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

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  
• Relevant Post-registration qualification
• A minimum of a postgraduate diploma and preferably a master’s degree which incorporates clinical work-based learning and has a core educational focus on the development of clinical competence within dermatology relevant to the role
• Level of interpersonal, strategic and technical skills combined with a supportive and visible leadership style
• Non-medical prescriber (V300)
• Appropriate experience at Level 6 within specialty
• Up to date advanced theoretical and practical knowledge regarding professional issues, clinical issues.
• Sound knowledge of dermatology
• Presentation and teaching skills

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 judgment 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

Dermatology Knowledge: Demonstrate a comprehensive knowledge and understanding of anatomy, physiology and immunology of normal skin, its appendages and barrier function, and their significance in skin disorders:

• Distinguish between normal and abnormal features of the skin structures and its appendages
• Demonstrate understanding of the anatomy and physiology of skin applied to skin disorders and relate abnormalities to skin disease processes
• Demonstrate understanding of the immunology of skin, its relationship to skin diseases, and its response to therapeutic immunomodulators
• Demonstrate knowledge and understanding of the common adult and childhood dermatological conditions as appropriate for local working environment:
  • • Eczema
    • Psoriasis
    • Bullous diseases
    • Drug eruptions
    • Erythrodermic conditions
    • Infections & Infestations
    • Acne
    • Rosacea
    • Scalp conditions
    • Urticaria
    • Hypertrophic and keloid scarring
    • Hyperhidrosis
    • Hidradenitis
    • Pre-cancerous lesions
    • Skin cancers

7C16

Assessment: Working autonomously, use comprehensive specialist knowledge to undertake an advanced clinical assessment of a patient with a dermatological condition:

1. Carry out a focused clinical assessment and history taking, maintaining patient privacy and dignity, which may include physical examination, symptom and therapy assessment. The assessment may be face to face, or by phone or by video call

• • Information to be collected should include: past medical history; allergies; medications; social factors; employment and hobbies; family history and history of skin condition; lymph node assessment and organ palpation where appropriate - See also Appendix 3
  • Demonstrate appropriate use and interpretation of assessment tools as appropriate to role: Dermoscopy; medical photography; scoring tools such as PASI, PEST, POEM, DLQI; biopsy results; blood results etc. and act appropriately on these

2. Undertake holistic assessment of a patient’s physical, psychological and social needs, actively involving the patient, their families and carers, and wider partners in assessments
3. Recognise and actively assess for comorbidities associated with various skin diseases and consider these when making a diagnosis and care plan
4. Understand and interpret patient assessment to diagnose skin disease including consideration of differential diagnoses
5. Identify patients with complex health issues and refer and liaise with colleagues and other disciplines as appropriate.  Communicate with other disciplines at an appropriate level
6. Demonstrate knowledge of local and national guidelines and follow these when assessing patients
7. Accurately document findings from assessment and history taking process
8. Make informed judgements in the absence of complete information or where information is inconsistent

7C17

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

1. Able to autonomously request and undertake dermatological investigations appropriate to scope of practice, liaising with other healthcare professionals as required
2. Refer for radiological investigations as per scope of practice and having completed IRMER training
3. Advise patient and/or carer on investigation rationale, potential results, mechanism of specimen procurement such as: swabs; skin scrapings; bloods; contact allergy testing; radiological investigations; skin biopsies; MED/MPD etc.  Also see Appendix 4
4. Demonstrate the correct collection of appropriate specimens pertinent to level of practice and local work practices, and in a manner so as to minimise adverse effects
5. Analyse and respond to results of investigations, such as interpretation of blood results and pathology, including initiating or adapting treatment plans as appropriate to ensure patient safety. Escalate appropriately as required
6. Relate the pathophysiology of skin disease and effects of treatment to results of investigations and onward management of the patient’s condition
7. Demonstrate knowledge of local and national guidelines and follow these when considering investigations
8. Present findings to colleagues and healthcare professionals such as multidisciplinary team where appropriate

7C18

Treatment and Care: Demonstrate and apply a comprehensive knowledge and understanding of a wide range of treatments used to treat dermatological conditions, in order to prescribe the most appropriate therapy including topical therapies, phototherapy and systemic / biologic medications:

1. Demonstrate a comprehensive knowledge of the criteria, including national and local protocols and guidance, determining treatment choice of therapeutic intervention for individual patients
2. Design, develop, implement and evaluate care pathways in partnership with the patient after explanation and discussion of all available options
3. Discuss all appropriate treatment options comprehensively with patients and carers, including risks and benefits, pre-treatment screening, dosing and monitoring, treatment evaluation, expectations and potential outcomes, thus enabling patients to be active partners in decision making
4. Provide appropriate individualised education and support for patients and carers so as to provide effective therapy, including potential variations in pattern, severity and duration of symptoms
5. Recognise side effects, potential adverse effects and unusual presentation of skin diseases and take appropriate action
6. Appraise the impact of skin disease and potential comorbidities on the patient
7. Demonstrate awareness of treatment compliance issues and how to reduce these whilst managing the patient's expectations
8. Review all decisions with the patient and seek advice or support from colleagues or other disciplines as appropriate
9. Assess, plan, implement, evaluate and alter treatment autonomously and in partnership with the patient, while managing adverse events appropriately and taking results of investigations into consideration. 
10. Has knowledge, skills, competence and authority to discharge patients from the service or make appropriate follow up arrangements
11. Outline the physiological and psychological processes and consequences that may result in an acute episode or with specific conditions or medications
12. Record accurate information during treatment to collate evidence for efficacy of/response to treatment
13. Recognise complex and acute presentational issues identifying support needed - both immediate and ongoing - and any necessary referral to senior colleagues or other Health Care Professionals
14. Lead and advise on clinically safe practices when caring for an ill patient, and act appropriately when emergency action is required
15. Recognise and intervene appropriately during an acute episode of care or deteriorating condition, implementing local and national guidelines and policies
16. Provide relatives and carers with the necessary information and support to deal with prolonged care
17. Demonstrate proficiency in the use of equipment, pertinent to individual workplaces and roles, such as phototherapy cabinets, photodynamic therapy lamps, Iontophoresis equipment, hyfrecators, diathermy etc.  See also Appendix 5

Skin Surgery: Is not a requirement of all level 7 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):

1. Demonstrates an understanding of the factors influencing choice concerning surgical options and can identify contraindications
2. Obtains informed consent as per local and national guidance
3. Demonstrates sufficient knowledge and skill to discuss risks, benefits and expectations of surgical procedure with patients and carers and understands factors influencing choice
4. Demonstrates competence to autonomously perform  relevant surgical procedures (such as those listed in Appendix 5) in accordance with role and locally agreed policy
5. Demonstrates competence to select appropriate post-operative care
6. Demonstrates ability to identify adverse effects of surgical procedure and escalates to senior staff and other healthcare disciplines appropriately as necessary

7C19

Psychosocial impact of skin disease: Comprehensive and deep understanding and recognition of psychosocial issues which may impact on persons with a skin condition:

1. Demonstrate detailed assessment of psychosocial needs of patients with skin conditions including cognitive, emotional, social and spiritual
2. Recognise the need for and document a detailed care plan, implement and evaluate interventions to address psychosocial needs
3. Recognise other psychological conditions or psycho-pathological conditions that impact on patients with skin disease
4. Understand and utilise appropriate care pathways / triage to address complex psychosocial needs
5. Undertake effective, appropriate and autonomous referral of patients requiring specialised support services e.g. psychiatry, psychology referral, further spiritual support
6. Actively signpost patients, carers and families to NHS and external sources of support as required
7. Use dermatology tools effectively – e.g. DLQI score, HADS score - and respond to scores appropriately/as required

7C20

Relationship Building & Communication:

1. Possess advanced communication skills.
2. Be visible as a leader and senior expert but also approachable to the team
3. Support and educate other members of the multidisciplinary team
4. Actively promote equality and diversity
5. Application of principles of motivational interviewing during consultations with patients.
6. Explore factors detrimental to healthy behaviours for the team.
7. As an integral team member, attends and contributes to team meetings and regular communication with the multidisciplinary team

7C21

Promoting health and self-management: Lead in promoting health and self-management for individuals and in the wider community:

1. Act as an expert advisor, as well as providing ongoing support for both national and locally developed health promotion campaigns, thus improving the health and wellbeing of the population.
2. Have the ability to evaluate health promotion interventions and their effectiveness and change accordingly to focus on a specific group or skin disease
3. Provide support for patients, carers and families.  Able to effectively signpost to appropriate resources
4. Excellent understanding and application of learning theories and those that support effective empowerment.
5. Actively promote self-management options leading to patient empowerment.
6. Optimise patient’s power (agency) through patient self-efficacy, concordance with treatment and confidence building through skilful education and support.
7. Develop dynamic interventions building patient’s self-esteem and confidence, leading to empowerment to take control and sound knowledge on their skin condition and know how to treat and manage.
8. Explore and understand the criteria against which patients judge treatment effectiveness in order to deliver effective education.
9. Identify tensions between the rights and choices of the individual

7C22

Specialist Resource: Act as a specialist resource to initiate and lead clinically safe practices within the wider healthcare team:

1. Develop care pathways with professionals
2. Development and implementation of local and national protocol, policy, care pathways standards and guidelines
3. Mentor colleagues including other Health Care Professionals in the wider MDT, and provide support and empower staff
4. Educate other Health Care Professionals, patients and carers

7C24

Has a comprehensive knowledge and ability to interpret key epidemiological data relating to non-melanoma skin cancer and malignant melanoma:

1. Knowledge of Scottish Cancer Registry and Intelligence Service, Public Health Scotland and other resources for epidemiological data to obtain facts and trends to assist with education and management
2. Can critically discuss and disseminate knowledge to others
3. Critically analysing and integrating skin cancer data in the provision and development of services at both local and national levels
4. Educates other healthcare professionals, patients and carers

7C25

Has a comprehensive knowledge of national and local guidelines and policies in relation to practice:

1. NHS Scotland Cancer Strategy and Action Plans
2. SIGN / NICE Guidelines
3. BAD Guidelines
4. AJCC Staging Systems
5. Melanoma risk calculators such as MIA SLNB risk prediction calculators
6. Local and regional MDT
7. Peer review and Quality Performance Indicators
8. Contributes to peer review process in own practice area and peer reviews others
9. Contributes to national, local guidelines and policies and initiatives pertaining to skin cancer
10. Educates other healthcare professionals, patients and carers

7C26

Has a comprehensive knowledge and understanding of the assessment of a patient with skin cancer or related condition (See Appendix 3):

1. Undertakes a holistic assessment and patient history
2. Undertakes full skin examination and diagnostic assessment
3. Undertakes examination of regional lymph nodes
4. Uses assessment and monitoring tools
5. Able to recognise skin cancer and distinguish from benign lesions
6. Critically analyses and acts on findings in line with current evidence-based practice but escalates when required
7. Reviews and updates assessment tools in light of current evidence-based practice
8. Refers to other healthcare professionals as appropriate by written, electronic or other means

7C27

Has a comprehensive knowledge and understanding of investigations needed for skin cancer patients, and is able to interpret results and initiate subsequent treatment (Appendix 4):

1. Dependent on role, to identify, refer for or perform relevant surgical intervention autonomously for specific skin cancer diagnosis
2. Demonstrate competency in requesting appropriate investigations for skin cancer and advanced disease according to local policies
3. Ability to interpret and action results appropriately, liaising with appropriate clinicians where necessary
4. To communicate with health professionals in primary, secondary and tertiary care
5. To educate and support other healthcare professionals
6. Minimise adverse effects
7. Refer to other disciplines
8. Participate with other members of the MDT in developing treatment plans

7C28

Has a comprehensive knowledge and understanding of therapeutic interventions for patients with skin cancer Appendix 5):

1. Competently advises / prescribes / refers for different therapeutic interventions for skin cancer patients
2. Autonomously plans and evaluates patient care including performing therapeutic interventions as deemed competent by local policies and guidelines
3. Mentors colleagues developing new interventional skills
4. Supports and educates other members of the MDT

7C29

Has a comprehensive knowledge and understanding of staging investigations for patients with skin cancer:

1. Demonstrates competency in ordering and requests appropriate radiological investigations with the necessary training for non-medical healthcare practitioners in accordance with the Ionising Radiation (Medical Exposure) Regulations 2000 and local policy
2. Demonstrates ability to evaluate outcome of investigative interventions
3. Plans patient care including ordering of investigations as appropriately discussed with MDT as per local protocol
4. Evaluates and acts on results of investigations liaising with appropriate MDT member or healthcare professional
5. Acts as a key worker for skin cancer patient through MDT clinics and patient journey
6. Supports and educates other members of the MDT team

