioners are working. For example, an adult-only ED may not require nurses to gain the competencies pertinent to the care of children, therefore ‘N/A’ should be marked against these. This will enable nurses to use the competency framework as a passport for moving between emergency care areas, and easily identify the competencies they have achieved and those that require development.
Alongside the development of emergency nursing over the past decade, there has been a plethora of new nursing titles. This is confusing for the public and other professionals, and creates uncertainty about roles, knowledge and skills when nurses transfer to another setting. The framework has defined the titles listed in the panel below to try to clarify nursing roles in emergency care settings. It is anticipated these will become widely adopted.
The clearly defined emergency nurse development pathway included in the framework enables nurses to identify where they are in their career journeys, consider future options and plan the steps required to achieve their aims. The framework outlines professional development pathways into management, education or clinical specialist roles.
Integrating the framework with practice
The RCN ECA curriculum and competency framework is huge, but so is the emergency nursing remit. It is arguably the only specialty where nurses require knowledge and skills in the recognition and treatment of life-threatening illnesses and injuries across the lifespan, in all biological systems.
Emergency nurses are responsible for identifying and responding to safeguarding concerns about patients of all ages, and patients’ dependents, and must be able to work across four fields of practice – adult, children, mental health and learning disability – despite most being registered in just one. Senior emergency nurses are required to manage care provision for multiple patients, and coordinate departmental resources to ensure maximum patient safety and efficiency. This framework acknowledges the breadth and depth of knowledge and skills required to be an emergency nurse.
Sadly, emergency nursing is facing unprecedented attrition rates and unfilled vacancies. Nurses often cite lack of development as a reason for leaving. The absence of a transparent career structure, as well as working conditions, could be deterring new recruits to the specialty. The adoption of this framework will help to reverse these trends. It should help ensure that nurses feel they have the necessary competencies to undertake their roles and have a career path to follow.
Effective implementation of the framework will require investment in the education strategies of emergency care settings. It will be more easily implemented in departments with established educational leads and where time is allocated for nurses’ development. When the framework is properly integrated into emergency care settings, recruitment, retention and morale are likely to flourish, alongside patient care.
Definition of emergency care nursing titles
Foundation staff nurse A registered nurse who is either newly qualified or new to emergency nursing and has not yet acquired the competencies of ‘emergency nurse’. These nurses require supervision in practice, ranging from direct supervision in their initial weeks to indirect supervision as they near accomplishment of emergency nurse. They should be working to complete level 1 competencies. Typically, they will be band 5.
Emergency nurse Registered nurses who have completed preceptorship and achieved the level 1 competencies. They can work with individual patients or groups of patients without direct supervision in emergency care settings. This includes initial assessment and treatment, but not diagnosis of patients. In EDs, this is likely to include working with patients in the resuscitation room, working with patients with major illness or injury, and with those with minor presentations. They should be working to complete level 2 competencies. Typically, they will be band 5 or 6.
Emergency charge nurse/sister Emergency nurses who have completed level 2 competencies, are clinical experts, and proactively develop themselves and others. They lead and supervise others’ clinical work and manage the emergency care setting as a whole, including patient flow and delegation of care. In EDs they should work in close partnership with the emergency medicine consultant to ensure safety of patients and best use of resources. They should focus on more in-depth leadership, and educational and/or research competencies, which are beyond the scope of this framework. Typically, they will be senior band 6 or 7.
Emergency nurse practitioner Registered nurses who have undertaken specific additional training to assess, diagnose and treat patients with minor injuries and/or illness. The role is subject to local variation in education and practice provision, therefore this framework does not provide the competencies required. Typically, they will be band 6 or 7.
Advanced clinical practitioner (ACP) Emergency nurses or other registered allied health professionals who have undergone master’s level education in examination, diagnosis and treatment of patients, and can provide clinical consultations for all patients who present to emergency care. They should be working to the Royal College of Emergency Medicine/Health Education England emergency care ACP competency standards. Typically, they will be band 8a or 8b.
Practice educator Emergency nurses who have completed level 2 competencies and who support and lead educational opportunities in emergency care settings. They provide supervision in practice, deliver training sessions and assess competencies. They often teach on nationally recognised courses, for example advanced life support. They should be working towards education-specific competencies and/or qualifications. Typically, they will be band 6 or 7, depending on the leadership responsibilities of the role.
Practice development lead Emergency nurses who have completed level 2 competencies, and who lead the education strategy for the emergency care setting. They provide supervision in practice and deliver some training sessions, while establishing training requirements to ensure the workforce skill mix is appropriate for the setting. They link the education strategy for the emergency care setting with the organisation’s overall strategy for education. They work closely with the lead nurse manager, the medical clinical director and other education providers, including higher education institutes. Typically, they will be band 7 or 8a.
Lead nurse manager Emergency nurses who have completed level 2 competencies, and who are responsible for the day-to-day operational management of the emergency care setting, including workforce management and implementing local policies and clinical guidelines. Typically, they will be band 7 or 8a.
Matron Emergency nurses who have completed level 2 competencies and who are responsible for quality assurance and quality improvement in the emergency care setting, including responding to patient feedback and ensuring clinical incidents are investigated and recommendations actioned. Typically, they will be band 8a.
Emergency nurse consultant Clinical experts in emergency nursing with responsibility for emergency care leadership, including strategic development of policy and practice, research, education and advanced clinical practice. Typically, they will be band 8b or 8c.
Find out more
- The RCN National Curriculum and Competency Framework for Emergency Nursing is available here.
- Two workshops are planned, in London on 24 November and Cardiff on 8 December, to explore how the framework can assist emergency nurses on their professional journeys. Information on the London workshop is available here and on the Cardiff workshop here.
- Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park CA.
- National Major Trauma Nursing Group (2016) Nursing and Allied Health Professionals Trauma Competencies in the Emergency Department. NMTNG, London.
About the author
Janet Youd is an emergency nurse consultant at Calderdale and Huddersfield NHS Foundation Trust, and chair of the RCN Emergency Care Association