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SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 1 of 47
Standard Operating Procedure for the induction of Agency Registered Nurses and Midwives
Primary Intranet Location
Version Number
Next Review Year Next Review
Month
Nursing and Midwifery 1 2020 February
Current Author
Adrian Debney and Amanda Small
Author’s Job Title
Corporate Practice Development Nurse and Head of Education and
Development
Department
Corporate Nursing – Trust wide
Ratified by
Nursing and Midwifery Policy and Standards Committee
Date
28th February 2019
Owner
Emma Hardwick
Owner’s Job Title
Chief Nurse
It is the responsibility of the staff member accessing this document to ensure that they are always
reading the most up to date version - This will always be the version on the intranet
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 2 of 47
Related Policies
Procedure for the recognition of previously acquired enhanced
Nursing, Midwifery and Operating Department practitioner skills
Associated Documents
Agency Orientation and skills passport document
Stakeholders
Agency nurses
Agency Midwives
Registered Nurses
Resourcing department
Practice Development team
Senior Nursing and Midwifery leadership team
Version Date Author Author’s Job Title Changes
V1
February
2019
Adrian
Debney
and
Amanda
Small
Corporate Practice
Development Nurse
and Head of
Education and
Development
New Procedure
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 3 of 47
CONTENTS
Ref No
SECTION TITLE Page No
1 INTRODUCTION 4
2 PURPOSE AND SCOPE 4
3 DEFINITIONS 4
4. RESPONSIBILITIES 5
4.1 External employing agencies 5
4.2 Trust Central Resourcing Department 5
4.3 Department Managers/Nurse or Midwife in charge 6
4.4 Agency Workers 6
4.5 Practice Development Team 7
5 PROCEDURE 7
6 REFERENCES 10
7 APPENDICES 10
Appendix 1: Booking form for agency workers 11
Appendix 2: Agency worker orientation booklet and skills
passport
13
Appendix 3: Process for agency worker employment, induction
and competency assessment.
46
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 4 of 47
1 INTRODUCTION
1.1
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust is committed to ensuring
the highest standards of patient care and safety at all times by ensuring that the services
they provide to their patients have appropriate governance assurances in place.
1.2 It is recognised that, in order to ensure the provision of services, agency workers may have
to be appointed to cover variable periods of time. Such cover may be necessary as a result
of staff shortages through absence or vacancies.
1.3 The Trust is committed to ensuring that all agency workers will:
receive an appropriate induction to the area in which they will provide work.
be aware of and work in accordance with trust policies and procedures.
have achieved the necessary standards of competence to practice enhanced clinical
skills.
have access to the necessary resources such as Information technology to be able to
effectively undertake their role.
2 PURPOSE AND SCOPE
2.1
The purpose of this document is to ensure that all key stakeholders including managers and
agency workers are aware of their responsibilities with regard to the induction and
competency assessment of agency workers.
2.2 The standard operating procedure (SOP) will ensure a consistent process is in place for
inducting agency workers into the trust and to ensure compliance with the Trusts policies
and procedures.
2.3 This procedure may also be used to provide guidance to additional training or practice and
educational interventions where practitioners have an identified skills, knowledge or
practice need.
2.4 This SOP applies to all agency workers employed through an external agency, it does not
apply to staff employed on the trust bank as these employees will receive their induction
via the Trust’s corporate induction process.
3 DEFINITIONS
3.1
Agency worker
A person from an external source providing the Trust with necessary skills on an “as and
when required” basis.
3.2 Competence
The NMC uses competence to describe skills and the ability to practise safely and effectively
without the need for supervision (NMC, 2018). Competence is contingent upon assessment
of specific knowledge and skills to ensure that practitioners are compliant with stated
standards of practice.
3.3 Assessment
Assessment is variably defined as ‘a means of collecting data to demonstrate that an
acceptable standard of practice has been reached and upon which a decision to declare a
practitioner competent can be made’. (Hand, 2006). Assessment may be reached using a
range of methods which are aligned with the stated learning outcome. This may include
reflection, rated observation, critical analysis, summative testing and peer review.
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 5 of 47
4 RESPONSIBILITIES
4.1
External employing agencies
External agencies are responsible for providing:
personal details and Curriculum Vitae (CV) for individual agency workers.
evidence of current professional registration including any restrictions placed upon
the agency workers practice and skills competencies for individual agency workers.
evidence that all pre-employment checks have been undertaken for individual
agency workers including DBS check and occupational health clearance.
evidence that the agency workers mandatory training compliance is up to date for
the following mandatory subjects:
- conflict resolution.
- Equality and diversity.
- fire safety awareness
- health and safety awareness.
- infection prevention and control.
- information governance.
- manual handling.
- Basic Life Support and anaphylaxis.
- safeguarding adults level 2.
- safeguarding children level 3 (as required).
evidence that the agency worker has undertaken the following training:
- Mental capacity act 2007
- NEWS2
agency workers will have access to trust information via The Queen Elizabeth
Hopsital Kings Lynn NHS Foundation Trust Agency workers website
https://qehklagency.wordpress.com/
4.2 Trust Central Resourcing Services (CRS) department
The Central Resourcing Services (CRS) department is responsible for checking and recording
the following information on the booking process for agency workers checklist (Appendix
1).
screening agency workers CV to ensure suitability to work.
forwarding the CV of suitable agency workers to the Deputy Chief Nurse or
Associate Chief Nurse for approval.
informing the agency of the decision to approve or decline the agency worker.
recording the agency workers professional registration details.
checking the personal identification of the agency worker
notifying the Trust’s Security office to provide ID badge
sending notification of new starter form to IT service desk to request IT user name
and password for the agency worker.
The CRS department is also responsible for:
maintaining records of the booking process.
providing the agency worker with a copy of the trust orientation and skills passport
booklet (Appendix 2).
maintaining records of completion of the local induction checklist for agency
staff (Within the skills passport Appendix 2).
