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Career development: advanced clinical skills

Tony Mayled
Nurse Clinician

Lynn Swift
Nurse Clinician
St Helen's Walk in Centre

A minor illness and injuries course at St Helens Minor Injuries Unit/NHS Walk-In Centre enables students to gain appropriate theory as well as the practical aspects of advanced healthcare assessment

Advanced nursing practice is at the forefront of enhancing the profile and scope of professional practice for all nurses, midwives and health visitors. Advanced practice requires advanced education. The educational road for registration has been challenging and revolutionary, with an all-degree career pathway now being the accepted way forward to nurse registration.

While the debate about degree registration continues, so does the question of what equates to advanced nursing practice and the level of education required for advanced practitioners to have a recordable qualification. However, the thirst for knowledge in nursing is undeniable. Advanced nursing skills courses are interspersed throughout the country and range from modular to full-time degree programmes.

Given the changes in service delivery within community nursing, the present economic climate and the subsequent drive for cost-effective healthcare that is ingrained throughout today's healthcare service, the task of undertaking appropriate qualifications can be challenging for many nurses.

Within the town centre of St Helens in Merseyside lies a busy NHS walk-in centre, seeing 80,000 patients a year presenting with minor illness or injury-related concerns. The centre relies on nurses with a high level of expertise to ensure safe, effective practice is maintained. The majority of nurses have a wealth of experience within either A&E or primary care. To underpin this knowledge base, education has always been a priority within the centre to ensure high standards of care are delivered and that less experienced staff have their potential unleashed for staff development to occur.

Due to the passion and drive of staff within the walk-in centre, the thirst for knowledge that is so often recognised in nursing resonates across the department. This resonance has expanded across the local primary care trust (PCT) and further afield to adjacent primary and secondary care trusts developing minor injury and illness walk-in centres, urgent care centres, general practice and many healthcare arenas. The centre recognises that nursing does not have definitive boundaries and that with appropriate training these boundaries are always open to negotiation, ensuring best practice is undertaken.

Providers and commissioning bodies are often keen to evaluate the educational opportunities that are available locally to expand their nursing staff members' level of expertise. Regular enquiries to the walk-in centre in St Helens are received from other such centres being established, asking whether a training programme has been developed that nurses can access to obtain a higher knowledge base in managing minor illness and minor injury presentations. Many existing courses offered within the north-west of England focus on either illness or injury and a joint programme was not accessible locally which addressed their specific service needs.

Minor illness and injury skills cannot be taught in isolation, and the two areas are entwined. The patient presenting with a painful wrist after falling, or with rib pain after coughing, may have an underlying medical pathology that initiated the presentation, resulting in the patient seeking a healthcare professional's opinion. To recognise and manage effectively the complexities of nursing care at such an advanced level requires a holistic educational approach.

Therefore, there was a need for a course for staff that would not only encompasses injuries and illness, but also a programme of study that was fit for purpose for our trust in terms of releasing staff at a time when fiscal pressures have never been so intense.

Is it appropriate to be sending nurses on courses that only give the nurse some of the tools and not the complete toolbox to ensure safe practice? Is it appropriate to send the patient away with advice and analgesia for a sprained ankle, but not be competent to assess and manage the predisposing cause to the fall?

Two nurse clinicians within the walk-in centre in St Helens with many years' experience in their chosen field of expertise investigated the feasibility of developing a modular programme encompassing both minor illness and injury components. They recognised that the course should be delivered by a team that was clinically competent and all too aware of the practical aspects of working in a busy healthcare environment.
Geographically and practically, the walk-in centre in St Helens was the ideal venue to deliver the module, as the staff had not only the clinical expertise but also the practical facilities to deliver the programme.

In conjunction with the University of Chester, a module was developed and underpinned with academic validation within the university, culminating in a 30-credit, six-month, part-time course, fitting into the BSc Community Health Studies programme. The course is run within the walk-in centre, which is ideal for employers due to the central location and for students. Given the busy nature of the centre there is no shortage of practical supervised experience available.

The course focuses on developing students' skills in health assessment and their ability to make effective, evidence-based decisions in the clinical environment in the spheres of minor illness and injuries. The course culminates in objective clinical examination (OCE) assessments and a professional portfolio to provide competencies in clinical practice on completion.
The course is taught by experienced nurse clinicians who have a vast amount of experience in A&E, acute medicine and primary care nursing. The course philosophy is that it is not appropriate to teach someone a high standard of theory without practical experience. There is a strong emphasis on hands-on education in assessment, planning and managing the patient with minor illness and injuries, covering the main systems of the body and the pathophysiology relating to these systems.

The course is not only unique in the north-west of England in its style of delivery, but it is also open to any post-registered nurse working academically at degree-level standard who requires clinical assessment skills to work in a sphere of advanced nursing practice. This style of delivery has resulted in great interest from a wide range of nurses employed in nursing disciplines (see Box 1 for examples).

Box 1. Nurse disciplines
A&E departments
Out-of-hours/walk-in centres
Specialist practice
Practice nursing
District nursing
Health visiting

The course began in 2008 with a multidisciplinary nursing intake and has had two intakes per year since. Small cohorts of students are enrolled onto the part-time programme of study. The wide range of expertise made available to the students creates a dynamic, rich learning environment, with all students bringing a positive culture to the classroom setting.
As the programme of study is based in a clinical setting there are always practical case studies brought in by the students as well as the educators, and given the wide range of nursing backgrounds it generates a wide parameter of discussion.

The course is made up of approximately 50% injuries and illness educational input, and requires student mentorship within their own clinical setting by either an experienced nurse practitioner, GP or senior doctor to ensure clinical objectives. Students complete an OCE assessment and a portfolio of evidence to complete the course successfully.

The course remains extremely popular with students, mentors, GPs and employers as it provides learning opportunities for students to gain what they require in their chosen field of work and provides a firm foundation for working at an advanced level of practice. The student evaluation remains encouraging and the course is currently in its third year.

It is envisaged that, while the main format of the course will remain unchanged, the potential for rolling it out to the wider multidisciplinary healthcare team is an option if their job specification requires minor illness and injury assessments at an advanced level.