Cardiac Nursing - Acute/Episodic Care Career Pathway

Competency Statements

Cardiac Nursing Competency Statements January 2004

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1 Foreword by Professor David Thompson

In an era of the so-called ‘knowledge economy’, the concept of ‘lifelong learning’ and the belief that ‘education matters’, there is a need to ensure that skills (be they basic, core or key) as well as knowledge are developed. Indeed, Skills for Health, a government-backed body which has the support of the four UK health departments, the independent health sector, voluntary sector and staff organisations, has as its key aim the development of skills for all those people employed by the NHS or in the independent health sector.

One of the key building blocks for Skills for Health is the use of ‘competency frameworks’. These frameworks identify the skills, experience and training which will help ensure consistency and quality across healthcare in the UK. The frameworks comprise a set of statements identifying what people or teams need to know and be able to do to deliver that service. These Cardiac Nursing – Acute/Episodic Care Career Pathway: Competency Statements, developed by the British Association for Nursing in Cardiac Care (BANCC) in collaboration with the Royal Brompton and Harefield NHS Trust and Thames Valley University, are an important contribution to nursing and work in conjunction with the Skills for Health competency framework being developed for prevention, heart failure and rehabilitation in coronary heart disease.

Well-defined competencies from entry to practice through to advanced practice are needed in nursing, and they need to be refined to ensure greater accountability to patients and clients and their families and carers, within the profession, in relation to other health professionals, and with regard to the various contexts of practice.

These Cardiac Nursing – Acute/Episodic Care Career Pathway: Competency Statements should certainly fulfil their purpose of guiding the career development of nurses across acute cardiac care settings. They should also help produce cardiac nurses who are ‘fit for purpose’, in that they are knowledgeable, clinically competent, thoughtful, critical and articulate.

Professor David R Thompson BSc MA PhD MBA RN FRCN FESC

January 2004

Cardiac Nursing Competency Statements 2 January 2004

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3 Contents

Introduction...... 6

Explanation of Competency Statements...... 7 Definition of competence ...... 7 Scope of the competency topics...... 7 Competency sections ...... 7 Competency development stages ...... 8 Assessment of competence...... 8 Evidence utilised...... 8 Peer review/assessors...... 9 Maintenance of competence...... 9 Example of use of the cardiac nursing competency pathway ...... 9 Acknowledgements...... 9 References ...... 11

Record of Peer reviewers/Assessors...... 12

Example of use of the cardiac nursing competency document...... 13

Competency sections ...... 15 Core Professional Competencies ...... 15 Respecting and promoting individuality ...... 15 Communication – patients ...... 17 Communication - multidisciplinary team ...... 19 Education - patients ...... 21 Education – staff...... 23 Leadership...... 25 Managing resources ...... 27 Standards and protocols...... 29 Research ...... 31 Core Clinical Competencies ...... 33 Haemodynamic monitoring ...... 33 ECG monitoring and interpretation ...... 35 Arterial oxygenation management ...... 37 Delivery of oxygen therapy – non-invasive ...... 39 Auscultation of heart sounds...... 41 Auscultation of breath sounds...... 43 Blood sampling and cannulation...... 45 Blood sample analysis ...... 47 Chest x-ray interpretation...... 49 Underwater seal chest drains ...... 51 Wound healing...... 53 Assessment of cardiac chest pain ...... 55 Specialised Clinical Competencies...... 57 Delivery of oxygen therapy – supportive...... 57 Resuscitation/ life support...... 59 Femoral arterial sheath removal ...... 61 Cardiac pacing – temporary...... 63 Cardiac pacing – permanent...... 65

Cardiac Nursing Competency Statements 4 January 2004

Intra-aortic counterpulsation ...... 67 Elective cardioversion...... 69 Thrombolysis – nurse-initiated...... 71 Exercise tolerance testing...... 73 Tilt-table testing ...... 75

Appendix 1...... 78

Feedback / comments on Cardiac Nursing – Acute/Episodic Care Competency Statements ...... 80

5 Introduction

The evolution of this career pathway has arisen from the desire to improve patient outcome through assuring a high quality cardiac nursing service delivery. The pathway, as illustrated in Figure 1, suggests that a balance between education, training and practice can be achieved in a way that will advance career progression. Driven by current professional, political and societal forces, this is in keeping with the current strategic intentions for nursing outlined by the Department of Health in the paper “Making a Difference” (Department of Health, 1999) and the Chief Nursing Officer’s key roles for nurses (The Stationery Office, 2001).

Figure 1. Career development pathway of the cardiac nurse

Advanced clinical development Higher degree/ Masters/PhD

Intermediate clinical development Specialist study/post-graduate diploma

Immediate post-registration clinical development Initial diploma/degree

Pre-registration clinical development Preparation for initial diploma/degree

Cardiac nursing takes place within various spheres of health care: primary, secondary and tertiary care. Within these, cardiac nursing expertise tends to fall into four domains: health promotion, cardiac prevention and rehabilitation, acute/chronic and episodic care, and palliative care (Riley, Bullock, West & Shuldham, 2003). The focus of this document is to present cardiac nursing competency statements for acute/episodic care that utilises the pathway described above. Appropriate settings for the use of these competencies may include cardiac surgical and medical wards, cardiac catheter laboratories, cardiac critical care units, coronary care units, rapid access chest pain clinics, and echocardiography, although this list is not exhaustive.

These competencies may be utilised: • For planning career development; • For determining areas needed for further training/study/experience; • In the Individual Performance Review/appraisal process; • As assurance of professional integrity; • To ensure public safety.

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Explanation of Competency Statements

Definition of competence

Competence is defined as the possession of “knowledge, skills and abilities required for lawful, safe and effective professional practice without direct supervision” (Nursing and Midwifery Council, 2002).

However, competence is more than possessing the knowledge or psychomotor skills necessary to perform a specific task – competence means the caregiver can integrate knowledge, skills, and personal attributes consistently in daily practice to meet established standards of performance (Fey, 2000).

Scope of the competency topics

These competency statements are specifically related to the delivery of acute/episodic cardiac nursing care, and as such do not include those generic acute care nursing competency statements already in place e.g. intravenous drug administration. They work in conjunction with the ‘Skills for Health’ competency framework currently being developed for prevention, heart failure and rehabilitation in Coronary Heart Disease.

The topics are designed to encompass the various skills and knowledge that nurses will require in the delivery of acute/episodic cardiac nursing care. However, not all topics are relevant to all areas of practice e.g. underwater seal chest drains are rare in coronary care units. It is anticipated that each clinical area will select the appropriate competency topics relevant to the development of staff for practice within that area. This will be under the guidance of the area manager.

Competency sections

The competency topics have been grouped into three sections.

The core professional competencies are comprised of skills and knowledge that are generic to all areas of nursing. They are hence imperative to all aspects of cardiac nursing and should be developed in parallel with the nurse’s development of specialised cardiac clinical practice. These are relevant to all clinical areas.

The core clinical competencies contain skills and knowledge that primarily have a practical clinical focus. They include the fundamental cardiac nursing skills likely to be encountered in most areas of the delivery of acute/episodic cardiac nursing care. They provide grounding skills that will enable the nurse to further specialise within acute/episodic cardiac nursing.

The specialised clinical competencies have been identified as the skills and knowledge required for specific areas of acute/episodic cardiac nursing. These skills all require competence in many, yet not all, of the general skills as prerequisite for delivering care, and hence have a focus on the management and integration of skills and knowledge. For example, exercise tolerance testing requires competence in ECG monitoring and interpretation, haemodynamic monitoring, auscultation of heart sounds, blood sampling and cannulation, and resuscitation/ life support.

