Competency Title: Pressure Ulcer Prevention and Management

Developing and Sustaining a Competent and Confident Clinical Workforce through Essential Clinical Competencies for Registered Practitioners Competency Title: Pressure Ulcer Prevention and Management Competency Leads: Glenn Smith

Document Author Authorised Signature Written by: Authorised by:

Signed: Signed: Date: Date: Job Title: Job Title:

Effective Date: Review Date

Approval at: Date Approved: TBC

Authors: Glenn Smith, Karen Barnett, Donna Baker - 2013

CC/RP/Template November 2016 – Template review due November 2017v10.2 How to use this Competency Framework This Competency Framework has been developed to enable the assessment of clinical competence.

Definition of Competence

“A set of specific and detailed outcomes that need to be achieved in order to a] prove immediate competence in essential skills or b] aid personal and professional development in desirable skills. The competencies must incorporate knowledge, skill, behaviour and demonstration of how these all equate to personal professional accountability for competent care of the patient” (Barnett 2013).

This definition focuses attention on the importance of recognising individual personal responsibility and accountability to deliver high quality care. This means taking appropriate actions following clinical assessments to ensure care or treatment is personalised and is delivered with care and compassion.

Responsibilities Competency Lead: to develop the competency statements using the agreed framework, develop and co-ordinate the delivery of any underpinning knowledge, prioritise staff groups requiring assessment, and undertake competency assessments where appropriate ensuring the outcome is recorded on the Trust’s Learning Management System.

Clinical Lead :to ensure that they and their registered staff are competent within their scope of practice. The clinical lead may undertake competence assessments themselves or delegate to Registrants who meet the requirements for assessor. The selection of an assessor will be based mainly on relevant experience and training. The following criteria should be considered: • Amount of experience working in their role (minimum of two years) • Experience of assessing and supervising others i.e. pre-registration students and/or qualified staff • Successful completion of a local or nationally recognised practice educator qualification.

The clinical lead should also monitor compliance and ensure that essential competencies are recorded on the Trust’s Learning Management System and reviewed annually at appraisal. The clinical leads are professionally accountable to the Executive Director of Nursing and their relevant Professional Body.

Individual Registered Practitioner: to provide evidence of the achievement of each competence and ensure that they maintain competence within their scope of practice and are reviewed annually at appraisal. Individuals are professionally accountable to the Executive Director of Nursing and their relevant Professional Body.

Assessor: to facilitate an environment conducive to learning, judge that the evidence provided/demonstrated meets the competence safely, effectively and consistently to the required standard and provide feedback to develop practice further.

CC/RP/Template November 2016 – Template review due November 2017v10.2 Process of Competency Assessment – Registered Practitioners

All the relevant underpinning knowledge needed to inform practice and prepare for the competency assessment will be made available prior to assessment.

The registered practitionerhttp://intranet/index.asp?record=4457 feels prepared for the competency assessment.

Yes No

Contact the relevant competency Contact their clinical lead to organise a date lead to arrange further input. for assessment.

First Assessment The first assessor provides feedback to the assessee, documents the outcome and The outcome of the competency completes PART 1 of the action plan. No The assessor will refer the outcome to the assessment is a Pass. assessee‘s line manager. The line manager will complete an individual learning plan in preparation for the second reassessment. A different assessor will be Yes identified for the second assessment. The line manager will consider invoking informal capability.

The assessor provides feedback to the assessee and completes the assessment documentation. Second Assessment The second assessor provides feedback to the assessee, documents the outcome and completes PART 2 of the action plan. The outcome of the competency assessment The assessor will refer the outcome to the assessee‘s will be emailed to [email protected] line manager. by the competency assessor within 48 hours The line manager will complete an individual learning plan and arrange an individual tutorial led by the of the assessment being undertaken competency lead in preparation for the final reassessment. The line manager will consider invoking formal capability.

Final Assessment Referral at the final attempt may lead to further performance management in line with Trust policy. This will be discussed in 3 confidence with the registered Practitioner and their line manager. CC/RP/Template November 2016 – Template review due November 2017v10.2 Role: Band:

First Assessor Name and Role: Second Assessor Name and Role:

Competency Statement Expected Level of Competency Evidence Types: DO=direct Signature of Assessor (Core Competencies to be included in all observation; QA=questions and answers; RD=reflective Competency Assessments) discussion; WR=written records; WS=witness statements Registered Practitioners deliver person centred care During this assessment the practitioner is observed acting with with sensitivity and compassion respecting the respect, kindness, compassion and sensitivity. Demonstrates dignity and diversity of patients, relatives, carers, consistent person centred care with very good professional visitors and colleagues. conduct/behaviour in line with trust expectations. Registered Practitioners gain consent for all During this assessment the Practitioner consistently uses helpful interventions and maintain confidentiality as per strategies to enable people to understand the interventions in Trust policy and professional body requirements. order to give informed consent. They consistently recognise the significance of confidential information and acts in relation to who does or does not need to know. Registered Practitioners provide accurate and During this assessment the Practitioner is able to consistently meaningful verbal information in a polite and communicate safely, sensitively and effectively using appropriate respectful manner to patients, relatives, visitors and methods according to the situation.

