The framework - Level 6 Senior Practitioner

Role and responsibility

People at level 6 require a critical understanding of detailed theoretical and practical knowledge within and/or their field and/or have management or leadership responsibilities. They demonstrate initiative and are creative in finding solutions to problems. They have some responsibility for team performance and service development, and they consistently undertake self-development.

Title: Specialist/Senior Practitioner

The level outline is informed by the Clinical Nurse Specialist (Paper 8)

Qualifications and experience expected for practitioners at this level of career framework

• Registered as a Nurse or Midwife with the Nursing and Midwifery Council or registered with the Health and Care Professions Council
• Ordinary or Honours degree
• Graduate Diploma
• 60 Credits at SCQF (Grad Cert), 60 credits at SCQF 11 recommended

6C1

Work autonomously as part of the team, assuming accountability and responsibility to facilitate the delivery of safe, effective, and person-centred care.

6C2

Use a wide range of skills and strategies to communicate with people about difficult matters or situations.

6C3

Act and influence others to incorporate non-judgemental, values-based care into practice.

6C4

Apply knowledge and raise awareness of relevant guidance, policies, and legislation that govern legal and ethical aspects of service provision.

6C5

Lead and support the implementation of local policies, guidelines, and protocols, ensuring they reflect national policy, legislation, and current evidence.

6C6

Monitor and maintain the health, safety, and security of self and others by applying knowledge of health and safety legislation and infection control policies and advising others.

6C7

Apply critical thinking and evaluation skills to make timely and informed clinical decisions related to all aspects of the care process.

6C8

Use a range of sources and experiences to inform professional judgement.

6C9

Select and use technology and information systems to both inform and support practice.

6C10

Provide and share complex information effectively and concisely for a range of situations and contexts to ensure safety and continuity of care.

6C11

Practise in ways that recognise and respond to health inequalities, respect diversity, protect against discrimination, and support others to do the same.

6C12

Apply a wide range of skills to promote health and well-being, improve health literacy, and empower patients to share decision-making.

6C13

Assess, investigate, and communicate/act on risk.

6C14

Apply and continue to develop specialist clinical knowledge, skills, and behaviours appropriate to specific areas of practice.

6C15

Raise concerns and/or report incidents in accordance with local reporting procedures.

6C16

Recognise the effects and potential symptoms of trauma or vicarious trauma and respond appropriately. Practising at a minimum of trauma Informed practice level.

6C17

Ability to escalate concerns if unable to carry out their duty and responsibilities outlined within health and care staffing legislation. Practicing at skilled level.

6C18

Baseline cardiology knowledge:

1. Undertake a comprehensive assessment of a person’s physical, psychological, and social unmet needs.
2. Actively involve the person, their family and carers, and wider partners in assessments.
3. Describe the structure and function of the cardiovascular system.
4. Understand coronary anatomy and relate to the ECG and patient presentation.
5. Describe the cardiac conduction system and mechanism of common arrhythmias and relate to the ECG and patient presentation: conduction disorders, atrial and ventricular arrhythmias.
6. Describe the aetiology, pathophysiology, and natural history of coronary artery disease, arrhythmia, valvular heart disease, disease of the aorta, Heart Failure with reduced Ejection Fraction (HFrEF), Heart Failure with mid-range Ejection Fraction (HFmrEF), Heart Failure with preserved Ejection Fraction (HFpEF), pulmonary hypertension, endocarditis.
7. Demonstrate awareness of the typical and atypical signs & symptoms of cardiac presentations.
8. Demonstrates awareness of the haemodynamic burden of pregnancy and relates the normal changes in pregnancy to the patient.
9. Recognise patients who need early involvement of specialist MDT.

6C19

Focused history taking:

1. Physical examination: which can include auscultation, palpation and percussion of heart and lung fields, assessment of jugular venous pressure, central or peripheral oedema, abdominal examination, cyanosis, and peripheral pulses, and awareness of adaptations to examination and assessment based on underlying disease e.g. congenital heart disease, vascular disease.
2. Symptom and treatment assessment: accurately assess, describe and document the signs and symptoms of people who present with chest pain, palpitations, heart failure, cyanosis or fatigue, use of assessment or monitoring tools where indicated, understands the assessment and diagnostic tools used in diagnosing cardiac disease and follows local pathways/guidelines when implementing, demonstrate a comprehensive understanding of and identify common ECG Rhythms and abnormalities and their management, including but not limited to:  Sinus Rhythm , Atrial and ventricular extrasystoles , SVT, Junctional (nodal) rhythms, Atrial fibrillation and flutter (and stroke risk assessment), Heart blocks, Cardiac arrest rhythms, differentially diagnose broad QRS complex tachycardias.
3. Analyse and synthesis findings from any relevant assessments (including those carried out by other members of the MDT), tests and investigations.