4.3 Department managers/Nurse or Midwife in charge
All ward managers or the Nurse/Midwife in charge is responsible for:
checking workers are carrying accurate ID for the Trust and their agency and are
complying with trust uniform policy.
completing part one of the agency local induction checklist within the individual
agency workers skills passport (Appendix 2) in every new clinical area the agency
worker is rostered to.
completing part two of the induction checklist within 2 hours of the agency workers
https://qehklagency.wordpress.com/
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 6 of 47
first shift in the trust.
ensuring the agency workers is assessed undertaking drug administration.
returning the agency local induction checklist to the CRS department.
ensuring that the Clinical skills Declaration assessment form (Within the skills
passport Appendix 2) is completed for pre-existing skills appropriate to the clinical
area that the agency worker has evidence of competency for and send a copy of the
completed form to the CRS department.
4.4 Agency workers:
All agency workers are responsible for ensuring:
that their conditions for practice are maintained and recorded with the Nursing and
Midwifery Council (NMC) through revalidation to ensure entry onto the professional
register.
identifying practice requirements and any educational, development or training
needs which may be needed to meet these requirements to the requisite standard.
accessing and engaging with information, expectations and orientation
requirements of the Queen Elizabeth Kings Lynn Hospital NHS Foundation Trust
provided via the Agency Nurse Website (https://qehklagency.wordpress.com/) and
agency worker orientation booklet (Appendix 2).
completion of assessments as detailed on the welcome page of the agency website
prior to commencing in trust.
that they arrive on time and report to the operations centre to sign in before being
deployed to the clinical area that they are booked to work.
they collect their IT user name and temporary password from the operations centre
and undertake online IT training.
they perform their assigned tasks and responsibilities to the standards of
performance required including adherence to the Trust’s core values and policies
and procedures.
that they wear the agency uniform that they are representing and have their name
badge present at all times.
seeking clarification if they are unclear of any duties assigned to them
they work within their professional guidelines and within their scope of practice
(NMC 2018).
escalating any concerns to the nurse/midwife in charge.
accepting redeployment to other clinical areas according to patient acuity and
dependency unless they have a justifiable reason.
that they take their allotted breaks throughout their shift (1 hour total break time
during a long day and 30 minutes in an 8 hour shift).
4.5 Practice Development Team
The practice development team are responsible for ensuring that all information contained
within the dedicated trust agency website is current and updated as required. The practice
development team can also be contacted to provide training, support and competency
assessment of individual agency workers.
5 PROCEDURE (illustrated in Appendix 3)
5.1 The employing agency will undertake appropriate pre-employment and professional
registration checks for individual agency workers. This will include a robust framework for
declaration and recording of current competency status.
5.2 The employing agency will send each individual agency workers CV, evidence of pre-
employment checks and competency checklist to the trust CRS department for
consideration of employment.
https://qehklagency.wordpress.com/
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 7 of 47
5.3 The CRS department screens the individual agency workers information to ascertain
suitability for employment within the trust and collates details of the agency worker using
the agency booking process checklist (Appendix 1). If any agency workers are deemed
unsuitable at this point, the agency is contacted to inform them that the agency worker has
been declined employment and the reason for this.
5.4 Suitable Agency worker details are forwarded to the Deputy Chief Nurse (DCN) or Associate
Chief Nurse (ACN) for consideration. These details are reviewed and a decision made to the
suitability of the agency worker for employment within the trust. This decision is
communicated to the CRS department.
5.5 The CRS department will inform the agency of the decision to approve or decline the
agency worker employment within the trust. The CRS department will send a new starter
form to the IT service desk to request an IT user name and password be set up for the
agency worker. These temporary log in details will be provided in a sealed envelope for
the agency worker to collect from the operations centre on their first shift.
5.6 Following confirmation of employment, the agency will provide the agency worker with
the website address for the Trust agency worker website
https://qehklagency.wordpress.com/ . The agency will inform the agency worker that they
must access the website prior to their first shift with the Trust. The Agency worker can
download and complete the drug administration competency assessment and access other
competency assessment documents listed in their induction checklist however copies of
these are contained within the skills passport (Appendix 2) which will be provided to them
on their first shift within the trust.
5.7 On arrival for their first shift, the agency worker will report to the operations centre to:
Sign in and confirm ward allocation with the site manager.
Collect their induction booklet and skills passport.
Collect their temporary IT log in details.
The agency worker should then report to their allocated ward or clinical area.
5.8 Within the first hour of the agency workers first shift within a new clinical area, the
nurse/midwife in charge must orientate the agency worker to the clinical environment and
complete with the agency worker, the first section of the induction checklist (within the
skills passport Appendix 2).
5.9 Within the first 2 Hours of the agency workers first shift, part 2 of the induction checklist
should be completed. This section relates to a more in depth orientation to the clinical
area, medicines management and documentation. The nurse/midwife in charge may
delegate this to another member of the team to complete or the Practice Development
team can be contacted to support this process.
5.10 Agency workers must be assessed undertaking administration of medicines/a drug round
during their first shift by a registered professional who is competent in administering
medications. The drug round assessment form should be completed (contained within the
skills passport), a copy should be sent to the CRS department and competence must be
recorded on part 2 of the induction checklist. The Practice Development team can be
contacted to support this process.
5.11 On completion of part 1 and 2 of the induction checklist, the nurse/midwife in charge must
take a copy of the completed checklist and send to the CRS department for central record
keeping. The agency worker should keep the original document within their skills passport
for future assurance for other clinical areas.
5.12 For subsequent shifts the agency worker should be asked for their skills passport for
evidence of competence and completion of orientation. When working in a new clinical
https://qehklagency.wordpress.com/
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 8 of 47
area, the nurse/midwife in charge must orientate the agency worker to the ward layout
and complete section 1 of the induction checklist. There is no requirement to repeat
completion of section 2 if the agency worker has evidence of completion within their skills
passport. If the agency worker is not able to provide this evidence then this section must
be completed again.
