The framework - Level 6 - Clinical Nurse Specialist

Role and responsibility

Practitioners at level 6 require a critical understanding of detailed theoretical and practical knowledge within 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: Clinical Nurse Specialist

The level outline is informed by the Clinical Nurse Specialist (Paper 8) Transforming Roles Paper and the BDNG competency documents.

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

• Registered as a Nurse with the Nursing and Midwifery Council
• Ordinary or Honours degree
• Graduate Diploma
• Post-registration expertise within speciality / area of practice that demonstrates the required breadth of knowledge to lead safely, effectively and efficiently
• A minimum of a graduate certificate (honours degree level) qualification centred around dermatology with a core educational focus on development of clinical competence relevant to the role, although a Postgraduate Certificate is recommended
• V300 Independent and supplementary non-medical prescriber is 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 polices, guidelines and protocols, ensuring they reflect national policy, legislation and current evidence

6C6

Monitor and maintain 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 which 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 area of practice

6C15

Raise concerns and/or report series 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. Practising at Skilled level

6C18

Dermatology Knowledge:

1. Demonstrate knowledge and understanding of anatomy and physiology of normal skin, its appendages and barrier function
2. Distinguish between normal and abnormal features of the skin structure and its appendages
3. Demonstrate understanding of anatomy and physiology of skin applied to skin disorders
4. Demonstrate understanding of the immunology of the skin and its relationship to skin diseases
5. Relate abnormalities in the anatomy and physiology of the skin to the disease process

6C19

Demonstrate knowledge and understanding of the common adult / childhood dermatological conditions as appropriate for working environment and role such as (list not exhaustive):

1. Eczema
2. Psoriasis
3. Bullous skin disorders
4. Severe drug eruptions
5. Erythrodermic conditions
6. Acute skin infections and infestations
7. Acne and Rosacea
8. Scalp conditions
9. Skin cancers and pre-cancerous conditions
10. Hypertrophic and keloid scarring
11. Urticaria

6C20

Assessment: Demonstrate knowledge and understanding of the assessment required in caring for patients with dermatological conditions:

1. Carry out a comprehensive clinical assessment and history taking, maintaining patient privacy and dignity, which may include physical examination, symptom and treatment assessment. The assessment may be face to face, or by phone, or by video call
2. Demonstrate knowledge and appropriate use of the assessment tools available for measuring skin conditions and comorbidities such as PASI, PEST, DLQI, POEM, EASI (not exhaustive list)
3. Demonstrate appropriate use of basic dermoscopy and medical photography to aid assessment if relevant to role
4. Understand, recognise and assess patients for comorbidities associated with skin conditions
5. Has the diagnostic skills to confirm pre-diagnosed conditions and identify where a differential diagnosis is suspected and escalate where necessary and take appropriate action
6. Undertake holistic assessment of a patient’s physical, psychological and social needs, actively involving the person, their family and carers, and wider partners in assessments
7. Be competent within identified scope of practice, including non-medical prescribing.
8. Demonstrate knowledge of local and national guidelines and follow these when assessing patients.
9. Communicate findings with senior colleagues and with other disciplines at an appropriate level
10. Accurately document patient assessment and take appropriate action on findings

6C21

Investigations: Demonstrate knowledge and understanding of the common dermatological investigations required for diagnostic purposes and subsequent treatment:

1. Advise patient/carer on investigation rationale, potential results and mechanism of specimen procurement, such as swabs, skin scrapings, bloods, contact allergy tests, MED/MPD, skin biopsy, radiological investigations (list not exhaustive)
2. Request and undertake dermatological investigations pertinent to level of practice/ role, liaising with other Health Care Professionals as required
3. Demonstrate the correct collection of appropriate specimens, pertinent to level of practice, in a manner so as to minimise adverse effects 
4. Analyse and respond appropriately to results of investigations within identified scope of practice and refer on to other disciplines or senior staff as appropriate
5. Demonstrate knowledge of local and national guidelines and follow these when considering investigations

6C22

Treatment and care: Demonstrate and apply knowledge and understanding of a wide range of treatments used to effectively treat common dermatological conditions including topical therapy, phototherapy and systemic medication.