6C20

Investigations:

1. Authority to request and/or discuss a range of investigations.
2. Apply knowledge and understanding of pathophysiology and investigations. 
3. Request investigations appropriate to their scope of practice including but not exclusive to: ECG, Echocardiogram, Bloods: FBC, LFTs, U&Es, NTproBNP/BNP, TFTs, HBA1C, Iron Studies, Amyloidosis screen, troponin, lipid profile.  
4. Discuss with appropriate HCP if referral to clinical genetics team is indicated for consideration of genetic testing.
5. Interpret specific investigations and will act on investigation reports.
6. Understand the pathophysiology involved in the development of cardiac disease as a result of co-morbidities and relate this to investigation results and onward management within scope of practice.
7. Appraise investigation results and any incidental findings and escalate appropriately as required.
8. Know the effects of fever, pain, electrolyte disturbances, hypoxia, and hypotension on haemodynamic, cardiac rhythm, and perfusion in patients with or at risk of cardiovascular disease. 
9. Use appropriate guidelines and/or protocols where they exist.
10. Where appropriate, present findings to an MDT forum and/or with other health and social care professionals. 

6C21

Differential diagnosis:

1. Analyse and synthesise clinical information based on the patient’s presentation, history, physical and psychological examination, and findings from relevant investigations to inform a differential diagnosis or confirm a diagnosis.
2. Have an awareness of common differential diagnoses of symptoms associated with key cardiac symptoms.  
3. Have an awareness of the relationship between mental health and cardiac disease.  
4. Have an awareness of the interactions of comorbidities (such as diabetes, chronic renal failure, hypertension, respiratory disease, liver disease, etc.) with cardiac disease and take into account when making a differential diagnosis.
5. Make informed judgements in situations in the absence of complete or consistent data/information. 

6C22

Treatment and care:

1. Formulate a person-centred treatment and care plan based on synthesis and analysis of assessment and investigations. This may include the prescription of medicines.
2. Use guidelines and protocols to inform care and treatment planning where they exist.
3. Is aware of relevant current local, national and international clinical guidelines for assessment, management, interventions, and surgery for people with cardiac disease.
4. Know the major cardiovascular risk stratification tools and principles of primary and secondary prevention of cardiovascular disease.
5. Determine frequency of review to assess the therapeutic response.
6. Refines patient care plan utilising specialist input as appropriate to the patient’s underlying cardiac disease, presentation, and co-morbidities.
7. The following list is not exhaustive; however, a Clinical Nurse Specialist should be cognisant of: Common symptoms associated with the disease /condition /disability or any comorbidities and demonstrates an understanding of the pathophysiology of cardiac disease (acquired, congenital and inherited) and its effects on perfusion, organ function, nutrition, and energy metabolism.  
8. Utilises the New York Heart Association functional class (I, II, III, and IV) for assessment of heart failure symptoms and the Canadian Cardiovascular Society Angina Classification for angina symptoms. 
9. Understands the close relationship between the cardiovascular and renal systems and the effects of renal impairment on the patient’s condition.
10. Understand the effect of arrhythmias, ischaemia on cardiac status, escalating care appropriately in the presence of haemodynamic compromise.
11. Treatment and care to prevent/minimise secondary complications.
12. Has an awareness of how therapies are used to treat co-morbidities which impact cardiovascular health and vice versa.  
13. Recognition of frailty and its impact on the patient with cardiac disease to inform appropriate action in line with local policies and procedures.
14. Develops an understanding of the indications and contra-indications for cardiac transplant and mechanical circulatory support.
15. Has an awareness of the indications for the following percutaneous and surgical interventions: Ablation, TAVI, Mitraclip, PCI, Cardiac surgery: CABG, Valvular surgery, Aortic surgery, Congenital, Septal myectomy in HOCM, Structural interventions: closure of atrial or ventricular septal defects.
16. Awareness of the anticoagulation plan for patients prior to all cardiac procedures/interventions to provide appropriate guidance/information.
17. Monitor for side effects, intolerance, or nonadherence to treatment.
18. Has an awareness of assessment and treatment options available for palpitations and/or syncope:  Recognise ‘red flags’ in presentation which will determine urgency of investigations and referral (e.g.  Existing structural and congenital heart disease, family history of sudden cardiac death etc.), lifestyle modification. 
19. Describes assessment and treatment options available for chest pain:  Accurately assess patient reported chest pain, initiating appropriate investigations to aid diagnosis. Recognise ‘red flags’ in presentation which will determine the urgency of investigations and referral (e.g. acute MI, aortic dissection, PE, congenital heart disease), understand the pharmacological therapies in suspected acute coronary syndrome, interventional strategies and pathways, and lifestyle modification.
20. Describes assessment and treatment options available for breathlessness: Accurately assess patient reported breathlessness, initiating appropriate investigations to aid diagnosis. Recognise ‘red flags’ in presentation that will determine the urgency of investigations and referral (e.g. acute heart failure, PE, congenital heart disease), understand the pharmacological therapies in initial management of acute presentations, interventional strategies, and local/regional pathways, lifestyle modification.
21. Understand the transitional and outpatient strategies to support early supported discharge and admission avoidance for patients with cardiac disease.
22. Identification and management of deterioration, including supporting future care planning and end-of-life care where required.
23. Sensitively appraise the impact of cardiac disease and co-morbidities on the patient, their family, and significant others.  
24. Acknowledge irreversible decline and escalate to appropriate HCP on realistic treatment strategies.
25. Adopt an approach to palliative and end-of-life care that respects the principles of equality, diversity, and inclusion, whilst being sensitive to specific cultures and beliefs associated with diverse patient or carer groups.
26. Have an awareness of the comprehensive assessment outcomes and cohesive working with the wider professional team to plan, discuss, and evaluate the evolving palliative and end-of-life care needs of persons living with advanced cardiac disease. 
27. Have an awareness of symptom burden, apply sound clinical judgement, and escalate to appropriate HCP for referral to symptom management guidelines in partnership with specialist palliative care colleagues.  
28. Enable patients and carers to be active partners in their decision-making process by engaging in meaningful conversations about “What Matters” and “Realistic Medicine” principles associated with advancing cardiac disease, and care preferences.
29. Recognise there are different specialities within cardiology (Palliative, Inherited, Congenital, Cardio-Obstetrics, Cardio-oncology) and be cognisant of the contribution of these specialities by referring appropriately.
30. Medical emergencies commonly seen within the speciality.  
31. Psychological distress, anxiety, and depression.  
32. Recognises the need to assess psychological distress associated with cardiac disease and uses validated screening tools to assess. 
33. Recognition of the ethical implications of defibrillator implantation and subsequent device therapy on psychological status and lifestyle. 
34. Health promotion including lifestyle choices.  
35. Actively assess for opportunities for primary and secondary prevention of CVD through risk reduction, pharmacological therapies, and lifestyle advice. 
36. The wider network support for patients and their families.  
37. Broader public health issues relevant to their area of practice.
38. Consideration of the socioeconomic, racial, and sex-based inequalities within cardiac disease.

6C23

Co-ordination of care, referral, admission, and discharge:

1. Plan, deliver, and/or co-ordinate care utilising highly specialist knowledge.
2. Authority to admit and discharge from speciality area, depending on patient need and relevant legislation. This includes referral to a range of appropriate health and social care professionals and agencies. The Clinical Nurse Specialist may receive referrals directly or via the MDT team.
3. Understand the transitional and outpatient strategies to avoid preventable hospitalisations in patients recently discharged with cardiac disease.
4. Provide advice to other health and social care professionals that may inform admission/discharge, planning, or referral.

6C24

Expert specialist resource:

1. Provides specialist advice and support for patients throughout the care pathway.
2. Provides a comprehensive overview of the patient’s cardiac disease and plan of care, including self-care strategies.
3. Identifies the trajectory for the patient’s cardiac disease and supports patients and relatives with information to support future care planning.
4. Has an awareness of the impact of cardiac disease on travel and recreation and provides advice to patients.
5. Assess or refer for assessment of CV risk associated with competitive sport, physically demanding occupation or other physical activity.
6. Discusses the evidence base, indications, contraindications, side effects and lifestyle implications of therapies used for the treatment of cardiac disease or co-morbidities, e.g. erectile dysfunction, bleeding risk, etc.
7. Informs patients on the impact of their cardiac disease, symptoms, and interventions on driving, remaining up to date with DVLA guidance for medical professionals, e.g. driving restrictions post cardiac surgery, device implantation, impact of heart failure symptoms, palpitations, and syncope.
8. Identifies cardiovascular risk in pregnancy using WHO classification.
9. For men and women of reproductive age with inherited cardiac disease, recognise the need to inform of options relating to pre-implantation genetic diagnosis and refer appropriately for further advice.
10. Utilise the range of third sector information to support patients and their relatives in decision-making and living with cardiac disease.
11. Links patients and relative to local cardiac support groups.
12. Acts as an expert clinical advisor for colleagues across a range of settings.  
13. Acts as a resource or educator to others. 
14. Participate in clinical conferences, team meetings, and morbidity and mortality meetings to enhance communication, learning, and care of patients with cardiac disease.
15. Is a key member of the wider MDT, contributing to case management presentations and clinical management decisions.
16. Including the following specialist MDT: valve, heart failure, endocarditis, arrhythmias, device, obstetrics, congenital heart disease, inherited cardiac conditions, palliative, cardio-oncology, and cardiac surgery, appropriate to role. 