Registered Practitioners complete documentation During the assessment the Practitioner is observed practicing or in accordance with Organisational and Professional is able to explain the standards for documentation applicable to the Trust and their Professional Body. E.g. accurately and contemporaneously with dates, times and signatures. Registered Practitioners demonstrate professional During the assessment the Practitioner consistently recognises accountability and act with a ‘duty of candour’. and works within the limitations of their knowledge, skills and professional boundaries, understanding their responsibility and accountability for their own actions and omissions. Registered Practitioners demonstrate how to During the assessment the practitioner is observed or is able to safeguard vulnerable adults and children, and when recognise and respond correctly when people are in vulnerable to raise identified concerns through the appropriate situations, at risk or in need of support and protection.

Registered Practitioners demonstrate their During the assessment the practitioner is able to explain their professional responsibility and accountability professional responsibility and accountability for delegating care delegating care to non-registered practitioners. to non-registered practitioners. Competency Statement Expected Level of Competency Signature of Assessor Subject Specific Competencies Registered nurse can demonstrate an Nurse can describe the structures of the skin and how understanding of the physiology of the these are affected by the application of pressure. skin and how this relates to pressure ulceration Registered nurse can complete Nurse can describe the process of using the Waterlow accurate Waterlow scoring, and can scoring to come up with a risk score. Nurse can describe prioritise on the basis of the scoring how the components of the Waterlow are scored in various clinical situations. Nurse can describe how this score relates to the overall risk level of the patient and what this indicates in terms of prioritisation and their own accountability in terms of ensuring care is planned, delivered and evaluated to reduce the risk of harm to the patient. Registered nurse can demonstrate that Nurse can describe the frequency of how often the they are aware of the frequency with Waterlow needs to be reassessed in relation to patient which the Waterlow scoring needs to condition. be reassessed. Registered nurse can demonstrate how Nurse can demonstrate an understanding of the four 4

CC/RP/Template November 2016 – Template review due November 2017v10.2 to accurately grade a pressure ulcer. grades of pressure ulcer according to EPUAP and This includes reference to issues which accurately grade pressure ulcers according to this system. may make grading difficult, i.e. The nurse can describe the various pitfalls or difficulties which may make grading difficult, and can describe Blistering strategies to improve the accuracy of their grading. The nurse can describe how pressure ulcers might present on Blanching versus non-blanching various areas of the patient’s body. erythema

Necrosis or slough in wound

Moisture lesions

Fungal infections

Registered nurse demonstrates that Nurse can list various types of equipment which are all they understand that other sources of potential causes of pressure damage to the skin, and the pressure can cause pressure relevant precautions required to ensure that this skin ulceration, such as devices or damage is avoided. bandaging applied to the patient’s

Registered nurse can demonstrate that Nurse can verbalise how pressure relieving and pressure they understand the difference reducing devices support a patient’s pressure areas and between pressure relieving and how this relates to the reduction of pressure on patient’s pressure reducing devices. skin. Registered nurse can demonstrate Nurse can verbalise when a root cause analysis will be their understanding of the root cause initiated, give a brief overview of how the process works to analysis process, when this is initiated identify key issues and how this translates into action plans and how this impacts on patient care which correct any problems with patient care. Registered nurse can demonstrate Nurse clearly states that pressure ulcers of all grades that their understanding of their are acquired or deteriorate under NHS care are reportable responsibility to report pressure using Datixweb. Furthermore nurse clearly states that their ulceration on Datixweb and how to responsibility is to report the pressure ulcer as soon as it is accurately report them. discovered. Registered nurse can demonstrate Nurse clearly states and demonstrates that they their understanding of their understand that it is their responsibility to ensure that accountability when delegating care to non-qualified staff to whom they delegate care tasks non-qualified staff in all settings. relating to pressure area care are trained and educated to sufficient degree to undertake the tasks competently. Registered nurse can demonstrate Nurse can describe the two stage process for determining knowledge of Mental Capacity act and patient’s mental capacity, and how the principle of acting how it relates to pressure ulcer in the patient’s best interest impacts on providing pressure management, in particular giving area care. Nurse can describe how this relates to patient advice to patients, and how to work choice when patient chooses not to take the advice of the with the non-concordant patient. professional, and that they should in all instances accurately document refusals and any verbal or written advice given.

Registered nurse can demonstrate how Nurse clearly describes how nutrition, continence, and to manage other aspects of patient’s pain, contribute to skin breakdown, and what care which contribute to avoiding skin interventions they would need to put in place in order to breakdown, e.g. nutrition, continence, reduce the likelihood of the patient developing a pressure ulcer.