5.13 During the agency workers first two shifts, the agency worker must complete the Clinical
skills Declaration assessment form (contained within the skills passport Appendix 2) in order
to maintain and use the clinical skills that the agency worker has already been deemed to
be competent with and has been practicing regularly. In order to be deemed competent to
undertake the skill within the trust, the agency worker must:
Provide evidence of previously being assessed as competent, such as a completed
competency assessment package.
Read the trusts policy related to the clinical skill.
Have undertaken the skill in practice within the last 12 months.
Been observed and deemed competent by a trust substantive registered practitioner
who is competent in the identified clinical skill (The Practice Development team are
available to support in the assessment of competence if required).
The registered professional observing the skill being delivered must:
ask the agency worker for evidence of competence, such as a completed
competency package.
observe the skill being undertaken and be assured that the agency worker is
undertaking the skill safely and in accordance with trust policy.
sign the clinical skills declaration form to confirm that the agency worker is
competent to undertake the task.
If the registered practitioner is not assured that the agency worker is able to undertake the
clinical skill to the required level then they must not sign the clinical skills declaration form.
5.14 On form completion, the agency worker must send a copy of the form to the CRS
department who will update the agency workers file. The agency worker should also keep
the original within their skills passport which should be kept with them at all times when
working in the trust and should be available for inspection should this be required.
5.15 The agency worker will need to log into a PC with the temporary details provided to them
in the operations centre. Once logged in, the agency worker will be asked to change their
password. This access will enable the agency worker to access the trust intranet to access
policies and procedures, report incidents, book a porter etc.
5.16 The agency worker is expected to use the trust electronic platforms for patient care whilst
working clinically. In order to be able to access and use the trust E-Discharge and Web-ICE
blood results system, the agency worker will need to undertake the online training which
can be accessed via the trust intranet page or via the following link http://qehkl-
inet/his2/WebICE_eLearn.aspx If the agency worker has trouble with accessing the system,
please contact the IT service desk on extension 4422 who will be able to provide guidance.
5.17 The agency worker is expected to be able to monitor blood glucose levels whilst working in
the trust, using the Nova StatStrip Glucometer. Training is available throughout the day on
the Friday of trust induction however should agency workers not be working on this date,
there are a number of train the trainers who can deliver this training on a one to one basis.
Ward managers must ensure that the agency worker has access to this training by
contacting the divisional train the trainer.
5.18 The agency worker is expected to undertake the blood transfusion e-learning modules via
the LearnPro system prior to their first shift to ensure that blood transfusions are
administered in line with national guidance. This e-learning should be accessed via
http://qehkl-inet/his2/WebICE_eLearn.aspxhttp://qehkl-inet/his2/WebICE_eLearn.aspx
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 9 of 47
http://nhs.learnprouk.com
5.19 The CRS department will keep records of all training and induction checklist compliance
within the agency workers personal file.
5.20 Adherence to this SOP will be monitored via quarterly audits of completion rates of the
agency induction checklist.
6 REFERENCES
6.1 Hand H (2006) Assessment of learning in clinical practice, Nursing Standard, 21, 4, 48-56
Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice
and behaviour for nurses, midwives and nursing associates
7 APPENDICES
Appendix 1: Booking form for agency workers
Appendix 2: Agency worker orientation booklet and skills passport
Appendix 3: Process for agency worker employment, induction and competency assessment.
http://nhs.learnprouk.com/
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 10 of 47
Appendix 1: Booking form for agency workers
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 11 of 47
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 12 of 47
Name…………………………………….
Welcome Guide for Agency Nurses Working at
The Queen Elizabeth Hospital Kings Lynn
NHS Foundation Trust
Skills Passport and Orientation Information
Appendix 2: Agency worker orientation booklet and skills passport
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 13 of 47
Dear Agency Nurse,
On behalf of Team QEH, I would like to welcome you to the Queen Elizabeth Hospitals NHS Foundation
Trust Kings Lynn. This document will outline the standards, requirements and expectations of you as an
Agency Nurse working as part of our team and will outline the support you will receive whilst working with
us.
We want all of our patients to experience care in our hospital that is safe and effective and delivered at all
times with care and compassion. Our Values are integral to this and our expectation is that all staff
including agency workers will observe these as a consistent underpinning for their conduct, attitude,
practice and aspirations.
Agency Nurses are an essential part of our Nursing workforce, whilst working at the hospital you can
expect to be treated with the same high standards of professional respect which are accorded to all staff
regardless of position or role.
We recognise that you bring with you a wealth of experience and skills gained from working in a wide range
of organisations and specialities. You will also have completed some core mandatory training requirements
with your Agency. Therefore, this document outlines the standards agreed to ensure that your skills can be
used appropriately and safely to the benefit of our patients.
I hope you enjoy working with us.
Yours Sincerely,
Emma Hardwick
Chief Nurse
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 14 of 47
Telephones and the Bleep System
It is everyone’s responsibility to answer the telephone. Please do not let a call go unanswered.
Whenever you answer the telephone remember that you are the first point of contact for the person calling.
Please state:
• Ward/Department
• Your name and position
The internal bleep system can be used to contact medical staff, senior nurses, specialist nurses/AHPs and
operational staff. Bleep numbers can also be found by looking on the intranet home page by clicking the
telephone icon.
You can check any departmental or personnel number in the hospital by simply typing the name or title into
the QEH directory which can be found on the Trust intranet page. Simply click on ‘phone book’ from the
menu on the left and the directory search engine will be displayed as shown.
.
Emergencies Dial 2222 and state the emergency and location i.e. ‘cardiac arrest, West Raynham ward’.
Bleeps
1) Dial 10 (you’ll hear ‘welcome to the multi-tone paging system’
automated message)
2) Dial the desired bleep number
3) Dial your extension
4) Replace the receiver
It may be that you cannot find the correct title or name for the department which you are searching for, in which case you can
dial 0 for Trust switchboard assistance.
