The framework - Level 7 Advanced Clinical Nurse Specialist

Role and responsibility

People at level 7 of the career framework have a critical awareness of knowledge issues in the field and at the interface between different fields. They are innovative and have a responsibility for developing and changing practice and/or services in a complex and unpredictable environment.

Title: Advanced Clinical Nurse Specialist  

The level outline is informed by the Advanced Practice Transforming Roles Papers 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
• Post-registration qualification
• Advanced CNS 120 credits SCQF 11 (Postgraduate Diploma)
• Evidence of operating/thinking at Master’s level
• Evidence of working towards relevant Master’s level award

7C1

Demonstrate advanced competence, innovation and leadership in the management and delivery of safe, effective, person-centred care within own area of practice.

7C2

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

7C3

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

7C4

Use in-depth knowledge of legislation, professional regulation, and codes of practice to lead the development, embedding, and evaluation of protocols, guidelines, and policies at operational level.

7C5

Promote, monitor and maintain best practice in health, safety, and security, in accordance with health and safety legislation and infection control policies, acting on concerns and/or reporting incidents in line with local reporting procedures.

7C6

Apply critical thinking and evaluation skills to make timely and informed clinical decisions related to all aspects of the care process, utilising professional judgement to manage risk appropriately.

7C7

Demonstrate the ability to use and evaluate technology and information systems to inform and improve health outcomes.

7C8

Identify and share more complex information effectively and concisely for a range of situations and contexts to ensure patient safety and continuity of care and act on professional judgement about when to seek help.

7C9

Advance equality and value diversity, challenging discriminatory behaviours and acting to improve inclusion.

7C10

Engage with, appraise, and respond to individuals’ motivation, development stage and capacity, working collaboratively to promote health and well-being, improve health literacy and empower individuals to participate in decisions about their care and to maximise their health and well-being.

7C11

Contribute to the development of organisational objectives and create opportunities to involve other practitioners.

7C12

Apply advanced clinical knowledge, skills, and behaviours appropriate to specific area of practice.

7C13

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

7C14

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

7C15

Baseline cardiology knowledge:

1. Describe the structure and function of the cardiovascular system. 
2. Understand coronary anatomy and relate appropriately to the ECG and patient presentation. 
3. Describes the cardiac conduction system and mechanism of common arrhythmias and relate to the ECG and patient presentation: conduction disorders, atrial and ventricular arrhythmias. 
4. Describe the aetiology, pathophysiology, and natural history of coronary artery disease, arrhythmias, valvular heart disease, disease of the aorta, HFrEF, HFmrEF, HFpEF), pulmonary hypertension, and endocarditis.
5. Demonstrate awareness of the typical and atypical signs and symptoms of cardiac presentations, including differential diagnosis and conditions that can mask or mimic cardiac disease. 
6. Demonstrates awareness of the haemodynamic burden of pregnancy and relates the normal changes in pregnancy to the patient.
7. Recognise patients who need early involvement of specialist MDT.  

7C16

Focused history taking:

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. Use ethical, regulatory and legal frameworks to underpin professional practice during complex moral and ethical dilemmas associated with symptoms, treatment, intervention, and supportive palliative and end-of-life care needs, such as DNACPR and device deactivation as appropriate.
4. Assessment should include a full analysis and interpretation of their history.
5. A comprehensive cardiovascular history should include family history of cardiovascular disease, specifically IHD in younger relatives (<50 yrs), relatives that died suddenly or who have had conditions such as aneurysms, dissections, or required interventions e.g. surgery, pacemakers or implantable cardiac devices (ICDs), familial hypercholesterolemia, cardiomyopathy, and channelopathies. Adverse pregnancy outcomes e.g., gestational diabetes, hypertensive disorders of pregnancy. Awareness and understanding of the therapies used in cancer treatment and the potential cardiac consequences. 

7C17

Focused clinical assessment:

1. Carry out a focused clinical assessment of the patient, which may include physical examination such as auscultation, palpation, and percussion of heart and lung fields. 
2. Assessment of jugular venous pressure (JVP), central or peripheral oedema, abdominal examination, cyanosis, and peripheral pulses. 
3. Aware of adaptations to examination and assessment based on underlying disease, e.g., congenital heart disease, vascular disease. 
4. 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.  
5. Use of assessment or monitoring tools where indicated.  
6. Understands and implements assessment and diagnostic tools to diagnose cardiac disease and align with local pathways/guidelines appropriately.
7. 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, and cardiac arrest rhythms.  
8. Differentially diagnose broad QRS complex tachycardias. 
9. Analyse and synthesise findings from relevant assessments, tests, investigations, and the wider MDT review.
10. The assessment may be face-to-face, over the phone, or by video conference. 