• Demonstrate awareness of different treatment options and the concept of first-, second- and third-line treatments
• Identify and implement national and local protocols and guidance that would determine choice of therapeutic intervention
• Discuss all appropriate treatment options comprehensively with patients and carers including risks and benefits, pre-treatment screening, dosing and monitoring, treatment evaluation, potential outcomes.
• Formulate a treatment plan and adjust therapies according to patient need within locally agreed scope of prescribing practice – see 16 & 17 below for examples
• Assess response to treatment and monitor for and recognise side effects, potential adverse effects and unusual presentation of skin disease and take appropriate action, escalating to senior staff where appropriate
• Provide patient education so as to promote effective therapy including potential variations in disease pattern, severity and duration of symptoms
• Demonstrate awareness of treatment compliance issues and how to reduce these while managing the patient’s expectations
• Record accurate information during treatment to collate evidence for efficacy of / response to treatment
• Demonstrate proficiency in the use of equipment, pertinent to individual workplaces / roles, such as: Phototherapy cabinets, Photodynamic therapy lamps, Iontophoresis equipment, Hyfrecator, Diathermy (not exhaustive list)
• Demonstrate knowledge and understanding, and facilitate clinically safe practices when caring for an ill patient and act appropriately when emergency action is required
• Identify nursing measures to keep a patient infection free during an acute illness
• Demonstrate understanding of maintaining nutritional, fluid and electrolyte balance and in what circumstances these might be potentially disrupted
• Recognise and manage signs of skin deterioration, escalating appropriately if required
• Provide relatives and carers with the necessary information and support to deal with prolonged care
• Maintain accurate and complete records
• Demonstrate and apply knowledge and understanding of topical medications used to effectively treat common dermatological conditions, i.e. Eczema; psoriasis; bullous skin disorders; severe drug eruptions; erythrodermic conditions; acute skin infections and infestations; cutaneous cancers and pre-cancerous lesions; acne and rosacea; leg ulcers; scalp conditions
  • • Be able to describe a wide range of topical treatments for the common dermatological conditions
    • Be able to discuss different treatment options comprehensively with patients and carers
    • Ability to discuss risks and benefits of these topical treatments
• Able to provide patient education so as to promote effective topical therapy
  • • Ability to discuss expectations and potential outcomes of topical treatments
    • Demonstrate awareness of treatment compliance issues and how to prevent / manage such issues
    • Assess response to treatment and escalate issues to senior staff where appropriate
• Demonstrate knowledge and understanding of systemic treatments used to treat the common dermatological conditions, i.e. Eczema; psoriasis; bullous skin disorders; severe drug eruptions; erythrodermic conditions; acute skin infections and infestations; acne and rosacea; scalp conditions
• Demonstrate awareness of different treatment options and the concept of first, second- and third-line treatments
  • • Ability to discuss the common systemic treatments comprehensively with patients and carers, including:

• • • Risks and benefits of the treatments
    • Dosing and monitoring
    • Expectations / potential outcomes
    • Assist with monitoring and evaluating outcomes
    • Able to recognise potential adverse effects and take appropriate action, escalating to senior staff where appropriate

Skin Surgery: Is not a requirement of all level 6 Dermatology posts. Performing skin surgery alone does not determine the level of practise demonstrated by the practitioner. If performing skin surgery is part of a job description, then following competencies should be considered.

Demonstrates knowledge and understanding of surgical procedures for patients with skin cancer and inflammatory skin disease (see Appendix 5):

• Demonstrates an understanding of the factors influencing choice concerning surgical options and can identify contraindications
• Obtains informed consent as per local and national guidance
• Demonstrates sufficient knowledge and skill to discuss risks / benefits/ expectations of surgical procedure with patients and carers and understands factors influencing choice
• Demonstrates competence to perform relevant surgical procedures (such as those listed in Appendix 5 but list not exhaustive) in accordance with role and locally agreed policy
• Demonstrates competence to select appropriate post-operative care
• Demonstrates ability to identify adverse effects of surgical procedure and escalates to senior staff / other healthcare disciplines appropriately as necessary

6C23

Relationship Building and Communication: Understand the importance of, and demonstrate ability to form, a professional therapeutic relationship with patients:

1. Develop an effective questioning and clarification technique with patients and carers, checking that understanding has been reached
2. Identify tensions and constraints in relationships and demonstrate how these can be overcome
3. Involve patients and carers at all stages in decision making processes
4. Communicate at a level appropriate to individuals and identify patients that require the involvement of interpreting services
5. Recognise and demonstrate therapeutic opportunities for patient support through nursing interaction

6C24

Psychosocial impact of skin disease: Demonstrate knowledge and understanding of psychosocial issues which impact on a patient with a dermatological condition:

1. Demonstrate clear assessment and documentation of patients’ cognitive, emotional, social and spiritual needs in relation to their skin condition and how it impacts on their lives
2. Use holistic assessment to recognise the need for nursing / medical / psychosocial intervention as appropriate
3. Understand and utilise the appropriate care pathway to address psychosocial needs of patients with skin conditions
4. Recognise when patients may require specialist support services and effectively facilitate onwards referrals as appropriate

6C25

Promoting health and self-management: Demonstrate knowledge and understanding of self-management strategies and be able to encourage the individual and their family / carers to foster a self-management approach:

1. Understand theories which influence patient choice concerning self-management and patient education
2. Demonstrate a knowledge of self-efficacy concept
3. Identify and explore patient empowerment, including internal and external motivation and factors that may lead to the withdrawal of medication, and adopt strategies to improve health by encouraging concordance
4. Offer guidance to patients regarding lifestyle changes and the long-term implications of skin disease, while taking medication or following withdrawal
5. Refer to other Health Care Professionals and support services as appropriate
6. Demonstrate knowledge and understanding of health promotion and demonstrate active participation in health promotion projects and programmes to improve the health and wellbeing of communities and populations
7. Demonstrate the ability to relate health promotion theory to clinical practice

6C26

Specialist Resource:

1. Act as a specialist resource and educator for junior staff members and members of the wider multidisciplinary team
2. Participate in team meetings as a senior voice assisting in management and clinical decisions
3. Contribute to the development of policy, protocol and guidelines

Competencies 6C27 onwards are integral to role of Level 6 where the job plan includes lesion recognition / skin cancer care as it is recognised that some areas / posts are not involved in this area of care. It is however expected that Level 6 nurses working within dermatology will have an awareness of these conditions and recognise when to escalate concerns.

6C27

Demonstrate knowledge and understanding of the most common benign and malignant skin lesions:  Melanoma (Stages 0-4); Squamous Cell Carcinoma; Basal Cell Carcinoma; Keratoacanthoma; Atypical naevi; Bowen’s Disease; Actinic keratosis; Seborrhoeic keratosis; lichenoid keratosis; dermatofibroma; solar lentigo:

1. Recognise and describe benign naevi, benign lesions, pre-malignant lesions, non-melanoma skin cancers and all types of melanoma
2. Demonstrate knowledge of the assessment and monitoring tools used in assessing skin cancer using basic dermoscopy and digital imaging to aid diagnosis or monitor where appropriate and in line with local job plan
3. Able to discuss information with patients and carers and provide written information
4. Contribute to MDT discussions

6C28

Has knowledge of and understands importance of epidemiological data relating to skin cancers:

1. Understands the morbidity and mortality rates of skin cancers
2. Understands the incidence, prevalence and causative factors of skin cancers
3. Understands increasing numbers of skin cancers diagnosed in Scotland and subsequent burden on services

6C29

Demonstrates comprehensive knowledge of national/local guidelines and policies in relation to practice:

1. SIGN / NICE guidelines
2. BAD Guidelines
3. AJCC Staging System
4. Melanoma Risk prediction tools
5. Quality Performance Indicators
6. Contributes to local guidelines, policies and initiatives pertaining to skin cancer
7. Acts as a resource for junior staff and other health care professionals

6C30

Demonstrates knowledge and understanding of the assessment of a patient with skin cancer or related condition (see Appendix 3):

1. Demonstrates understanding of holistic patient assessment and is able to take an in-depth patient history and undertake a full skin assessment, documenting findings clearly and concisely so as to provide a rationale for diagnosis and management plan
2. Demonstrates a knowledge of examination of regional lymph nodes
3. Uses assessment and monitoring tools appropriately and competently in line with agreed local scope of practice
4. Plans patient care based on assessment
5. Recognises limits of own practice and escalates complex cases or diagnostic doubt appropriately
6. Communicates with other disciplines at an appropriate level as per local policies

6C31

Demonstrates knowledge and understanding of investigations needed for skin cancer patients and is able to interpret results and initiate subsequent treatment within agreed local scope of practice (See Appendix 4):

1. Demonstrates an understanding of the different and most appropriate investigations required for diagnostic and prognostic indicators in the management of skin cancer patients
2. Demonstrate competence in requesting appropriate investigations for skin cancer as per locally agreed scope of practice and IRMER regulations
3. Demonstrates knowledge of local and national guidelines on consent
4. Is able to interpret results within locally agreed scope of practice and plan subsequent treatment accordingly
5. Advises patient/carer on investigations and treatment and assists in supporting patients undergoing investigations, including providing appropriate information to minimise adverse effects
6. Refers appropriately to other healthcare professionals