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 15 of 47
Admissions Main Desk 4010 ITU 3570
Castle Acre Ward nurse station 3710 Leverington Ward -SAU Nurse station
4110
A&E Reception front desk 4090 Main Theatres Reception 3740
A&E Paed Nurse station 3560 Marham Ward 4280
A&E Resus. 1 4420 Necton Ward Nurse station 4170
A&E Resus 4 4410 Gayton Ward Trauma Room 3280
A&E Resus. 4 4400 Oxborough Ward Nurse station 4380
Delivery Suite Nurse station 3720 Windsor Ward 4180
Elm Ward 4260 Physiotherapy 4240
Feltwell Ward 4370 Porters 2441
Gayton Ward Nurse station 4160 NICU Nurse station 3730
Discharge Lounge 3640 Stanhoe Ward Nurse station 3121
Endoscopy Recovery Nurse station 3760 Terrington Ward (Assessment Zone) Main desk
4310
Pathology 'Bacteriology con's office' 4360 Ops Centre 3058
Pharmacy (mobile phone) 3750 Tilney Ward 2547
Physiotherapy 4240 AEC 2923
Porters 2441 Occupational Health 3757
Rudham Ward Nurse station 4120 Switchboard 0
Blood transfusion lab 3782 Haemochemistry lab 2796
Some Useful Numbers….
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 16 of 47
An IT user name and password has been created for you by the IT service desk. Your log in details will be
held in a personalised envelope for you within the ‘operations centre’ for you to collect when you sign in to
work.
The ICT Service Desk is available for support during the following hours:
Monday to Thursday: 07:30-17:30
Friday: 07:30-17:00
They can be contacted on extension 4422 (01553 214422) or via email [email protected]
Logging into the PC for the First Time
Once you have collected your user name and password from the ‘operations centre’, you can log into a PC.
You will be prompted to change your password immediately:
Once logged in, you will be prompted to set three security questions via Passworks, which you can use to
reset a forgotten password in the future.
Locked Computer/Passworks Functionality
On the log in screen, click on the ‘Click here to reset your password or unlock your account’ link
on the blue banner.
Type in your Windows Username, then click ‘Next’. Answer the questions, then either Unlock, or reset your
password as appropriate.
In order to use our E-Discharge system, you will need to undertake the E-Discharge online training which
can be accessed via the trust intranet page. Go to Web-Ice/ICE on line training tab for more information.
IT Access and Induction
mailto:[email protected]
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 17 of 47
In order to be issued with a bar code to be able to administer blood transfusions, you are required to
undertake the blood transfusion e-learning modules via the LearnPro system. This e-learning package
should be undertaken prior to your first shift at The Queen Elizabeth Hospital Kings Lynn.
You can access learnPro NHS via http://nhs.learnprouk.com
Blood transfusion module
After you have registered with LearnPro NHS, please complete the blood transfusion e-learning module by
accessing https://www.learnbloodtransfusion.org.uk/ .
LearnPro – Blood transfusion e-learning
Registering with LearnPro NHS In order to undertake the e-learning module you must register with LearnPro NHS. On the login page, below where it asks for your login details, you will see a link to create an account. Please complete the registration form, selecting your location (Queen Elizabeth Hospital Kings Lynn) and Job role. An account will then be created for you.
Policies and Guidelines
You will need to log into LearnPro NHS using the login details provided to you when you completed the registration process. Please click on the bottom right hand corner of the webpage to go to the log in screen.
http://nhs.learnprouk.com/https://www.learnbloodtransfusion.org.uk/
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 18 of 47
Trust policies, procedures, protocols and guidelines underscore all practices for staff working here. These
are to support and guide you and to ensure that patient care is safe and consistent. You can access these
via our dedicated agency website via the following link: https://qehklagency.wordpress.com/ or via the
QEHKL trust intranet site.
The nurse in charge will help you to
identify policies which are specific to
specialist areas such as respiratory
medicine, stroke or surgical assessment
but you should also access pages on the
QEH intranet (see diagram on right) for
policies and guidelines for your general
reference. Nursing and Midwifery
documents are accessed via the Nursing
and Midwifery sub site.
You should begin by familiarising
yourself with the essential policies
below.
Procedure for the
recognition of previously
acquired enhanced Nursing,
Midwifery and Operating
Department Practitioner
skills
Control of medicines policy
Delegation by registered
practitioners to support
workers accountability
policy
Procedure for the
preparation and
administration of IV
medications
Practising Clinical Skills at the Queen Elizabeth Hospital Kings Lynn, NHS Foundation Trust
Dress code policy
Safeguarding vulnerable
adults
Student scope of practice
https://qehklagency.wordpress.com/
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 19 of 47
We wish to support you as a Registered Nurse to use and maintain the clinical skills you have already been
deemed to be competent with and have been practicing regularly in line with the trust procedure for the
recognition of previously acquired enhanced Nursing, Midwifery and Operating Department Practitioner
skills. These skills will include:
• Peripheral Intravenous Drug Administration
• Peripheral Cannulation
• Peripheral Venepuncture (routine bloods, but NOT blood cultures)
• ECG recording
As a Registered nurse/midwife and in line with the NMC code (2018) you are professionally accountable for
undertaking skills and tasks for which you are competent. If you are asked to do anything that is outside of
your scope of practice please report this to the Nurse in Charge or the Site Practitioner team and refer to
the relevant guideline or policy for details.
In order to undertake any enhanced Nursing skills, you will need to demonstrate the following:
Evidence of previous competency such as a completed competency assessment form.
Evidence of knowledge of the relevant QEH policy or procedure.
Demonstrate competence in line with the relevant QEH competency assessment document.
You may practice the skill under direct supervision of a competent practitioner prior to being formally
assessed if required. It is your responsibility to read and understand the policy and procedures related to
any pre-existing enhanced clinical skills you may have. The manager (or delegated assessor of clinical
competence) must be assured that you have sufficient knowledge of the relevant QEH policy or procedure
prior to deeming you competent to undertake that skill.