7C30

Has a comprehensive understanding of collecting and collating evidence to support patients and carers:

1. Designs, develops and implements care pathways in conjunction with patient and MDT
2. Empowers individuals to protect own health
3. Uses validated assessment tools to grade severity of conditions and psychosocial impact
4. Exercises professional judgement and uses critical appraisal when making an assessment
5. Critically analyses levels of knowledge
6. Distinguishes between subjective and objective information

7C31

Has a comprehensive knowledge and understanding of caring for the patient with progressive disease:

1. Initiates appropriate care pathway with professionals in anticipation of potential problems
2. Sympathetic to complex issues and identifies necessary ongoing referral
3. Develops and implements appropriate holistic needs assessment

7C32

Has a comprehensive knowledge and deep understanding of psychosocial issues that impact on persons with skin cancer (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 life. Is able to screen for psychological distress
2. Following assessment, recognition of the need for appropriate nursing and/or medical and/or psychosocial intervention(s). Documents a detailed care plan and implements nursing interventions which address identified psychosocial needs of the patient
3. Is able to use problem solving in order to implement appropriate coping strategies
4. Recognises other psychological conditions or psycho-pathological conditions which impact on patients with skin cancer
5. Understands and utilises the appropriate care pathway/triage to address complex psychosocial needs of this patient group
6. Understands the importance of and complexity of support that the patient’s significant others may require and is able to act as an enabler in accessing this support
7. Understands and acts as the patient advocate when appropriate. Instigates and undertakes relevant audit, focus groups and questionnaires to ensure care is patient-centred
8. Understands the specific needs of people living with and surviving skin cancer and is confident in referring patients to and or running survivorship or support groups
9. To include provision of ongoing emotional, health education and practical support
10. To respect the importance for patients to achieve self-efficacy in relationship to survivorship issues
11. Understands the complex issues related to end-of-life care and bereavement and is able to initiate support mechanisms for the patient and significant others

7C33

Demonstrates a capacity to empower individuals and their families to identify and reach realistic goals related to sun awareness, skin cancer prevention and self-examination theories (Appendix 7):

1. Excellent communication skills
2. Excellent understanding of learning theories
3. Explores factors detrimental to healthy behaviours
4. Actively promotes self-management options leading to patient empowerment
5. Empowerment through patient self-efficacy, concordance with treatment and confidence building
6. Develops dynamic interventions building patients’ self-esteem and confidence leading to empowerment

7C34

Demonstrates a commitment to develop, implement and evaluate strategies on skin cancer prevention for patients and the wider community:

1. Acts as an advisor on skin cancer prevention, as well as providing ongoing support for locally developed skin cancer competencies
2. Improving the health and wellbeing of communities and population as a whole through skin cancer prevention projects and programmes
3. Collaborates with external agencies and leads on skin cancer prevention educational events

7C35

Has a comprehensive knowledge of interventions and therapeutic procedures that may be offered – surgical interventions, topical therapies and systemic therapies to assist in health education and promotion and aid concordance:

1. Describes the criteria that would determine the choice of therapeutic intervention for a patient with skin cancer
2. Provides written, electronic and oral information as well as signposting to all other resources available for patients and carers on the potential variations in the pattern, severity and duration of their symptoms related to skin cancer interventions
3. Skilled in concordance consultation style with patients as a basis for enhancing patient adherence to minimising UV exposure risk
4. Communicates with MDT on clinical issues using written, verbal and electronic means as required
5. Reviews all decisions with the patient and considers the possibility of seeking advice and support regarding therapeutic interventions
6. Identifies tensions between the rights and choices of the individual

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 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 

7F16

Provide teaching sessions for staff within the organisation in relation to Dermatology and with external partners

7F17

Acts an advocate for the specialty, promoting Dermatology within Higher Education Institutes

7F18

Support interface working establishing positive working relationship with Primary Care (particularly with regards Nursing roles seeing patients with skin conditions)

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 polices 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 through 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

7E12

Has significant active role in dermatology research studies, within department, which may include Principal Investigator or Co-Principal Investigator

7E13

Disseminates knowledge and research through publication in Dermatology journals; writing independently or as part of a team