Competency development stages

Throughout the cardiac nurse’s career, skills and knowledge are continually developed. It follows that the depth of understanding and practice then differs between a newly qualified cardiac nurse and an experienced specialist cardiac nurse.

Using this competency pathway, career development can be mapped. Both clinical and academic development progress together. It is inherent that subsequent achievement of competence is reliant upon competence at the preceding stage. In other words, it is impossible to be competent at a higher level without first achieving competence at the lower levels.

The stages are differentiated and described as follows:

Clinical development Academic development 1 Pre-registration development Preparation for initial diploma/degree

2 Immediate post-registration Initial diploma/degree development 3 Intermediate development Specialist study/post-graduate diploma 4 Advanced development Higher degree/Masters/PhD

Each competency topic contains competency statements appropriate to these stages of development.

Assessment of competence

Evidence utilised The evidence required for initial achievement and maintenance of competence will vary according to the Competency Statement for skill and knowledge, and stage of clinical and academic development. Specific performance criteria will be determined at local level, and will be reliant upon the resources available. A summary of the evidence utilised for determining competence may be written into the competency document. One recommendation for the presentation of extensive or printed evidence is within the nurse’s Personal Professional Portfolio, with reference to specific location documented as appropriate in the Competency Statements document.

Evidence from the workplace may include: • Observed practice assessment • Publications/reports/protocols • Explanation of rationale • Participation in local/national • Care plans initiatives • Witness statements • Participation in special interest • Completion of self-directed worksheet groups/projects • Workshops • Contribution to professional • Completion of relevant recognised organisation awards • Attendance at national/international • Patient feedback cardiac conferences

Cardiac Nursing Competency Statements 8 January 2004

• Reflective practice diaries • Contribution at national/international • Specialised training conferences • Audit data

Peer review/assessors Assessors of competence are those professionals who themselves have achieved competence relevant to the skill/knowledge at appropriate level. They should have adequate expertise and training relevant to the level of competence under assessment. For example, this may be a clinical facilitator, the nurse’s assigned mentor, or their manager. Assessment is ongoing with the nurse’s continual professional development. Appropriate planning and review may take place within the individual performance review/appraisal process.

Maintenance of competence In much the same way as evidence will be provided for attainment of competence, so too there must be provision for ongoing maintenance of competence. This may include continuing performance of skill at required level. For example, ECG interpretation in nurse-led thrombolysis.

Example of use of the cardiac nursing competency pathway

To construct a wall, bricks are laid upon another, and so the wall grows. So too, does the career of a cardiac nurse. Competence is achieved in a range of topics, at progressive stages of development, and a wall of competence as a cardiac nurse appears. The career development of the nurse to work in the specialised area of a Rapid Access Chest Pain Clinic is diagrammatically represented in Figure 1. The highlighted bricks utilise exercise tolerance testing as an example in which competence in the professional skills and knowledge form the foundation, and the general skills and knowledge form the prerequisite components, in the development of the specialist nurse to perform in this area.

Acknowledgements

This project developed subsequent to work undertaken at the Royal Brompton and Harefield NHS Trust and Thames Valley University. The competencies have been developed jointly by the British Association for Nursing in Cardiac Care (BANCC), the Royal Brompton and Harefield NHS Trust, and Thames Valley University, and with funding provided by the West London NHS Workforce Development Confederation.

The project steering group, experts who contributed to parts of the document, and others who reviewed the document are listed in Appendix 1.

Figure 1. Competencies for Cardiac Nursing Career Pathway

(Highlighted bricks show the selection of competency topics required to practice in a Rapid Access Chest Pain Clinic.)

Exercise Cardiac stress Tilt testing Echo- Thrombolysis - Elective Comp

S tolerance testing testing cardiography nurse-initiated cardioversion p Clin e c e i a t ical e l i n s Resuscitation/ Cardiac pacing - Cardiac pacing - Femoral arterial Intra-aortic Oxygen therapy - c ed i

e Life Support permanent temporary sheath removal counterpulsation supportive s

Assessment of Auscultation of Auscultation of Chest x-ray C Blood sample Blood sampling C o

o analysis and cannulation cardiac heart sounds breath sounds interpretation m r e p chestpain

e C t e l i n n i c

c ECG monitoring Arterial Haemodynamic Oxygen therapy - Underwater seal Wound healing i a e l s & interpretation oxygenation monitoring non-invasive drains

management

C Managing Standards & Research Leadership Professio o resources protocols m p C e o t r e e n

c n Respecting and Education – Education - Communication - Communication - i a e l s promoting patients colleagues patients colleagues individuality 10 Cardiac Nursing Competency Statements January 2004

References

Department of Health (1999) Making a difference. London: Department of Health. www.doh.gov.uk/nurstrat.htm

Fey, M. & Miltner, R. (2000) A competency-based orientation program for new graduate nurses. Journal of Nursing Administration, 30(3), pp 126-132.

Nursing & Midwifery Council (2002) Code of Professional Conduct. London: NMC. www.nmc-uk.org/cms/content/Publications/Code%20of%20professional%20conduct. pdf

Riley, J.P., Bullock, I., West, S. & Shuldham, C. (2003) Practical application of educational rhetoric: a pathway to expert cardiac nurse practice? European Journal of Cardiovascular Nursing, 2:283-290.

The Stationery Office (2000) The NHS Plan. London: Her Majesty’s Stationery Office http://www.nhs.uk/nationalplan/nhsplan.pdf

Record of Peer reviewers/Assessors

Date Name (print) Signature Designation Relationship to Assessee (e.g. Organisation Manager, mentor)

Feb E.g. Sarah Jones S.J. RGN Mentor – Clinical placement Cardiology ward, XX Hospital 2000 Mar E.g. Mary Brown M.B. RGN Mentor Cardiothoracic ward, YY 2001 Hospital

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Example of use of the cardiac nursing competency document

ECG monitoring and interpretation

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Performed independent and SJ Performed ECG recording at least MB Demonstrates the ability to correctly prepare patient, accurate patient and equipment 5/3/1998 once/week. 23/4/1999 equipment and environment for recording of ECG e.g. preparation (observed 5 times) 12-lead, telemetry, hard-wire monitoring.

Knowledge: Attended teaching session on ECG. SJ Read article on ECG recording and MB Describes cardiac surface anatomy for correct Accurately explained electrode 28/2/1998 completed reflective practice (see 23/3/1999 electrode placement and methods for placement, skin preparation and SJ PPP pg 4) minimising/eliminating abnormalities in recording. patient positioning. 6/3/1998

2.1 Skill: Correctly identified rhythms of MB Responded appropriately when MB Demonstrates the ability to distinguish normal from patient in allocation. 18/4/1999 patient haemodynamically 6/3/2000 abnormal ECG trace and refer to another member of compromised with AF. the multidisciplinary team e.g. rhythm strips.

Knowledge: Attended ward teaching session on MB Describes basic cardiac anatomy, the conduction ECG interpretation. 8/2/1999 system and the normal PQRST complex. Completed self directed package on MB Recognises basic cardiac arrhythmias. ECG rhythm interpretation. 22/2/1999 Correctly identified rhythms on MB rhythm identification test. 7/4/1999 13

3.1 Skill: Correctly analysed ECG for MB Identified new MI from ECG of MB Demonstrates the ability to analyse the ECG and patients in allocation. 6/6/2000 patient experiencing chest pain. 12/12/2001 respond appropriately e.g. 12-lead ECG, rhythm strip.