Demonstration of achieving all of the above must be noted on the ‘Clinical Skills declaration form’ which
can be found at the back of this skills passport.
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 20 of 47
The Queen Elizabeth Hospital Kings Lynn utilises the adult sepsis screening tool below to aid the
identification of sepsis and to ensure timely escalation to the Critical Care Outreach team or medical team.
Please familiar yourself with this screening tool before your first shift.
Adult Sepsis Screening Tool
Sepsis 6 Care bundle
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 21 of 47
The sepsis 6 care bundle must be used for any patients that have sepsis. Please familiarise yourself with
the sepsis 6 care bundle below before commencing your first shift.
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 22 of 47
Uniform
We expect all candidates to have a clean and ironed uniform whilst on duty within The Queen Elizabeth
Hospital Kings Lynn NHS foundation trust, this is to ensure that agency staff are upholding the same
standards as substantive staff.
The Trust won’t allow candidates to have plain scrubs/tunics on whilst working, they need to wear the
agency uniform they are representing and also have their name badge present to ensure they can be
identified correctly.
Moving Wards
The Trust expect all Nursing staff including agency Nurses to be flexible whilst on duty and if required may
ask a nurse to move departments during their shift. This is to ensure that staffing levels throughout the
wards are balanced and that patient safety is kept to high standards.
If Nurses are found to challenge the ward or refuse to move whilst on duty they may face being restricted
from the Trust. If there are extreme circumstances as to why a candidate cannot work on a ward, this
needs to be stated in advance to be reviewed by the Trust leadership team.
If you do move to a different ward, please get a timesheet signed to reflect the hours spent in each
department, this may mean that you need to bring extra timesheets to work.
Signing in
All candidates need to report to the Ops centre prior to their shift starting to sign into the attendance book,
the reason for this is to ensure the candidates are accounted for and to ensure they attend the correct
department. When you sign in for your first shift, please also collect the envelope containing your IT user
name and password.
Break Policy
All Nurses working a long day within the Trust will be given 1 hour break and Nurses working an 8 hour
shift will be given a 30 minute break. You must take your allotted breaks throughout your shift as you will
not be paid if you work through your break unless the timesheet is countersigned by the Nurse in
charge/ward manager to confirm this was agreed.
Our expectations of you
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 23 of 47
Name…………………………………….
Induction Checklist and Skills Passport for Agency Nurses working at
The Queen Elizabeth Hospital Kings Lynn
NHS Foundation Trust
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 24 of 47
Prior to commencing in the trust, please ensure that you have completed the following core mandatory
training with your Agency and record evidence of this below.
Training Required: Date Obtained Conflict Resolution Equality & Diversity Fire Awareness Health & Safety Infection Prevention and Control Information Governance Manual Handling Basic Life Support Safeguarding Adults Safeguarding Children Level 2/3 – as appropriate
Mental Capacity Act 2007 NEWS2 Training
You will also have received enhanced DBS clearance – please complete details below Enhanced DBS clearance number
Date DBS clearance obtained
Type of DBS Barring Check undertaken
Induction to Ward/Area Checklist to be Completed by Ward Staff
Mandatory Training Compliance
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 25 of 47
PART 1 to be completed within 1 hour by Nurse in charge Confirm name of Nurse and photo ID Discuss expected duties Check adherence to uniform policy Give patient handover and identify bays working in Introduction to the ward speciality Hand washing and PPE expectations Confirm sickness reporting process IG & confidentiality standards Confirm clinical skills assessment Introduce to ward team Confirm process for escalating concerns Identify coat & bag storage and discuss valuables
Ensure Nurse has collected IT login details from the operations centre
Discuss breaks & timekeeping
PART 2 to be completed in 2 hours by ward staff
Around the ward Infection control and waste Location of patient information
Screening and isolation procedures
Dietary supplements and patient food
Stool charting
Beds & mattresses
Waste management
Confirm cardiac arrest process
Storage and disposal of linen
Incident reporting process
Medicines
Ward rounds, MDT meetings and safety huddles
Location and code for the medicines room
Friends and family form – document location and procedure
Describe CD requirements – policy on website or intranet (https://wordpress.com/view/qehklagency.wordpress.com)
Medical Equipment Briefing: Practice and policy for medicines keys Tympanic thermometer Bedside medicines cupboards and code/Self
administration policy
Vital signs monitor Patient Care and related documents Emergency call bell system Risk assessments
Resuscitation trolley & contents Care rounds
Portable oxygen & suction equipment including cylinder safety
Admission MDT document
Pulse oximeter NEWS2 & deteriorating patient standards
Glucometer and how to obtain training Blood transfusion management including completion of e-learning via http://nhs.learnprouk.com
Nebulizer Mental capacity and DOLs standards
12 lead ECG Raising concerns
Piped O2 & suction (where applicable) End of life care
Assessments process and policy for discharging patients safely
Administration of medicines / drug round (Appendix a)
Fluid balance charts
Hand Hygiene assessment (Appendix b)
Agency Nurse: Confirmation of Induction to the Ward/Department
https://wordpress.com/view/qehklagency.wordpress.comhttps://wordpress.com/view/qehklagency.wordpress.comhttp://nhs.learnprouk.com/
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 26 of 47
Name………………………………………….….Signature………………………. Agency……………………………………………Date……………………………. Ward staff Name……………………….Signature………………….Designation………………. Date……………….
Professional Declaration
I………………………………………………………………………….NAME IN CAPITALS Declare that I have completed the core mandatory training requirements and undertaken relevant training and/or assessment in the skills that I undertake. I have received a local induction to the clinical area (above) and will comply with all NMC and Trust standards relating to the nursing care that I deliver. I understand that I am personally and professionally accountable for my actions whilst working as a Registered Nurse at the Queen Elizabeth Hospital Kings Lynn NHS foundation trust. NAME OF YOUR AGENCY……………………………………………………………………… Date of first shift at the QEHKL…………………………………………………………………… Signature…………………………………………………Date…………………………………..