6F1

Use learning theories to plan, implement, and evaluate learning in the local environment.

6F2

Create an effective learning environment that ensures learning opportunities for staff and learners.

6F3

Apply a wide range of facilitation, teaching, and assessment skills to develop and improve practice.

6F4

Identify and support the achievement of the learning needs of individuals/team in response to service need and personal development planning.

6F5

Demonstrate on-going reflection on practice and support reflection in others.

6F6

Demonstrate knowledge and use of a range of information to review/evaluate and enhance the learning environment.

6F7

Participate in learning needs analysis, educational audit, and evaluation of educational interventions.

6F8

Ability to effectively apply practice supervision, applying quality standards to facilitate pre and post-registration learners to develop knowledge, skills, and proficiency, using appropriate assessment criteria and quality standards to assess competence within own scope of practice.

6F9

Ability to engage in [clinical] supervision, using reflective practice and feedback to develop the quality of care and outcomes.

6F10

Source and evidence use of a range of educational materials to support own and others’ development.

6F11

Evidence use of a wide range of skills to motivate, stimulate, and encourage others to facilitate the learning process.

6F12

Apply and continue to develop specialist knowledge of andragogy appropriate to specific role.

6F13

Engages with appraisal and the development and activation of a personal development plan.

6F14

Ability to effectively undertake the role of [clinical] supervisor for all functions of clinical supervision, within own scope of practice.

6F15

Use leadership skills to empower and enable others to engage in meaningful [clinical] supervision and use feedback to improve the quality of care.

6L1

Use national leadership frameworks to assess and develop self-leadership and leading others.

6L2

Communicate complex information at an appropriate level to a range of audiences, adapting to context and purpose.

6L3

Actively promote a supportive culture where constructive feedback is received positively and regarded as a learning opportunity.

6L4

Display creativity and innovation in exploring and implementing possible solutions to problems and evaluating their effectiveness.

6L5

Provide leadership for quality improvement and service development to enhance people’s well-being and experiences of healthcare.

6L6

Support others to take responsibility for ensuring concerns are addressed in a timely manner, applying relevant policies such as whistleblowing and complaints.

6L7

Demonstrate the ability to form, contribute to, and lead a team and work in collaboration with others to achieve the team’s purpose and objectives.

6L8

Contribute to and manage other members of a team by sharing information and expertise.

6L9

Demonstrate leadership behaviours when managing people, applying human resource policies and processes.

6L10

Recognise early signs of poor performance and take appropriate measures to address concerns.

6L11

Respond in a transparent and structured way to any complaints from staff about the unacceptable or unfair behaviours of other members of the team.

6L12

Contribute to workforce development through personal and professional development of individuals and teams aligned to organisational priorities.

6L13

Demonstrate the ability to use recognised workload assessment and skill mix tools to manage resources and budgetary demands, including workforce resources.

6L14

Apply and continue to develop leadership skills and behaviours appropriate to specific role.

6E1

Use a range of research approaches to assess how evidence is being used, by self and others, to inform and develop practice, improving the quality of care.

6E2

Demonstrate the ability to search and critically appraise evidence to inform and develop practice supporting audit, research, and quality improvement activity.

6E3

Participate in research related activity, including analysis of information.

6E4

Share with others good practice and the lessons learned from audit, research, and quality improvement activity to enhance practice locally.

6E5

Identify and disseminate information on NHS Board/University programmes of research/forums/ special interest groups/networks relevant to the area of practice.

6E6

Use understanding of research governance, including Good Clinical Practice, ethics, data protection and confidentiality, to support self and others in the research process.

6E7

Demonstrate the ability to use a wide range of Quality Improvement/Clinical Audit/ Research skills to inform and develop practice of self and others.

6E8

Ability to critically identify, define, and analyse complex/professional problems and issues.

6E9

Apply and continue to develop specialist knowledge of research and development appropriate to specific role.