Knowledge: Completed ECG interpretation MB Completed Cardio-respiratory MB Examines the ECG, recognising abnormalities and course and exam (over 8 weeks) 10/2/2000 course, Level 3. 9/7/2001 their potential causes e.g. ST changes.

3.2 Skill: Appropriate administration of MB Provides regular teaching sessions MB Demonstrates the ability to initiate treatment in atropine for vaso-vagal attack. 7/8/2001 for nursing management of 2002 response to ECG analysis e.g. pacing, atropine, refer arrhythmias. to cardiologist, refer to electrophysiologist, discharge home.

Knowledge: Successfully completed ALS course. MB 8/2003 Critically analyses the appropriateness of varying interventions on the ECG.

4.1 Skill: Contributed to protocol for the MB Demonstrates the ability to evaluate the impact of treatment of vaso-vagal attack. 11/2004 intervention on the ECG and suggests alternatives.

Knowledge: Published journal article on “Vaso- MB Evaluates the outcomes and implications of vagal attack – the role of the 10/2005 therapeutic interventions on the ECG. nurse”

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Competency sections

Core Professional Competencies

Respecting and promoting individuality

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to approach the patient and their family with dignity, and treat them as unique individuals.

Knowledge: Describes factors that underpin interpersonal relationships and the importance of the individual.

2.1 Skill: Demonstrates an awareness of influences on individual response to illness e.g. gender, culture, ethnicity, illness, pain.

Knowledge: Identifies factors which underpin professional nurse- patient/family relationships, recognising the implications of external factors e.g. response to crisis.

3.1 Skill: Demonstrates the ability to provide emotional support in times of crises e.g. diagnosis of disease, referral for surgery, bereavement.

Knowledge: Applies consistent understanding and knowledge of support mechanisms to individual patient situations.

4.1 Skill: Demonstrates the ability to develop therapeutic relationships with the patient and their family at all times.

Knowledge: Appreciates the importance of the individual, and evaluates all behaviours and responses when dealing with the patient and their family.

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Communication – patients

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to ask for and receive information.

Knowledge: Describes questioning styles and methods of communication e.g. open/closed questions and recognises own limitations.

2.1 Skill: Demonstrates the ability to give and receive information in response to direct cues and refer to another member of the multi-disciplinary team e.g. access interpreter service, specialist nursing and other services.

Knowledge: Identifies theories of communication, barriers to effective communication, appropriate situations and locations, and recognises scope of own knowledge base.

3.1 Skill: Demonstrates the ability to ask for and give information in response to both direct and indirect cues e.g. listening skills, selects appropriate methods of communication.

Knowledge: Applies appreciation of verbal and non-verbal cues and differing communication techniques in communication with patients e.g. body posture, positive feedback, maintaining client-centred focus.

4.1 Skill: Demonstrates the ability to provide guidance in response to direct and indirect cues and external factors at all times e.g. encourages informed personal decision-making.

Knowledge: Perceptive to the nuances of language e.g. written, body posture, verbal and the effect of external factors.

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Communication - multidisciplinary team

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to use communication equipment e.g. written, computer, telephone, fax.

Knowledge: States communication equipment available in local area.

2.1 Skill: Demonstrates the ability to clearly and accurately record all nursing interventions using local communication equipment e.g. written, computerised. Demonstrates a developing ability to communicate with other members of the multidisciplinary team.

Knowledge: Identifies local proforma to document care, and understands the professional and legal requirements for accurate record-keeping e.g. confidentiality, Data Protection Act. Comprehends and recognises own limitations in communication e.g. gaps in knowledge. Differentiates roles and responsibilities of the multidisciplinary team.

3.1 Skill: Demonstrates the ability to communicate clearly and effectively with other members of the multidisciplinary team, in varying situations e.g. ward rounds, emergency situations, case conferences, presentation at study days.

Knowledge: Applies appreciation of verbal and non-verbal cues (e.g. body posture) and professional issues affecting communication techniques.

4.1 Skill: Demonstrates the ability to use a wide range of communication skills (e.g. professional presentations, writing for publication) with organisational structures (e.g. committees, national/international bodies, professional associations).

Knowledge: Perceptive to the nuances of language (e.g. written, body posture, verbal) and the effects of external factors (e.g. interprofessional working)

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Education - patients

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to recognise that the patient and their carers have educational needs.

Knowledge: Describes why the patient and their carers have learning needs in context of current situation e.g. hospitalisation, limited knowledge of cardiac problems.

2.1 Skill: Demonstrates the ability to recognise own limitations in cardiac patient education, and refer to another member of the multidisciplinary team.

Knowledge: Explains common cardiac patient and family learning needs related to acute/episodic cardiac problems, and identifies appropriate sources of information.

2.2 Skill: Demonstrates the ability to participate in cardiac patient education and training e.g. with delivery of care, formal sessions.

Knowledge: Identifies learning opportunities for cardiac patients.

3.1 Skill: Demonstrates the ability to identify patient learning needs and initiate cardiac patient and carer education.

Knowledge: Interprets patient learning needs and the need to modify delivery methods to suit the individual.

3.2 Skill: Demonstrates the ability to contribute to and apply appropriate educational materials for cardiac patient/carer education.

Knowledge: Differentiates and applies principles of adult education and behaviour change, theories of learning and educational materials appropriate for cardiac patients/carers e.g. retention of information, reinforcement of knowledge and skills.

4.1 Skill: Demonstrates the ability to develop, utilise and evaluate innovative and relevant cardiac patient/carer educational strategies and materials e.g. leaflets, posters, videos, role modelling, interactive IT

Knowledge: Evaluates and researches the outcomes of educational strategies and implications of external factors on education of cardiac patients/carers e.g. rapid changes in healthcare, governmental policy.

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Education – staff

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to recognise own learning needs against specific outcomes.

Knowledge: Describes own learning needs in context of defined curriculum guidelines.

2.1 Skill: Demonstrates the ability to recognise learning needs in others, limitations of self, and teach staff.

Knowledge: Identifies appropriate educational materials for cardiac nursing e.g. environment, resources, knowledge of subject.

3.1 Skill: Demonstrates the ability to contribute to and apply appropriate educational materials for cardiac nursing.

Knowledge: Differentiates and applies theories of learning and educational materials appropriate for cardiac nursing.

4.1 Skill: Demonstrates the ability to develop, utilise and evaluate innovative and relevant educational materials for cardiac nursing, and utilise in teaching junior staff across healthcare disciplines.

Knowledge: Evaluates the outcomes and implications of external factors to education in cardiac nursing e.g. multidisciplinary nature of healthcare, governmental policy.

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Leadership

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to take the lead for allocated tasks.

Knowledge: Describes the contribution of effective leadership to their immediate scope of practice/work area.

2.1 Skill: Demonstrates the ability to lead a team on a short-term basis to achieve clearly defined local goals.

Knowledge: Recognises leadership skills and their impact on patient, team and local work area.

3.1 Skill: Demonstrates the ability to lead a team to determine local goals in conjunction with achieving external goals.

Knowledge: Critically analyses and applies a range of leadership skills, delegation/collaboration, principles of leadership theory, and methods for managing change.

4.1 Skill: Demonstrates the ability to act as a professional leader within cardiac nursing, the organisation and across the wider healthcare setting.

Knowledge: Evaluates the outcomes and implications of leadership on the strategic direction of cardiac nursing.

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Managing resources

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to participate at local level in identifying resource needs.

Knowledge: Recognises the impact that the ineffectual use of resources can have on service delivery.

2.1 Skill: Demonstrates the ability to assist in the planning of individual components of workload/caseload for local environment.

Knowledge: Identifies basic principles of resource management.