Registered nurse can accurately Nurse can describe in unambiguous terms the anatomical describe the anatomical location of the location of a pressure ulcer.

CC/RP/Template November 2016 – Template review due November 2017v10.2 pressure ulcer. Registered nurse can demonstrate Nurse specifically names pressure, shearing and friction as their understanding what a pressure the three forces that cause skin breakdown, and can ulcer is, and of the basic forces that differentiate between how each of the forces affects the cause skin breakdown. patient’s skin. Registered nurse can demonstrate on Nurse can describe those instances when a patient what basis they will refer a patient to requires referral to other practitioners, specifically other professionals. dietetics, tissue viability, pain nurse, continence team, physiotherapy, Occupational therapy and wheelchair service. Registered nurse can demonstrate how Nurse can describe how they would set out an increasing seating tolerance needs to be built up regime of seating tolerance in order to build up patient’s for when a patient spends long periods sitting time after they have been on long periods of bed on bed rest. rest. Nurse describes when it would be appropriate to stop increasing the time a patient sits out when this is detrimental to their wellbeing. Registered nurses can demonstrate Nurse can describe the use of these pressure relieving value and use of various pressure devices, and when they would implement them. relieving devices, including Repose and Parafricta bootees, and wedges. Registered Nurse can demonstrate Nurse can write repositioning regime, including setting out how to set out a repositioning regime, when a patient would be sat out and when the need to go including how often patient needs back to bed, how often this takes place, and what positions turning, the value of the 30 degree tilt, the patient needs to be nursed in while in bed. and the balance between seating and Nurse demonstrates an awareness that each episode of bed positioning. repositioning or movement must be documented in the patients notes.

Registered nurse can demonstrate that Nurse can describe and demonstrate the accurate they understand how to describe the measurement of a wound in a consistent manner. wound, including accurately taking Nurse can accurately describe the state of the wound bed, measurements. They need to be able including devitalised tissue and peri-wound state. to demonstrate their understanding of Nurse can accurately describe the anatomy of the wound the following characteristics of the so that the wound’s state and progress can clearly be wound and how to measure them: charted through the patient’s documentation. Necrosis and Slough Erythema and Moisture damage Granulation Undermining and Sinus tracts Tracking or tunnelling Registered nurse can demonstrate that Nurse can describe how these conditions affect patient’s they understand how the following sensation, mobility, perfusion and oxygenation, and how conditions affect the patient’s risk of these can increase the patient’s risk of pressure ulcers. developing pressure ulceration, and Nurse can describe what care planning they would put in what they would need to take into account as part of pressure ulcer place in order to minimise the impact of these conditions prevention: on the patient’s pressure ulcer risk.

Terminal or chronic illness Neurological disease. Vascular disease Acute illness.

CC/RP/Template November 2016 – Template review due November 2017v10.2 Assessment Outcome – Please sign in relevant box

Outcome Actions Assessor Signature and Assessor Signature and Assessor Signature and date date date Initial Assessment 2nd Assessment 3rd Assessment Pass - All essential No action required. Review competencies evidenced. annually at appraisal. Revisit any development learning points listed below as recommended by assessor. Refer - One or more Clinical practice in relation to competencies not evidenced. the specific competency not evidenced is to be supervised and reassessed within 2 weeks.

Learning points to revisit following successful competency assessment:

First Assessors Signature: Registered Practitioners Signature:

CC/RP/Template November 2016 – Template review due November 2017v10.2 Action Plan following referral at FIRST assessment. To be completed following this assessment in preparation for second assessment.

First assessor to tick, initial and date once completed

Outcome of assessment and feedback given to registered practitioner Initial: Date:

Line manager informed of referral at first assessment Initial: Date:

Registered Practitioner signposted to further underpinning knowledge/ Competency Lead Initial: Date:

First Assessors Signature: Registered Practitioners Signature:

ACTION PLAN

Individual Learning Plan between line manager and Registered Practitioner. To be completed following this assessment in preparation for second assessment.

Date for re-assessment:

Line Managers Signature: Registered Practitioners Signature:

Action Plan following referral at SECOND assessment. To be completed following this assessment in preparation for final assessment.

Second Assessor to tick, initial and date once completed

Outcome of assessment and feedback given to registered practitioner Initial: Date:

Line manager informed of referral at first assessment Initial: Date:

Registered Practitioner signposted to further underpinning knowledge / competency Lead Initial: Date:

Second Assessors Signature: Registered Practitioners Signature:

ACTION PLAN

Individual Learning Plan between line manager and Registered Practitioner. To be completed following this assessment in preparation for final 8

CC/RP/Template November 2016 – Template review due November 2017v10.2 assessment

Date for Reassessment:

Line Managers Signature: Registered Practitioners Signature:

CC/RP/Template November 2016 – Template review due November 2017v10.2