The White Paper Liberating the NHS signals a new decentralized approach to workforce planning, education and training in England (Department of Health (DH), 2010), with implications for all sectors of the health service, including ambulance services.
Stroke is a prime example of a condition where ambulance services and other NHS organizations deliver care according to national quality markers and guidelines from the National Institute for Health and Clinical Excellence (NICE), the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and elsewhere; but in the context of significant local heterogeneity in models of care (The Intercollegiate Stroke Working Party, 2010).
In 2007, the DH published an ambitious 10–year strategy for improving stroke services, describing what ‘good care’ looks like and, crucially, a commitment to develop the clinical workforce. Expert panels and public representatives examined the stroke care pathway described in the National Stroke Strategy (DH, 2007) to identify learning outcomes for each of its clinical and service recommendations.
The stroke-specific education framework (SSEF) (UK Forum for Stroke Training (UKFST), 2009) developed by expert panels (consisting of clinicians; staff from health and social services; voluntary sector; education and stroke networks, and service users), is a guide for NHS staff and training providers intended to help shape local workforce development. The SSEF is made up of 16 elements of care, based on the quality markers in the stroke strategy, which have relevance to the standards and recommendations found in the stroke strategies of all four UK nations. Each element consists of competencylike items that an individual who works with those affected by stroke should have knowledge and skills in.
UK forum for stroke training
The SSEF is being implemented through the UKFST. With multidisciplinary and lay representation from across the UK, the UKFST directs and manages the application of the SSEF to the development of the clinical workforce.
In order to promote high quality local education and training, UKFST offers quality assurance through a detailed review process, irrespective of provider or the size of the intended audience. Training content is mapped onto the SSEF to guarantee relevance to national standards, and of trainer's expertise. Each application for endorsement (including actual course materials) is assessed by trained reviewers to assure relevance and quality. Those courses or events meeting the standard are featured on a searchable online database and approved providers can use the UKFST logo on their course materials. UKFST processes are not intended to compete with university accreditation or professional CPD credits, but are an attempt to direct NHS staff working towards the most relevant, up-to-date learning opportunities in the context of local commissioning arrangements.
The UKFST experience demonstrates that condition-specific guidance for clinical outcomes can be deconstructed into a clear framework that maps onto educational objectives. By keeping traditional professional boundaries to a minimum, multidisciplinary teams— including ambulance personnel— can identify and access high quality education and training to support further improvement in patient outcomes and experience.
Full details about the UKFST, the endorsement process, approved events and role profiles can be found at: www. ukstrokeforum.org and clicking on the link for the UKFST.
Job role profles
The work of the UKFST has now extended beyond endorsement of training, with the SSEF also being used to support the development of job role profiles. These role profiles are a way to identify what knowledge and understanding, and skills and abilities staff should have, depending on their role on the stroke pathway. Where knowledge and skills are needed, a descriptor is provided to show the level needed.
Using definitions provided by Skills for Health, the descriptors are: basic; factual; working; in-depth and critical. A definition for the descriptors can be found in the SSEF document. Staff role profiles are in development for a wide range of staff and this will also include ambulance staff.
Taking the example of frontline ambulance staff, it is reasonable to assume that they would have knowledge and skills relevant to the first element of care: ‘Awareness raising.’ But do they need the knowledge and skills for all items, and where these are needed, at what level? Table 1 gives an example of what role profiles for different types of frontline staff might look like. Staff in those roles can assess themselves and compare their levels of knowledge and skills with suggested ideal levels. By doing this, they can identify both training needs as well as areas for development so that they can progress their careers.
| E1 | Awareness raising | Emergency | Ambulance | Paramedic | Paramedic |
|---|---|---|---|---|---|
| Care Assistants | Technician | band 5 | band 6 | ||
| Knowledge and understanding of… | SSEF level? | SSEF level? | SSEF level? | SSEF level? | |
| e1k_1 | Signs and symptoms of stroke | Basic | Factual | Working | In-depth |
| e1k_2 | Features of less common (atypical) presentation of stroke | Basic | Factual | Working | In-depth |
| e1k_3 | Stroke mimics and likely presentation | Basic | Factual | Working | In-depth |
| e1k_4 | Stroke and TIA as medical emergencies | Basic | Factual | Working | Working |
| e1k_5 | Emergency response, investigations, interventions and treatments for stroke and TIA | Basic | Factual | Working | Working |
| e1k_6 | Timeframe for emergency investigations, interventions and treatments for stroke and TIA | Basic | Factual | Working | In-depth |
| e1k_7 | Anatomy and physiology of the central nervous system | Basic | Factual | Working | Working |
| e1k_8 | Timeframe of physiological and neurological changes during stro | ke Basic | Factual | Working | Working |
| e1k_9 | Advocates for stroke patients when there is a legal duty to instruct an IMCA, taking account of religious and cultural aspirations | Basic | Factual | Factual | Factual |
| Skills and ability to… | SSEF level? | SSEF level? | SSEF level? | SSEF level? | |
| e1s_1 | Initiate emergency protocol (stroke factual improvement programme) | Factual | Factual | Working | Working |
| e1s_2 | Communicate current event and need for ermergency treatment | Factual | Factual | Working | Working |
| e1s_3 | Know when to apply screening tests for stroke (FAST) and how to act on the results | Factual | Factual | Factual | Working |
| e1s_4 | Know when to apply vascular risk assessment tools for TIA (ABCD2) and how to act on the results | Basic | Basic | Factual | Working |
| e1s_5 | Identify emergency interventions and treatments for stroke and TIA available locally and know how to refer patients | Factual | Factual | Factual | Working |
| e1s_6 | Take and interpret thorough history, taking third party information where possible, and assess mental capacity | Factual | Factual | Factual | Working |
| e1s_7 | Identify and appropriately treat stroke mimics, e.g. hypoglycaemia, epileptic seizure | Factual | Factual | Factual | Working |
The role profiles should be considered the minimum level needed for that knowledge or skill. In addition, it is important to take account of individual staff and/or service requirements, which may mean that levels need to be adjusted. For example, an ambulance service may introduce new screening tools which are compulsory for all staff. An implication of this might be that the levels suggested for items e1s_3 and e1s_4 in Table 1 need to be uplifted.
Conclusion
Stroke-specific knowledge gained through training can be used in practice, allowing staff from a wide range of disciplines to develop stroke-specialist competence. Role profiles can help identify training needs and knowledge and skill levels.