3.1 Skill: Demonstrates the ability to take responsibility and accountability for a defined caseload.

Knowledge: Applies an understanding of the business planning process.

4.1 Skill: Demonstrates the ability to evaluate available resources to enhance service delivery to practice within the clinical governance framework e.g. assure and improve quality of care, individual and organisational objectives/accountability.

Knowledge: Evaluates and produces effective plans for the management of resources.

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Standards and protocols

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to use protocols and standards in clinical practice.

Knowledge: Defines standards and protocols for cardiac nursing practice.

2.1 Skill: Demonstrates the ability to implement standards and protocols in relevant cardiac nursing situations.

Knowledge: Identifies factors that impact on the implementation of standards and protocols in cardiac nursing practice.

3.1 Skill: Demonstrates the ability to critically analyse standards and protocols relevant to cardiac nursing practice and contribute to multi-disciplinary development.

Knowledge: Applies standards and protocols relevant to cardiac nursing practice, recognising areas for development and change.

4.1 Skill: Demonstrates the ability to take the lead in devising and writing protocols and standards relevant to cardiac nursing, in response to external factors e.g. against National targets, patient group directions, current research.

Knowledge: Evaluates outcomes and implications of standards and protocols with consideration of external factors.

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Research

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to read research reports.

Knowledge: Identifies the research paradigm e.g. quantitative, qualitative.

2.1 Skill: Demonstrates the ability to implement findings of research studies relevant to cardiac nursing practice.

Knowledge: Recognises the rationale for research in changing nursing practice.

3.1 Skill: Demonstrates the ability to critically analyse existing research, identify areas of practice that could lead to primary research opportunities, and co-ordinate research studies relevant to cardiac nursing practice.

Knowledge: Discusses the implications of appropriate research for clinical practice e.g. appropriate methodologies.

4.1 Skill: Demonstrates the ability to supervise, collaborate, seek funding for, generate original research, and disseminate findings in accordance with approved/recognised standards. Demonstrates the ability to disseminate and support implementation of findings.

Knowledge: Devises and conducts appropriate research studies, including decisions regarding sources of funding, ethical approval, and alternatives in the construction, implementation and evaluation processes.

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Core Clinical Competencies

Haemodynamic monitoring

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to correctly prepare patient and equipment, and monitor and report reading from non-invasive haemodynamic monitoring. e.g. NIBP.

Knowledge: Describes the equipment required, anatomical locations for measurement, and normal ranges of pulse and arterial blood pressure.

2.1 Skill: Demonstrates the ability to analyse and intepret readings from non-invasive haemodynamic monitoring.

Knowledge: Recognises and describes the reasons for abnormal readings and potential causes e.g. changes in patient's condition, incorrect cuff placement, troubleshooting.

2.2 Skill: Demonstrates the ability to correctly prepare patient and equipment, and monitor and interpret waveforms from invasive haemodynamic monitoring e.g. CVP, arterial, PA, RA, PAWP, LA.

Knowledge: Describes the equipment and safety considerations required for measurement of invasive haemodynamic monitoring, and the normal waveforms and value ranges produced by invasive intracardiac pressures e.g. CVP, arterial, PA, RA, PAWP, LA.

2.3 Skill: Demonstrates the ability to analyse readings from invasive haemodynamic monitoring.

Knowledge: Recognises and describes the reasons for abnormal traces/readings and potential causes e.g. changes in patient's condition, troubleshooting.

3.1 Skill: Demonstrates the ability to utilise interventions which affect haemodynamic parameters in response to patient requirements according to protocols e.g. inotrope titration, antihypertensives.

Knowledge: Analyses impact of interventions on haemodynamic parameters e.g. titration of inotropic support.

3.2 Skill: Critically analyses the impact of interventions against similar alternatives e.g. inotropes, fluid replacement.

Knowledge: Critically analyses the differences in interventions and their applicability to varying situations.

4.1 Skill: Demonstrates the ability to critically analyse waveform patterns from haemodynamic monitoring in order to identify underlying pathology e.g. c waves.

Knowledge: Evaluates waveform patterns and pathological and physiological causes of waveform alterations, and identifies implications for haemodynamic monitoring e.g. c waves.

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ECG monitoring and interpretation

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to correctly prepare patient, equipment and environment for recording of ECG e.g. 12-lead, telemetry, hard-wire monitoring.

Knowledge: Describes cardiac surface anatomy for correct electrode placement and methods for minimising/eliminating abnormalities in recording.

2.1 Skill: Demonstrates the ability to distinguish normal from abnormal ECG trace and refer to another member of the multidisciplinary team.

Knowledge: Describes basic cardiac anatomy, the conduction system and the normal PQRST complex. Recognises basic cardiac arrhythmias.

3.1 Skill: Demonstrates the ability to analyse the ECG and respond appropriately.

Knowledge: Examines the ECG, recognising abnormalities and their potential causes e.g. ST changes.

3.2 Skill: Demonstrates the ability to initiate treatment in response to ECG analysis e.g. pacing, atropine, refer to cardiologist, refer to electrophysiologist, discharge home.

Knowledge: Critically analyses the appropriateness of varying interventions on the ECG.

4.1 Skill: Demonstrates the ability to evaluate the impact of interventions on the ECG and suggest alternatives.

Knowledge: Evaluates the outcomes and implications of therapeutic interventions on the ECG.

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Arterial oxygenation management

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates ability to perform and interpret oxygen saturation monitoring.

Knowledge: States normal oxygen saturation range and recognise variations.

2.1 Skill: Demonstrates ability to interpret arterial blood gas and refer to another member of the multi-disciplinary team.

Knowledge: States normal arterial blood gas ranges and recognises variations.

2.2 Skill: Demonstrates the ability to analyse findings of arterial blood gas, determine cause of changes and refer to another member of the multi-disciplinary team.

Knowledge: Examines arterial blood gas results and differentiates respiratory/metabolic causes.

3.1 Skill: Demonstrates the ability to use guidelines/algorithms to initiate treatment in response to findings of arterial blood gas analysis e.g. extubation.

Knowledge: Identifies different methods of treating abnormalities in arterial blood gas results.

3.2 Skill: Demonstrates the ability to evaluate the impact of interventions on arterial blood gas results and consider alternative interventions.

Knowledge: Critically analyses varying interventions and their impact on arterial blood gas results.

4.1 Skill: Develops protocols/guidelines/algorithms for the management of arterial oxygenation in a variety of clinical situations.

Knowledge: Evaluates the outcomes and implications of the management of arterial oxygenation for clinical practice.

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Delivery of oxygen therapy – non-invasive

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to correctly prepare patient and equipment for non-invasive oxygen therapy e.g. nasal speculae, face mask.

Knowledge: Describes the advantages and disadvantages of different types of non-invasive oxygen equipment, their appropriate placement, and safety considerations.

Pre-requisite competence: Arterial oxygenation Level 1.1 YES/NO

2.1 Skill: Demonstrates the ability to recognise patient need for the administration of oxygen therapy e.g. shortness of breath, decreased oxygen saturation, cardiac chest pain.

Knowledge: Identifies factors in the patient’s clinical presentation that will be affected by the administration of oxygen therapy e.g. arterial oxygenation, respiratory rate.

2.2 Skill: Demonstrates the ability to analyse patient response to non-invasive oxygen therapy.

Knowledge: Applies understanding of the physiological response to oxygen delivery.

3.1 Skill: Demonstrates the ability to initiate changes to oxygen therapy in response to patient condition, utilising patient group directions and protocols.

Knowledge: Relates changes in non-invasive oxygen therapy to expected patient responses e.g. flow rates, humidification, delivery system.