6C32

Demonstrates knowledge and understanding of therapeutic interventions for patients with skin cancer (see Appendix 5):

1. Demonstrates an understanding of the factors influencing choice concerning treatment options
2. Obtains informed consent as per local and national guidance
3. Demonstrates sufficient knowledge and skill to discuss risks, benefits and expectations of treatment and/or trial options with patients and carers and understands factors influencing choice
4. Demonstrates competence to perform different therapeutic interventions (such as those listed in Appendix 5 but list not exhaustive) in accordance with role and locally agreed policy
5. Assists with planning patient care and
6. Demonstrates ability to evaluate outcome of therapeutic interventions and escalates to senior staff and other healthcare disciplines appropriately as necessary
7. Acts as a key worker for skin cancer patients through MDT clinics and patient journey as appropriate
8. Demonstrates support for patients requiring therapeutic and/or palliative care

6C33

Demonstrates knowledge and Understanding of Staging Investigations for patients with skin cancer:

1. Demonstrates understanding of different and most appropriate investigations required as diagnostic and prognostic indicators in the management of patients with skin cancer
2. Demonstrates knowledge of side effects from radiological investigations
3. Demonstrates competence in ordering appropriate radiological investigations in accordance with local policy and IRMER
4. Evaluates and acts on results of investigations liaising with senior staff and/or other healthcare professionals as appropriate and as per locally agreed scope of practice
5. Assists with planning of appropriate care once results of investigations are evaluated

6C34

Demonstrates knowledge, understanding, and facilitates clinically safe practice when caring for a patient with progressive disease:

1. Identifies signs and symptoms of progressive disease
2. Assists with the preparation of a plan of care appropriate to the disease process
3. Ensures that relatives and carers have the necessary guidance to deal with prolonged care and death
4. Acts as a key worker for the patient throughout the patient journey and MDT process
5. Involves the most appropriate healthcare professional and/or service

6C35

Demonstrates knowledge and understanding of psychosocial issues that impact on patients diagnosed with skin cancer (see Appendix 6):

1. Demonstrates clear assessment and documentation of patients’ cognitive, emotional, social and spiritual needs in relation to their skin cancer diagnosis and how it impacts on their lives. 
2. Is able to screen for psychological distress using validated assessment tools
3. Following assessment, is able to recognise the need for appropriate nursing, medical and/or psychosocial interventions
4. Is able to implement appropriate coping strategies
5. Understands and utilises the appropriate care pathway in addressing psychosocial needs of skin cancer patients
6. Understands the specific needs of people living with and surviving skin cancer and can signpost to relevant national and local survivorship programmes and support groups
7. Provides ongoing emotional, health education and practical support and, in so doing, assist the patient to achieve self-efficacy
8. Refer patients where appropriate to other professional and charitable bodies for help with financial, psychological and emotional support
9. Understand importance for some patients of spiritual support and know how to access chaplaincy services and other faith support

6C36

Demonstrates an ability to encourage the individual and their family to adapt current theories related to skin awareness, skin cancer prevention and self-examination (Appendix 7):

1. Understands theories that influence patient choice and relate them to sun awareness
2. Improves health by encouraging concordance
3. Has understanding of the learning theories influencing patient education
4. Identifies and explores patient empowerment including internal and external motivation
5. Demonstrates the ability to promote self-examination as part of skin cancer prevention strategies with the individual and the wider community
6. Demonstrates the ability to relate health promotion theory to skin cancer prevention in a clinical setting

6C37

Demonstrates knowledge on improving treatment adherence in relation to skin cancer prevention / management:

1. Makes an initial assessment of the potential problem and clarifies whether the patient understands the conclusion reached
2. Has a good understanding of the skin cancer intervention and/or therapeutic procedures that may be offered
3. Can link signs and symptoms with interventions and treatment options
4. Ability to offer guidance to patients regarding sun awareness, self-examination and lifestyle changes while having interventions and/or medication or following withdrawal of these

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 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 criterion 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 

6F16

Provide teaching sessions for staff within the organisation in relation to Dermatology

6F17

Actively involved in public and patient information initiatives

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 wellbeing 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 and lead a team and work in collaboration with others to achieve the teams’ 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

6L15

Actively participates in quality improvement projects concerning specialty and team

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 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

6E10

Aware of dermatology literature surrounding practice and able to use this to inform practice