7C18

Investigations:

1. Authority to request and/or discuss a range of investigations.  
2. Apply knowledge and understanding of pathophysiology and investigations to. Request investigations appropriate to their scope of practice, including but not exclusive to: ECG, echocardiogram, cardiac CT, cardiac MRI, CXR, CPET, 6MWT, Holter monitor, exercise tolerance testing, myocardial perfusion scan, coronary angiography, stress echocardiogram, Reveal Monitor, and Ajmaline challenge. 
3. Bloods: FBC, LFTs, U&Es, NTproBNP/BNP, TFTs, HBA1C, Iron Studies, Amyloidosis screen, troponin, lipid profile, Fabry. 
4. Referral to clinical genetics team for consideration of genetic testing. 
5. Interpret specific investigations and act on investigation reports.  
6. Have robust understanding of the pathophysiology involved in the development of cardiac disease as a result of co-morbidities, and relate this to investigation results and onwards management. 
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 haemodynamics, 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. 

7C19

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. Know the common differential diagnoses of symptoms associated with key cardiac symptoms.  
3. Understand the relationship between mental health and cardiac disease. 
4. Recognise the interaction of comorbidities (such as diabetes, chronic renal failure, hypertension, respiratory disease, liver disease, etc.) with cardiac disease and consider it when making a differential diagnosis. 
5. Recognise the cardiac and co-morbidity relationship (such as diabetes, chronic renal failure, hypertension, respiratory disease, liver disease, etc.) to inform a differential diagnosis. 
6. Make informed judgements in the absence of complete or consistent data/information. 

7C20

Treatment and care:

1. Sensitively appraise the impact of cardiac disease and co-morbidities on the patient, their family, and significant others.  
2. Exclude and treat reversible causes associated with deterioration, including onwards referral for catheter and surgical interventions where appropriate. 
3. Acknowledge irreversible decline and agree on realistic treatment strategies. 
4. 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. 
5. Use 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.  
6. Appraise symptom burden, apply sound clinical judgement, and refer to symptom management guidelines in partnership with specialist palliative care colleagues.  
7. Enable patients and carers to be active partners in their decision-making process by engaging in meaningful conversations about “What Matters”, “ReSPECT” and “Realistic Medicine” principles associated with advancing cardiac disease and care preferences.  
8. Recognise there are different specialities within cardiology (Palliative, Inherited, Congenital, Cardio-Obstetrics, , Cardio-oncology) and have understanding and knowledge of utilising the appropriate team within cardiology to refer on to. 
9. Medical emergencies commonly seen within the speciality.  
10. Psychological distress, anxiety, and depression.  
11. Recognises the need to assess psychological distress associated with cardiac disease and uses validated screening tools to assess. 
12. Recognition of the ethical implications of defibrillator implantation and subsequent device therapy on psychological status and lifestyle. 
13. Health promotion including lifestyle choices.  
14. Actively assess for opportunities for primary and secondary prevention of CVD through risk reduction, pharmacological therapies and lifestyle advice. 
15. The wider network support for patients and their families.  
16. Broader public health issues relevant to their area of practice: consideration of the socioeconomic, racial, and sex-based inequalities within cardiac disease.  
17. The Advanced Clinical Nurse Specialist will teach, advise, and coach patient/client/carers about their condition, treatment options, and health/lifestyle activities. 

7C21

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 Advanced 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.