3.2 Skill: Demonstrates the ability to evaluate the impact of non- invasive oxygen therapy on the patient’s condition.

Knowledge: Critically analyses the effect of changes in non- invasive oxygen therapy to the patient.

40 Cardiac Nursing Competency Statements January 2004

Auscultation of heart sounds

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to position stethoscope in appropriate location for auscultation of heart sounds.

Knowledge: Describes cardiac anatomy and cardiac surface anatomy for auscultation of heart sounds.

2.1 Skill: Demonstrates the ability to recognise normal heart sounds.

Knowledge: Explains physiology of normal heart sounds.

3.1 Skill: Demonstrates the ability to detect abnormal heart sounds and refer to another member of the multidisciplinary team

Knowledge: Explains causes for abnormal heart sounds.

3.2 Skill: Demonstrates the ability to recognise different types of abnormal heart sounds e.g. murmurs, rubs, clicks, snaps.

Knowledge: Applies understanding of abnormal cardiac function to differentiate types and causes of abnormal heart sounds.

4.1 Skill: Evaluates the significance of abnormal heart sounds with patient’s clinical condition, and initiates appropriate referrals e.g. echocardiography.

Knowledge: Synthesises understanding of abnormal heart sounds with the clinical symptoms of the patient and rationale for further investigation.

42 Cardiac Nursing Competency Statements January 2004

Auscultation of breath sounds

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to position stethoscope in appropriate location for auscultation of breath sounds.

Knowledge: Describes respiratory anatomy and respiratory surface anatomy.

2.1 Skill: Demonstrates the ability to recognise normal breath sounds.

Knowledge: Explains causes of normal breath sounds.

2.2 Skill: Demonstrates the ability to detect abnormal breath sounds, and refer to another member of the multidisciplinary team.

Knowledge: Explains causes of abnormal breath sounds.

3.1 Skill: Demonstrates the ability to differentiate types of abnormal breath sounds e.g. wheeze, crackles.

Knowledge: Applies understanding of abnormal respiratory function to differentiate types and causes of abnormal breath sounds.

3.2 Skill: Demonstrates the ability to evaluate the significance of abnormal breath sounds with patient’s clinical condition, and plan/change treatment in accordance with protocols/patient group directions e.g. refer for chest x-ray, changing medications.

Knowledge: Synthesises understanding of abnormal breath sounds with the clinical presentation of the patient and rationale for appropriate referral/further investigation/changes in management regimen.

44 Cardiac Nursing Competency Statements January 2004

Blood sampling and cannulation

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to identify surface anatomy relevant to the circulatory system e.g. location of appropriate arteries/veins.

Knowledge: Describes the anatomy of the circulatory system.

2.1 Skill: Demonstrates the ability to collect blood for sampling from pre-existing access in accordance with protocol e.g. arterial line, central venous line.

Knowledge: Describes access routes appropriate for collection of blood samples.

3.1 Skill: Demonstrates the ability to collect blood for sampling in accordance with protocol e.g. venepuncture, arterial stab, venous cannulation

Knowledge: Assimilates knowledge of blood sampling and cannulation techniques and safety considerations.

46 Cardiac Nursing Competency Statements January 2004

Blood sample analysis

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to interpret the blood sample results and refer to another member of the multidisciplinary team.

Knowledge: States the normal ranges and recognises abnormalities in blood sample results.

2.1 Skill: Demonstrates the ability to analyse the blood sample results and respond appropriately.

Knowledge: Identifies potential causes of abnormalities in blood sample results.

3.1 Skill: Demonstrates the ability to initiate blood sampling and treatment in response to patient’s clinical condition.

Knowledge: Applies knowledge of patient’s clinical condition in relation to results of blood sample analysis.

3.2 Skill: Demonstrates the ability to evaluate treatment in response to blood sample analysis.

Knowledge: Critically analyses the appropriateness of treatment. Discuss implications of abnormal blood sample results.

48 Cardiac Nursing Competency Statements January 2004

Chest x-ray interpretation

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 2.1 Skill: Demonstrates the ability to prepare patient for chest x- ray e.g. positioning, potential causes of interference, safety issues.

Knowledge: Describes thoracic surface anatomy for appropriate positioning, safety issues, and methods of minimising interference.

2.2 Skill: Demonstrates the ability to interpret the chest x-ray, and refer to another member of the multidisciplinary team.

Knowledge: Recognises basic thoracic anatomy on the normal chest x-ray.

3.1 Skill: Demonstrates the ability to analyse the chest x-ray and respond appropriately.

Knowledge: Examines the chest x-ray, recognising abnormalities and their potential cause e.g. atelectasis, positioning of endotracheal tube, chest drains.

3.2 Skill: Demonstrates the ability to initiate events in response to chest x-ray analysis e.g. order repeat chest x-ray, referral to physiotherapy, changes in mechanical ventilation, discharge home in accordance with protocols/patient group directions.

Knowledge: Critically analyses the appropriateness of varying interventions in response to chest x-ray analysis.

50 Cardiac Nursing Competency Statements January 2004

Underwater seal chest drains

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates ability to accurately record drainage and suction.

Knowledge: Describes types of drainage and units of suction.

2.1 Skill: Demonstrates the ability to interpret chest drainage/ air leak, recognise abnormal, and refer to another member of the multi-disciplinary team.

Knowledge: Describes thoracic anatomy and principles of chest drainage e.g. location of chest drains. Recognises abnormal volumes of drainage/air leak relevant to patient condition, and identifies units and range of suction.

2.2 Skill: Demonstrates ability to manage chest drains e.g. position patient, change bottles, wound care.

Knowledge: Analyses and applies understanding of need for intervention from drainage assessment e.g. full bottle.

3.1 Skill: Analyses findings and initiates appropriate treatment in response e.g. remove chest drains as per protocol, orders bleeding/clotting screen/chest xray as per protocol.

Knowledge: Assimilates knowledge of chest drain protocol in determining appropriate course of action.

52 Cardiac Nursing Competency Statements January 2004

Wound healing

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to perform simple clean dressings. Demonstrates the ability to perform simple aseptic wound dressings, recognises changes in wound condition and refer to another member of the multidisciplinary team e.g. tissue viability team.

Knowledge: Describes normal wound healing. Explains the principles of asepsis and describes the causes, signs and symptoms of wound infection.

2.1 Skill: Demonstrates the ability to perform complex aseptic wound management and assess risk factors for wound healing.

Knowledge: Identifies varying methods of wound management and risk factors to impaired healing e.g. co-morbidities, poor nutrition.

3.1 Skill: Demonstrates the ability to initiate changes in wound management in response to wound condition.

Knowledge: Applies and analyses varying methods of wound management in determining appropriate action.

3.2 Skill: Demonstrates the ability to evaluate the impact of wound management on wound healing.

Knowledge: Evaluates the outcomes and implications on wound healing of current guidelines and research.

54 Cardiac Nursing Competency Statements January 2004

Assessment of cardiac chest pain

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: reviewed: 1.1 Skill: Demonstrates the ability to identify the significance of chest pain and refer to another member of the multidisciplinary team. Knowledge: Lists the signs and symptoms of chest pain.

Pre-requisite Competence: Haemodynamic monitoring Level 2.1 YES/NO

2.1 Skill: Demonstrates the ability to recognise cardiac chest pain from patient verbal and non-verbal cues/ physiological effects and refer to another member of the multidisciplinary team.

Knowledge: Identifies physiological effects and descriptors of cardiac versus non-cardiac chest pain.