Original copy to be retained by Agency Nurse/Midwife.
1 copy to be sent to the Central Resourcing Department, Inspire Centre.
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 27 of 47
In order to use and maintain the clinical skills you have already been deemed to be competent with and have been practicing regularly, you will need to be observed for each skill to demonstrate safe practice in accordance with Trust policies. Additionally, you will need to have your declaration form signed by a Trust Registered Nurse who is competent in that procedure. Please amend the form on the following page by striking through those items which are not applicable to you. Please keep your signed declaration form on you at all times while you are working in clinical areas at the QEH and be prepared to produce it if asked by a member of Trust staff. Please send a copy of the signed declaration form to the Central Resourcing Department to enable our records to be updated accordingly.
Clinical Skills Declaration form
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 28 of 47
Clinical Skills Declaration Form
Surname Forename
Correspondence Address
Home Email
Telephone
Mobile
NMC PIN and expiry date
Agency Nurse Trust Registered Practitioner IV Administration of Medications (Please tick and initial the relevant boxes below)
I have observed the above named person and assessed them as safe to practice Peripheral Intravenous Administration of Medications including: Adherence to ANTT at all times Correct drug calculation Knowledge of medication being administered and potential complications Knowledge of anaphylaxis The individual has provided evidence that they have been trained in this skill to the same standards as the QEH competency assessment
I have read the QEH procedure for the preparation and administration of intravenous medications for adult patients
I have been assessed as competent in this skill
Signature……………………… Print……………………………… Designation……………………. Ward/Dept……………………….
I have undertaken this skill in clinical practice within the last 12 months
Peripheral Intravenous cannulation (Please tick and initial the relevant boxes below)
I have observed the above named person and assessed them as safe to practice Peripheral Intravenous Cannulation including: Adherence to ANTT Knowledge of basic anatomy/physiology of upper limb Adherence to IP&C measures Safe use of sharps as per HSE 2013 regulations The individual has provided evidence that they have been trained in this skill to the same standards as the QEH competency assessment
I have read the QEH Cannulation policy
I have been assessed as competent in this skill
Signature……………………… Print……………………………… Designation……………………. Ward/Dept……………………….
I have undertaken this skill in clinical practice within the last 12 months
Venepuncture (Please tick and initial the relevant boxes below
I have observed the above named person and assessed them as safe to practice Venepuncture including: Adherence to ANTT Knowledge of basic anatomy/physiology of upper limb Adherence to IP&C measures Safe use of sharps as per HSE 2013 regulations The individual has provided evidence that they have been trained in this skill to the same standards as the QEH competency assessment
I have been assessed as competent in this skill
Signature……………………… Print……………………………… Designation……………………. Ward/Dept……………………….
I have undertaken this skill in clinical practice within the last 12 months
ECG (Please tick and initial the relevant boxes below)
I have observed the above named person to demonstrate safe practice in recording ECG’s including: Knowledge of anatomy and conduction systems Recognising life threatening abnormalities Correct recording of ECG Correct labelling and processing of ECG post recording
I have been assessed as competent in this skill
Signature……………………… Print……………………………… Designation……………………. Ward/Dept……………………….
I have undertaken this skill in clinical practice within the last 12 months
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 29 of 47
Appendix A
Declaration
I, the undersigned, make a formal declaration that I have attended previous
training and have been assessed as competent in the above named clinical
skills. I acknowledge my professional accountability and agree to only act within
the limits of my knowledge and competency; maintaining my knowledge and
skills for safe and effective practice (NMC The Code 2018)
Name ……………………………………………………………………..
Your Agency……………………………………………………………..
Signature………………………………………………………………….
Date: ___ / ___ / _______
Original copy to be retained by Agency Nurse/Midwife 1 copy to be sent to the Central Resourcing Department, Inspire
Centre
SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 30 of 47
Clinical Practice Assessment
Administration of Medicines by
Registered Practitioners
Author Ragna Page
Author’s Job Title Practice Development Nurse
Department Division 1
Ratifying Committee The Nursing & Midwifery Policy & Standards Committee
Ratified Date December 2018
Review Date December 2021
Owner Emma Hardwick
Owner Job Title Chief Nurse
NAME OF CANDIDATE (PLEASE PRINT)……………………………………………………………………………
NAME OF ASSESSOR/S (PLEASE PRINT)……………………………………………………………………………
NAME OF ASSESSOR/S (PLEASE PRINT)……………………………………………………………………………
NAME OF ASSESSOR/S (PLEASE PRINT)……………………………………………………………………………
DATE STUDY DAY ATTENDED (if applicable) ……………………………………………………………………
DATE OF ASSESSMENT……………………………………………………………………………………………..
SIGNATURE OF ASSESSOR…………………………………………………………………………………………..
SOP for Induction of Agency Registered Nurses and Midwives v1 2020 02.docx Page 31 of 47
INTRODUCTION
The purpose of this document is to verify that Registered Practitioners working in the Queen
Elizabeth Hospital Kings’ Lynn NHS Foundation Trust are familiar with local policies and procedures
relating to the safe administration of medications (excluding IV Medications) to patients.
This document is designed to be used in conjunction with The Queen Elizabeth Hospital King’s Lynn
NHS Foundation Trust’s “Medicines Management – Safe and effective use of medications on the
wards” booklet.
Guidance for Completion
Candidate
Please complete the sections on pages 4-7 and 15 PRIOR to your observed medications assessment.
In areas where no ‘formal’ drug rounds are conducted the section relating to that element may be
marked as Not Applicable. However, you will still be observed/assessed in terms of your practice
relating to underpinning knowledge and safe administration of medications in the setting that you
are working in.
Assessor
Assessors must be Registered Practitioners who are deemed competent in the administration of
medications and have completed their preceptorship programme.