7C22

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. Recognises 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.
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. For men and women of reproductive age with inherited cardiac disease, recognise the need to consider options relating to pre-implantation genetic diagnosis and refer appropriately for further advice. 
9. Identifies cardiovascular risk in pregnancy using WHO classification. 
10. Routinely discusses with women of reproductive age the importance of safe and effective methods of contraception to avoid an unplanned pregnancy. Clearly documents which methods of contraception are safe in the context of heart failure in patient notes to facilitate access. 
11. Utilises the range of third sector information to support patients and their relatives in decision-making and living with cardiac disease. 
12. Links patients and relative to local cardiac support groups. 
13. Acts as an expert clinical advisor for colleagues across a range of settings.  
14. Acts as a resource or educator to others.  
15. Actively look for opportunities across medical specialities to increase awareness of cardiac presentations and management as well as the role of the ACNS in the MDT and patient pathway. 
16. Participate in clinical conferences, team meetings, and morbidity and mortality meetings to enhance communication, learning, and care of patients with Cardiac Disease. 
17. Is a key member of the wider MDT, contributing to case management presentations and clinical management decisions. 
18. Including the following specialist MDT: valve, heart failure, endocarditis, arrhythmias, device, obstetrics, congenital heart disease, inherited cardiac conditions, cardio-oncology and cardiac surgery.  

7F1

Role model exemplary facilitation and teaching skills and develop those skills in others.

7F2

Demonstrate and understand the key theories of adult learning and apply a wide range of facilitation, teaching and assessment skills to practice.

7F3

Evaluate reflection on practice and facilitate reflection in others.

7F4

Review data collected from educational audits and other feedback to plan and lead change at a local level to enable a positive learning environment.

7F5

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

7F6

Evaluate, develop, lead, and facilitate the use of education materials for students, staff and service users at a local level.

7F7

Develop, lead and support teaching, supervision and assessment skills in others.

7F8

Engage with education providers to contribute to curriculum development and delivery.

7F9

Apply advanced knowledge of adult learning appropriate to specific role.

7F10

Critically assess and address own learning needs, negotiating a personal development plan that reflects the breadth of ongoing professional development across the four pillars of advanced clinical practice.

7F11

Engage with, appraise, and respond to individuals’ motivation, development stage, and capacity, working collaboratively to support health literacy and empower individuals to participate in decisions about their care and to maximise their health and well-being.

7F12

Enact the Health and Care Staffing legislation to ensure there is adequate time provision to support the learning and development of the team.

7F13

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

7F14

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 criterion and quality standards to assess competence within own scope of practice.

7F15

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

7L1

Provide strong and effective leadership across professional and organisational teams/boundaries broadening sphere of influence.

7L2

Evidence a positive impact of own exemplary leadership qualities and behaviours.

7L3

Role model highly developed verbal, non-verbal, and written communication skills.

7L4

Demonstrate how feedback is used by the service to positively improve services.

7L5

Use creative and innovative solutions to address complex problems.

7L6

Promote a culture of empowerment to enable concerns to be raised, addressed, and/or appropriately escalated.

7L7

Lead innovation and quality improvement and promote involvement of others.

7L8

Build and lead teams, engage stakeholders, and work in collaboration with others.

7L9

Demonstrate and support others to manage people effectively using organisational policies and exemplary leadership qualities.

7L10

Progress workforce development plans aligned to organisational priorities.

7L11

Critically apply advanced clinical expertise and role model the values of NHS Scotland to influence the sharing and adoption of best practice, reduce unwarranted variation, and enhance quality.

7L12

Use creative and innovative solutions to ensure [clinical] supervision is prioritised and others have the resources required to access support appropriate to needs and role.

7E1

Act as a role model for the wider team by promoting a positive research culture.

7E2

Further enhance knowledge of research approaches, including advanced evaluation methods, to promote and embed evidence in practice.

7E3

Identify and apply impact measures and use findings to enhance practice.

7E4

Demonstrate the ability to search, critically appraise, and synthesize evidence to inform practice and to underpin audit/ research/quality improvement activity.

7E5

Share good practice and the lessons learned from audit, research, and quality improvement activity locally, and nationally through professional and peer-reviewed processes.

7E6

Utilise appropriate policies to ensure support for clinical research activity and adherence to research governance, including Good Clinical Practice, ethics, data protection and confidentiality.

7E7

Demonstrate the ability to use a wide range of Quality Improvement/Clinical Audit/Research skills to improve practice and supports others to do so.

7E8

Critically analyse, evaluate, and synthesise complex/professional problems and issues and help others do the same.

7E9

Develop original and creative solutions to problems and support others to do so.

7E10

Contribute to the wider research agenda by initiating or supporting NMAHP led research activity.

7E11

Facilitate collaborative links between clinical practice and research through proactive engagement, networking with academic, clinical, and other active researchers.