Pre-requisite Competence: Blood sample analysis Level 2.2 YES/NO ECG monitoring and interpretation Level 3.1 YES/NO

3.1 Skill: Demonstrates the ability to interpret cardiac pain from patient description/history, physiological effects and investigative results e.g. ECG, troponin levels.

Knowledge: Assimilates results from clinical investigations and patient’s clinical presentation e.g. ECG, troponin levels.

Pre-requisite Competence: Blood sample analysis Level 3.1 YES/NO Delivery of oxygen therapy - non-invasive Level 2.1 YES/NO

3.2 Skill: Demonstrates the ability to initiate therapeutic interventions for managing cardiac pain e.g. STEMI, non-STEMI, acute coronary syndrome.

Knowledge: Discusses the appropriateness of varying interventions on cardiac pain e.g. oxygen, nitrates, opioids, patient education, patient transfer, thrombolysis.

3.3 Skill: Demonstrates the ability to evaluate the effects of therapeutic interventions on cardiac pain e.g. decrease in pain, decrease in ischaemia, changes in ECG.

Knowledge: Critically analyses the effects of therapeutic interventions on patient condition and outcomes.

4.1 Skill: Demonstrates the ability to co-ordinate, evaluate and make recommendations for clinical practice involving the processes and management of cardiac chest pain e.g. audit, development of protocols/patient group directions.

Knowledge: Evaluates the outcomes and implications of therapeutic interventions on cardiac pain with respect to external factors e.g. local/governmental policy.

56 Cardiac Nursing Competency Statements January 2004

Specialised Clinical Competencies

Delivery of oxygen therapy – supportive

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: Pre-requisite competence: Delivery of oxygen therapy – non-invasive Level 2.1 YES/NO

2.1 Skill: Demonstrates the ability to correctly prepare the patient and equipment for supportive oxygen therapy e.g. CPAP, endotracheal intubation, tracheostomy.

Knowledge: Describes different types of supportive oxygen therapy, and the equipment necessary.

Pre-requisite competence: Arterial oxygenation Level 2.2 YES/NO Auscultation of breath sounds Level 2.2 YES/NO

2.2 Skill: Demonstrates the ability to recognise patient need for the administration of supportive oxygen therapy e.g. sedation, respiratory failure, worsening arterial blood gases.

Knowledge: Identifies factors in the patient’s clinical presentation that will be affected by the administration of supportive oxygen therapy e.g. arterial oxygenation, spontaneous respiration, safety concerns.

2.3 Skill: Demonstrates the ability to analyse patient response to supportive oxygen therapy.

Knowledge: Applies understanding of the physiological response to oxygen delivery.

Pre-requisite competence: Arterial oxygenation Level 3.1 YES/NO Auscultation of breath sounds Level 3.1 YES/NO

3.1 Skill: Demonstrates the ability to initiate changes to oxygen therapy in response to patient condition, utilising patient group directions and protocols e.g. weaning, extubation. Knowledge: Relates changes in supportive oxygen therapy to expected patient responses e.g. mechanical ventilation modes, pressure support/PEEP, spontaneous breathing. 3.2 Skill: Demonstrates the ability to evaluate the impact of supportive oxygen therapy on the patient’s condition.

Knowledge: Critically analyses the effect on patient condition of changes in supportive oxygen therapy.

4.1 Skill: Demonstrates the ability to develop protocols and guidelines for the delivery of supportive oxygen therapy e.g. weaning, extubation.

Knowledge: Identifies implications and makes recommendations for clinical practice regarding the delivery of supportive oxygen therapy e.g. in response to current research.

58 Cardiac Nursing Competency Statements January 2004

Resuscitation/ life support

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to perform Basic Life Support utilising the Resuscitation Council (UK) guidelines.

Knowledge: Describes the Resuscitation Council (UK) guidelines for Basic Life Support.

Prerequisite Competence: ECG monitoring and interpretation Level 2.1 YES/NO Haemodynamic monitoring Level 2.1 YES/NO Arterial oxygenation Level 1.1 YES/NO Delivery of oxygen therapy - non-invasive Level 2.2 YES/NO

2.1 Skill: Demonstrates the ability to perform Immediate Life Support utilising the Resuscitation Council (UK) guidelines.

Knowledge: Identifies resuscitation requirements, including mask ventilation, defibrillation and drug management, in accordance with Resuscitation Council (UK) guidelines. Recognises implications of ethical and legal issues of resuscitation e.g. not for resuscitation orders.

Prerequisite Competence: Arterial oxygenation Level 2.2 YES/NO Blood sample analysis Level 2.1 YES/NO Delivery of oxygen therapy - supportive Level 2.3 YES/NO

3.1 Skill: Demonstrates the ability to initiate and lead Immediate Life Support utilising Resuscitation Council (UK) guidelines.

Knowledge: Applies understanding of patient's condition in relation to Resuscitation Council (UK) guidelines, the identification of patients ‘at risk’ of deterioration/pre- arrest situations, and initial post-resuscitation care.

Prerequisite Competence: Haemodynamic monitoring Level 3.1 YES/NO Arterial oxygenation Level 3.1 YES/NO Blood sample analysis Level 3.2 YES/NO Blood sampling and cannulation Level 2.2 YES/NO

3.2 Skill: Demonstrates the ability to perform Advanced Life Support utilising Resuscitation Council (UK) guidelines.

Knowledge: Analyses patient's condition and applies appropriate measures in accordance with the Resuscitation Council (UK) guidelines.

4.1 Skill: Demonstrates the ability to evaluate the process and management of resuscitation/life support e.g. analyse audits, make recommendations for improved practice.

Knowledge: Evaluates the process of resuscitation/life support with respect to external factors e.g. local/National policy.

60 Cardiac Nursing Competency Statements January 2004

Femoral arterial sheath removal

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to perform environmental and patient preparation for femoral arterial sheath removal.

Knowledge: Identifies patient preparation and equipment required for femoral arterial sheath removal.

Pre-requisite Competence: Haemodynamic monitoring Level 2.1 YES/NO

ECG monitoring and interpretation Level 2.1 YES/NO

Blood sample analysis Level 2.1 YES/NO

2.1 Skill: Demonstrates the ability to utilise protocol for femoral arterial sheath removal, and refer appropriately to another member of the multi-disciplinary team.

Knowledge: Describes relevant anatomy of femoral region and physiology of haemostasis. Recognises deviations in patient condition from protocol for femoral arterial sheath removal e.g. potential for complications.

Pre-requisite Competence: Blood sample analysis Level 2.2 YES/NO

2.2 Skill: Demonstrates the ability to initiate and perform femoral arterial sheath removal in accordance with protocol.

Knowledge: Differentiates methods of achieving haemostasis after femoral arterial sheath removal and applies appropriately to situation e.g. digital pressure, mechanical compression device. Recognises safety considerations associated with femoral arterial sheath removal e.g. post-procedure management.

3.1 Skill: Demonstrates the ability to evaluate the effective management of femoral arterial sheath removal e.g. assessment of complications.

Knowledge: Evaluates the management of femoral arterial sheath removal including recognition of complications e.g. bruising, bleeding, vasovagal response.

4.1 Skill: Demonstrates the ability to develop protocols and guidelines for femoral arterial sheath removal e.g. auscultation for bruits.

Knowledge: Identifies implications and makes recommendations for clinical practice regarding nurse-led femoral arterial sheath removal e.g. early identification of femoral aneurysm.

62 Cardiac Nursing Competency Statements January 2004

Cardiac pacing – temporary

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: Prerequisite Competence: ECG monitoring and interpretation Level 1.1 YES/NO

1.1 Skill: Demonstrates safety when caring for patients requiring temporary pacing e.g. environment, infection.

Knowledge: Describes appropriate care considerations for patient safety e.g. environment, infection risks.