You must assess the individual’s competency to undertake this skill independently using this
assessment document. All elements of the procedure must be assessed. An omission of any element
of the assessment must result in the individual being referred, and re assessed at a later date,
following further supervised practice.
Once this assessment is completed a copy should be placed on the personal file, and a copy retained
for the individual portfolio. Local records should be kept detailing all individuals who are
competent in this skill.
Assessors are required to test the Registered Practitioner’s knowledge of the drugs commonly used
in ward/unit/department that is the Registered Practitioner’s primary ‘base’. This should include
knowledge relating to indications, contraindications, common side effects, therapeutic dosage
range and any special measures that relate to specific medications e.g. Insulin.
Use this document to record assessment/knowledge of a minimum of 10 different drugs routinely
used in the ‘base’ ward/department, randomly selected from a range of different categories of
drugs.
Should include a minimum of 1 of each of the below:
Antibiotics
Single drug analgesics
Combined analgesic preparations
Diuretics
Inhaled medications
SOP for Induction of Agency Registered Nurses and Midwives v1 2020 02.docx Page 32 of 47
Aperients
Respiratory medications
Cardiac medications
Diabetes medications
Anti-emetics
(In rare occasions this will not be possible - please speak to the practice development team for
advice in these circumstances).
In order to demonstrate competence in the ability to undertake calculations relating to medications
the calculation on page 15.of this document must be correctly completed by the Registered
Practitioner.
Assessment Tool for Administration of Medicines by Registered Practitioners
Performance Criteria
Evaluation method Achieved/Referred
Date Assessor
Knowledge of Legislative Framework & Trust Policy and
Procedures
Identify 3 Acts of Parliament relating to Medications.
Written response
Achieved/Referred
The Queen Elizabeth Hospital King’s Lynn NHS Foundation
Trust’s current Control of Medicines Policy relating to:
Ordering:
Describe how medications are ordered in your work area.
Written response
Achieved/Referred
Custody
Who may have the ‘keys’ to access medications?
Who is ultimately responsible for the ‘Keys’ in each
department?
Who can ‘supervise an unlocked Drugs Trolley or
Cupboard in the event that you have to leave it urgently?
Describe the process in the event that the ‘Keys’ are lost.
Written response
Written response
Written response
Written response
Prescribing
List the minimum requirements for a prescription to be
legally valid.
Describe additional safeguards for prescribing
Methotrexate.
Describe the prescription process for drugs that are
Written response
Written response
administered less frequently than once daily.
Patient Group Directives (PGD’s) - List those in place in
our your ward/unit/Department.
Written response
Written response
Administration
List 3 medications that require a 2nd checker.
Who can act as 2nd checker for non-Chemotherapy
medications?
Describe the process for administration of Controlled
Drugs.
Describe the process to be followed in the event of a
Drug Error.
Written response
Written response
Written response
Written response
Observed Practice:
Preparation
Ensures that drug trolley/cupboard is secure and
appropriately stocked and clean.
Able to identify different medication storage locations
within the department.
Observation
Questioning/observation
Patient Safety
Carries out hand hygiene correctly.
For every Patient - correctly verifies all elements of safety
checks prior to commencing administration:
Full name
Hospital number
Date of Birth
Allergy status
Patient Weight is documented
Patient Safety
Hand hygiene between patients.
Correctly documents any drugs being omitted and
escalates appropriately.
Identifies drug errors, escalates and reports in line with
the Control of Medicines Policy.
Ensures stocks are replenished/reordered and sufficient
stock/Patient Own medications will be available for next
practitioner.
Ensures storage areas/trolleys/cupboards are clean and
secure on completion.
The practitioner has knowledge of the correct procedure
to follow in the following situations so that medication
doses are not omitted.
Missing prescriptions.
Missing patient during a medicine round.
Drug not being available.
Observation
Observation
Observation
Observation
Observation
Observation/Questioning
Observation/Questioning
Observation/Questioning
Observation/Questioning
Communication
Seeks consent from patient
Carries out pain assessment prior to administration of
analgesics
Observation
Observation
Gives each patient suitable explanation of drugs about to
be administered
Provides adequate support/assistance and supervision for
patient to ensure patient takes medication
If patient refuses medication appropriately explores
reasons, documents accordingly and escalates if
indicated
Able to describe current assessment need/ condition for
each patient and how this relates to the indication for
each medication
Verifies validity of prescriptions
Verifies expiry dates of each medication prior to
dispensing
Ensures that any required checks relating to the patient’s
vital signs are verified/recorded e.g. BP, BM etc. prior to
administration.
Able to describe indication/contraindications/normal
dosage range/potential interactions with other
prescribed medications and common side effects of each
medication administered (May refer to BNF for
medications not routinely given in
ward/unit/department)
Signs for medications AFTER administration
Observation Observation Observation/Questioning
Observation/
Questioning
Observation
Observation
Observation/Questioning
Observation
Drug Calculations/Medication Questions
Calculation/Medication Questions on PAGE 15
completed 100% accurately
Calculations as part of observed practice 100% accurate
(if applicable)
Written response
Written response/
Observation
When the assessment is complete please delete and sign as indicated. A copy of the completed document must be placed in the practitioners personnel file PASS REFER Signature of Assessor ----------------------------- Signature of Candidate --------------------------------------- Date --------------------------------
Supervised Practice Record for
Use this to record your episodes of supervised practice & reflective discussion of issues highlighted or discussed throughout the clinical supervision period.
Date Performed Comments Comments/Signature of
Assessor
Assessors - Please record the drugs you have questioned the nurse, midwife or operating department practitioner on (Minimum of 10 different
drugs)
Category Drug Category Drug
Antibiotics
Aperients
Single drug analgesics
Respiratory medications
Combined analgesics
Cardiac medications
Diuretics
Diabetes medications
Inhaled medications
Anti-emetics
Other Others
Others
Others
Calculations/Medication Questions
Please complete the following calculation prior to observed assessment process. Additional calculations may need to be
undertaken as part of supervised practice – please record these below.
Convert the following:
3500micrograms = milligrams 4.320milligrams = micrograms
2760millilitres = litres 1.430litres = millilitres
1.25grams = milligrams
Complete the following calculations
A patient requires 450mg of a drug to be given that comes in 150mg tablets how many would you give?
A patient requires 7.5mg of a drug that comes as a solution of 5mgs/10mls, how much would you give?
A patient requires 500mcg of adrenaline that comes as 1mg/1ml, how much would you give?
Your patient is prescribed 40mgs of drug A. In your trolley you have ampoules for injection of 50mgs per 2mls. What volume will you be required
to administer?
Answer the following:
How long can a bottle of Lactulose remain in the trolley once opened?
Where would you store an insulin pen once opened?
How long can an insulin pen remain in use once opened?
Comments (Assessor)
Comments (Registered Practitioner)
When the assessment is complete please delete and sign as indicated.
A copy of the completed document must be placed in the practitioner's personnel file
PASS REFER _________________________ _________________________
Signature of Assessor Signature of Candidate
Date_____________________
* Throughout this document the term “practitioner” relates to Registered Practitioners who, in line with Trust Policy, may undertake the administration
of medications to patients.
Medications Assessment
Name: ...........................................................
Date of Final Assessment: ………………………………………………………….
Assessors Name: ...........................................................
Assessors Signature: ...........................................................
Ward/Department: …………………………………………………………
Once you have successfully completed all elements of your Medications Assessment, please scan and e mail or return this sheet to:-
E.S. R, [email protected]
SOP for Induction of Agency Registered Nurses and Midwives v1 2020 02.docx Page 44 of 47
Appendix B
Clinical Practice
Hand Hygiene
Assessment for
Professional Staff and
Support Workers
Online QEH Phone book
SOP for Induction of Agency Registered Nurses and Midwives v1 2020 02.docx Page 45 of 47
Assessment tool for hand hygiene technique for professional staff and support workers*
For the purpose of this document support worker is the term to describe any individual working in a supporting role to registered staff
When the assessment is complete please delete and sign as indicated.
A copy of the completed document must be placed in the practitioner's personnel file
PASS REFER _________________________ _________________________ ________________________
Signature of Assessor Signature of Candidate Print Name
Date__________________
Performance Criteria Evaluation Method Achieved/Not Achieved Date Assessor
Demonstrate Knowledge of:
a) The role of hand-washing in minimising the risk of patients
developing health care associated infections Questioning Achieved/Not Achieved
b) The ‘ 5 moments’ for hand hygiene Questioning Achieved/Not Achieved
c) Hand decontamination
When decontamination with soap and water is required
When it is suitable to decontaminate hands with hand
sanitiser
‘Bare below the elbows’
Use of hand moisturiser
Questioning Achieved/Not Achieved
Demonstrate knowledge / clinical competence of :
d) Hand decontamination technique
Routine hand decontamination using soap and water
Hand drying
Routine hand decontamination using hand sanitiser
products
Observation Achieved/Not Achieved
SOP for Induction of Agency Registered Nurses and Midwives v1 2020 02.docx Page 46 of 47
Appendix 3: Process for Agency worker employment, induction and competency
assessment.
Continued on next page
Agency worker details are reviewed by DCN
or ACN. Approval or decline communicated to CRS department.
Nursing agency provides Agency worker
with link to dedicated agency induction
website
(https://qehklagency.wordpress.com/) and
records staff engagement. Agency staff
MUST download and access documents and
assessments prior to their first shift as per
the directives on the welcome page.
Pre-employment and competency checklist completed by agency, CV and employment
checklist sent to CRS department.
CRS department screens Curriculum Vitae, employment checklist and NMC status.
Approval to employ
Any Agency workers deemed
unsuitable to employ are not considered further at this point
Suitable Agency worker details forwarded
to Deputy Chief Nurse (DCN) or Associate Chief Nurse (ACN) for consideration.
CRS department informs Agency
CRS department informs Agency
of reason for decline
Unsuitable Suitable
Unsuitable
Suitable
https://qehklagency.wordpress.com/
SOP for Induction of Agency Registered Nurses and Midwives v1 2020 02.docx Page 47 of 47
Within first Hour: Nurse in charge arranges for a member of the nursing team to complete
the induction checklist with the agency nurse. Some parts of this may be completed by a
Health Care Assistant.
Within first 2 Hours: Part 2 of the induction checklist should be completed. The Practice
Development team can be contacted to support this process.
During first Shift: Drug Round / administration of medicines. Agency nurses assessed during
first shift administering medications on drug round to at least one bay of patients. Complete
drug round assessment form, send a copy to the resourcing Dept and record on part 2 of the
induction checklist. The Practice Development team can be contacted to support this process.
During First Two Shifts: Clinical skills Declaration assessment form completed for pre-
existing skills appropriate to clinical area that the agency nurse has evidence of competency
for as per the Pre-existing clinical skills policy. One copy of the form to be retained by the Agency Nurse and an additional copy sent to the resourcing department.
During first Shift: Agency nurse and nurse in charge complete the induction checklist (parts 1
& 2). 1 copy to be retained by the agency nurse and an additional copy sent to the
resourcing Dept.
For Subsequent shifts the agency nurse should be asked for their skills passport for evidence
of competence and completion of orientation. When working in a new clinical area, the
Nurse in charge must orientate the agency nurse to the ward layout and complete section 1
of the induction checklist.
Within first Hour: nurse in charge completes the first section of the induction checklist with the agency nurse.
On arrival for their first shift, the agency worker will report to the operations centre to:
a) Sign in and confirm ward allocation with the site manager.
b) Collect their induction booklet and skills passport.
c) Collect their temporary IT log in details. d) The agency worker should then report to their allocated ward or clinical area.