Prerequisite Competence: ECG monitoring and interpretation Level 2.1 YES/NO

Blood sample analysis Level 2.1 YES/NO

2.1 Skill: Demonstrates the ability to prepare patient e.g. check INR, and remove temporary pacing wires (e.g. epicardial, transvenous) as per area protocol.

Knowledge: Describes principles of temporary cardiac pacing e.g. location of wires. Describes the equipment and patient preparation required for safe removal of pacing wires e.g. INR check.

2.2 Skill: Demonstrates the ability to recognise a pacing spike on ECG trace.

Knowledge: Describes the pacing spike on an ECG.

2.3 Skill: Demonstrates the ability to commence temporary pacing.

Knowledge: Explains the rationale and theory of pacing.

Pre-requisite Competence: ECG monitoring and interpretation Level 3.1 YES/NO

3.1 Skill: Demonstrates the ability to routinely check sensitivity/ threshold, different modes of pacing.

Knowledge: Understands the concepts of threshold and sensitivity, and the need for regular assessment. Discuss the different modes of pacing e.g. DDD, VVI.

3.2 Skill: Demonstrates the ability to effectively troubleshoot temporary pacing problems e.g. wire fracture, battery failure and evaluates appropriateness of troubleshooting actions.

Knowledge: Analyses causes of problems, explains reason of chosen intervention, and critically analyses the impact of various troubleshooting interventions on identified problem.

64 Cardiac Nursing Competency Statements January 2004

Cardiac pacing – permanent

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: Prerequisite Competence: ECG monitoring and interpretation Level 1.1 YES/NO

1.1 Skill: Demonstrates safety when caring for patients requiring permanent pacing e.g. environment, infection.

Knowledge: Describes appropriate care considerations for patient safety e.g. environment, infection risks.

Prerequisite Competence: ECG monitoring and interpretation Level 2.1 YES/NO

2.1 Skill: Demonstrates the ability to give general patient information regarding pacing.

Knowledge: Describes the normal cardiac conduction system. Explains the rationale and physiology of pacing.

2.2 Skill: Demonstrates the ability to recognise a pacing spike on ECG trace.

Knowledge: Describes the pacing spike on an ECG and its cause.

2.3 Skill: Demonstrates the ability to recognise pacing failure (to capture/sense).

Knowledge: Discusses the different modes of pacing (e.g. DDD, VVI).

3.1 Skill: Demonstrates the ability to provide psychological care for the person requiring a permanent pacing system.

Knowledge: Applies knowledge of permanent pacing systems to choice of pacemaker and the impact on lifestyle.

3.2 Skill: Demonstrates the ability to perform pacing check in Outpatients Clinic.

Knowledge: Understands the concept of pacemaker complications e.g. threshold/ sensitivity, runaway pacemaker, and the need for regular assessment.

4.1 Skill: Demonstrates the ability to evaluate the appropriateness of actions and consider alternatives for management of patients with permanent pacing systems e.g. managing pacing clinics.

Knowledge: Critically analyses the impact of various actions on the management of patients with permanent pacing systems.

66 Cardiac Nursing Competency Statements January 2004

Intra-aortic counterpulsation

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: Pre-requisite competence: Haemodynamic monitoring Level 2.2 YES/NO

ECG monitoring and interpretation Level 2.1 YES/NO

2.1 Skill: Demonstrates the ability to interpret waveforms and record pressures from intra-aortic counterpulsation.

Knowledge: Describes the anatomy/ physiology related to intra- aortic counterpulsation.

2.2 Skill: Demonstrates the ability to recognise changes in patient’s clinical condition related to intra-aortic counterpulsation e.g. peripheral circulation, reduced urine output.

Knowledge: Recognises and describes safety issues and complications surrounding intra-aortic counterpulsation e.g. patient positioning, puncture site management.

Pre-requisite competence Haemodynamic monitoring Level 3.1 YES/NO

3.1 Skill: Demonstrates the ability to analyse waveforms from intra-aortic counterpulsation.

Knowledge: Recognise and describe the reasons for abnormal traces and their potential causes for intra-aortic counterpulsation.

3.2 Skill: Demonstrates the ability to critically analyse patient responses to intra-aortic counterpulsation and manipulate according to protocols e.g. timing. Demonstrates the ability to troubleshoot equipment problems.

Knowledge: Discusses impacts of various manipulations on patient response to intra-aortic counterpulsation e.g. timing, mechanical failure, gas leaks.

4.1 Skill: Demonstrates the ability to develop protocols and guidelines for the management of patients receiving intra-aortic counterpulsation.

Knowledge: Evaluates outcomes and implications of nursing management on intra-aortic counterpulsation.

68 Cardiac Nursing Competency Statements January 2004

Elective cardioversion

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: 1.1 Skill: Demonstrates the ability to prepare equipment and the environment for cardioversion.

Knowledge: Lists equipment necessary for elective cardioversion.

2.1 Skill: Demonstrates the ability to prepare patient for elective cardioversion e.g. explain the basic procedure to the patient.

Knowledge: Describes procedure of elective cardioversion with anatomy/physiology.

Pre-requisite Competence: ECG monitoring and interpretation Level 2.1 YES/NO

Blood sample analysis Level 2.1 YES/NO

2.2 Skill: Demonstrates the ability to interpret diagnostic tests prior to cardioversion according to protocol e.g. INR, potassium level.

Knowledge: Explains results/condition of patient necessary for elective cardioversion within stated protocols/guidelines e.g. therapeutic INR.

Pre-requisite Competence: ECG monitoring and interpretation Level 3.1 YES/NO

3.1 Skill: Demonstrates the ability to correctly position paddles and perform elective synchronised cardioversion.

Knowledge: Applies understanding of safety and complications surrounding elective cardioversion.

Pre-requisite Competence: Resuscitation/ life support Level 3.1 YES/NO

3.2 Skill: Demonstrates the ability to recognise those patients who may benefit from elective cardioversion and refers appropriately.

Knowledge: Critically analyses clinical indicators and patient group directions for elective cardioversion.

4.1 Skill: Demonstrates the ability to evaluate effective management of elective cardioversion e.g. managing cardioversion clinics, auditing of results/process.

Knowledge: Evaluates the process of elective cardioversion with respect to external factors e.g. local/governmental policy.

70 Cardiac Nursing Competency Statements January 2004

Thrombolysis – nurse-initiated

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: Pre-requisite Competence: Haemodynamic monitoring Level 2.1 YES/NO

ECG monitoring and interpretation Level 3.2 YES/NO

Blood sample analysis Level 3.1 YES/NO

3.1 Skill: Demonstrates the ability to recognise and differentiate STEMI, non-STEMI, and acute coronary syndrome.

Knowledge: Discusses the anatomy and physiology of plaque rupture and thrombus formation. Identifies signs and symptoms of MI e.g. ECG abnormalities, pain assessment (cardiac/non-cardiac), cardiac markers, differentiate diagnosis from dissecting aortic aneurysm.

Pre-requisite Competence: Blood sampling and cannulation Level 2.2 YES/NO

3.2 Skill: Demonstrates the ability to initiate treatment with correct thrombolytic utilising patient group directions and protocols.

Knowledge: Discusses the appropriateness of thrombolytic therapy e.g. pharmacology of agent, contra-indicators of thrombolysis, consent.

3.3 Skill: Demonstrates the ability to evaluate the impact of thrombolytic therapy on the ECG and patient clinical condition.

Knowledge: Critically analyses the effects of thrombolytic therapy on patient outcomes e.g. complications.

4.1 Skill: Demonstrates the ability to audit data and develop protocols/ guidelines for improving nurse-initiated thrombolysis.

Knowledge: Evaluates outcomes and implications of thrombolytic therapy e.g. against National targets, patient group directions.

72 Cardiac Nursing Competency Statements January 2004

Exercise tolerance testing

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: Pre-requisite Competence: Haemodynamic monitoring Level 2.1 YES/NO

3.1 Skill: Demonstrates the ability to perform preparation of the patient and the environment for exercise tolerance testing.

Knowledge: Discusses rationale for performing exercise tolerance testing. Identifies patient preparation and equipment required for exercise tolerance testing e.g. consent, pre-procedure checks.

Pre-requisite Competence: ECG monitoring and interpretation Level 3.1 YES/NO Auscultation of heart sounds Level 3.1 YES/NO Blood sampling and cannulation Level 2.2 YES/NO Resuscitation/ life support Level 3.1 YES/NO

3.2 Skill: Demonstrates the ability to obtain consent and initiate exercise tolerance testing using patient group directions and protocols.

Knowledge: Applies knowledge of contraindications and risk stratification to assess appropriateness for nurse- supervised exercise tolerance testing.

Pre-requisite Competence: ECG monitoring and interpretation Level 3.2 YES/NO

Resuscitation/ life support Level 3.2 YES/NO

3.3 Skill: Demonstrates the ability to effectively troubleshoot equipment problems, interpret and evaluate patient’s condition and pre-, during and post-test results, and communicate results e.g. to patient, make appropriate referral.

Knowledge: Discusses factors which impact upon the results of exercise tolerance tests e.g. haemodynamic response to exercise, drugs, age, upsloping/planar, end-points of testing.

4.1 Skill: Demonstrates the ability to audit data, make recommendations and develop protocols/ guidelines for improving nurse-initiated exercise tolerance testing.

Knowledge: Evaluates outcomes and implications of nurse-led exercise tolerance testing with respect to external factors e.g. against National targets, local/governmental policy.

74 Cardiac Nursing Competency Statements January 2004

Tilt-table testing

Competency Statements Competence achieved Competence maintained

Evidence utilised: Peer Evidence utilised: Peer reviewed: reviewed: Pre-requisite Competence: Haemodynamic monitoring Level 2.1 YES/NO

3.1 Skill: Demonstrates the ability to perform environmental and physical patient preparation for tilt-table testing.

Knowledge: Identifies patient preparation and equipment required for tilt-table test e.g. consent, pre-procedure checks.

Pre-requisite Competence: ECG monitoring and interpretation Level 3.1 YES/NO Auscultation of heart sounds Level 3.1 YES/NO Blood sample analysis Level 3.1 YES/NO Blood sampling and cannulation Level 2.2 YES/NO Resuscitation/ life support Level 3.1 YES/NO

3.2 Skill: Demonstrates the ability to initiate tilt-table testing using patient group directions and protocols.

Knowledge: Applies risk stratification in relation to indications and contraindications for tilt table testing.

3.3 Skill: Demonstrates the ability to effectively troubleshoot equipment problems, and evaluate patient’s condition throughout tilt table testing procedure.

Knowledge: Discusses factors which impact upon the results of tilt- table testing e.g. haemodynamic response, drugs, age.

4.1 Skill: Demonstrates the ability to audit data, make recommendations and develop guidelines for nurse- initiated tilt-table testing.

Knowledge: Evaluates outcomes and implications of nurse-initiated tilt-table testing with respect to external factors e.g. local/government policy.

76 Cardiac Nursing Competency Statements January 2004

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77 Cardiac Nursing Competency Statements January 2004

Appendix 1

The project steering group consisted of: Maree Barnett Department of Health Project Manager & Specialist Nurse Advisor; non-voting BANCC council member Lyndell Brodie Cardiac Nursing Competencies Project Nurse, Royal Brompton & Harefield Hospital/Hammersmith Hospitals NHS Trusts; BANCC member Helen Chan Cardiology Unit Nurse Manager, Northwest London NHS Trust Gill Eyers Clinical Nurse Lead for Specialist Nursing, Chelsea and Westminster Hospital NHS Trust Richard Hatchett South Bank University; BANCC member Alison Hunt Lecturer Practitioner, St Mary’s Paddington Hospital NHS Trust/Thames Valley University; BANCC member Jillian Riley Cardiac Nursing Competencies Project Lead; Senior Lecturer, Thames Valley University; past-President BANCC Caroline Shuldham Cardiac Nursing Competencies Project Lead; Director of Nursing and Quality, Royal Brompton & Harefield Hospitals NHS Trust; BANCC member Molly Teoh Head Nurse, Hillingdon Hospitals NHS Trust

Experts who contributed to parts of the document: Celine Adams Sister, St Marys Hospital NHS Trust Linda Blue Heart Failure Nurse Co-ordinator, Western Infirmary Glasgow Ian Bullock Head of Education & Training, Royal Brompton & Harefield NHS Trust Elaine Coady Cardiac Nurse Consultant, Guy’s and St Thomas’ Hospital NHS Trust Ian Jones Lecturer in Cardiac Nursing, University of Salford Debbie Hughes Cardiac Nurse Specialist, Torbay Hospital Belinda Linden Cardiac Nurse – Medical Information Unit, British Heart Foundation Alison Pottle Consultant Nurse, Royal Brompton & Harefield NHS Trust Tom Quinn Professor of Cardiac Nursing, Coventry University Jill Rowe Service Manager for Cardiac & Neurosciences, Morriston Hospital Jennifer Tagney Cardiology Nurse Consultant, United Bristol Healthcare Trust David Thompson Professor of Clinical Nursing, The Chinese University of Hong Kong Pat Thomson Lecturer, University of Stirling Lucy Wright Nurse Facilitator, University of Oxford

Acknowledgement to other reviewers of the document:

Elizabeth Allibone Nurse Teacher, Royal Brompton & Harefield NHS Trust Denice Gately Head Nurse, Hammersmith Hospitals NHS Trust Rachel Matthews Lead Patient Care Advisor, London Chest Hospital Chris Mutton Senior Nurse – Cardiology, Torbay Hospital Marina Nicholas Practice Educator, Royal Brompton & Harefield NHS Trust Janette Palmer Programme Organiser - Specialist Nursing, Glasgow Caledonian University

Cardiac Nursing Competency Statements 78 January 2004

Sue Pearson Senior Nurse, Royal Brompton & Harefield NHS Trust Karen Rawlings- Senior Lecturer, St Bartholemews School of Nursing & Anderson Midwifery, City University Martin Regan Practice Education Nurse, Wythenshaw Hospital Alison Reddock Acting Senior Sister, Hammersmith Hospitals NHS Trust Cathy Ross Cardiac Nurse – Medical Information Unit, British Heart Foundation

And with grateful thanks to those that piloted the document.

79 Cardiac Nursing Competency Statements January 2004

Feedback / comments on Cardiac Nursing – Acute/Episodic Care Competency Statements

The Cardiac Nursing – Acute/Episodic Care Competency Statements is not a static document. As practice changes, review and revision will be necessary. Comments and feedback on this document are most welcomed. Please complete the form and return to the address provided overleaf.

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Cardiac Nursing Competency Statements 80 January 2004

Please return to:

British Association for Nursing in Cardiac Care (BANCC) C/o BCS 9 Fitzroy Square LONDON W1T 5HW

Email: [email protected]

Jillian Riley Department of Education Britten Street Wing Royal Brompton Hospital Sydney Street LONDON SW3 6NP

81 Cardiac Nursing Competency Statements January 2004