These standards provide, for the first time, a unified framework for neonatal qualified in specialty (QIS) education for neonatal nurses across England. This provides a blueprint for QIS programmes from learning outcomes through to quality assurance, monitoring and continuous improvement.
Investing in specialised neonatal training is essential. We expect healthcare and education providers across England to work collaboratively with neonatal operational delivery networks (ODNs) to adopt and embed these standards, driving consistency across neonatal services in England.
We want to thank all colleagues and key stakeholders who have contributed and engaged so constructively in the development of the standards, particularly the dedicated professionals within the QIS working group for their expertise and ongoing commitment to making consistent standards of QIS education for neonatal nurses a reality.
Louise Weaver-Lowe, National Neonatal Lead Nurse, NHS England Lucy Duncombe, National Neonatal Clinical Advisor, NHS England
Purpose and scope
These standards have been developed to improve the quality and consistency of neonatal QIS education programmes across England. They were developed in partnership with, and are endorsed by, the Neonatal Nurses Association, the British Association of Perinatal Medicine, and the Royal College of Nursing and supersede the work by the British Association of Perinatal Medicine to standardise the neonatal QIS syllabus.
By determining the minimum standards required for the delivery of QIS programmes, there will be greater parity in the knowledge, skills and behaviours of our future neonatal workforce. Higher education institutions (HEIs), other education providers and neonatal operational delivery networks (ODNs) will be expected to align their neonatal QIS educational programmes to meet these standards.
The framework primarily focuses on the education of registered nurses and midwives, setting out the minimum standards for education programmes leading to a post-registration qualification in neonatal care, but it is also relevant to the education of other registered healthcare professionals who provide cot-side neonatal care.
QIS programmes
The education pathway from entry into neonatal care through to qualified in specialty (QIS) training provides the platform for further career progression (see figure 1).
This document specifically focusses on the QIS education pathway followed by Nursing and Midwifery Council (NMC) registered nurses and midwives.
To gain neonatal QIS qualification, the whole programme (foundation and specialist) must be completed. Maintaining QIS skills learnt within the QIS programme is vital and will be considered outside of the remit of this document.
Healthcare professionals from other disciplines working in neonatal settings and undertaking cot side care may undertake some of the taught elements of this pathway during their career development. However, this does not result in QIS qualification.
Figure 1 – QIS education pathway
Click here for a text description of the above image
A flow chart showing the education pathway, from entry into neonatal care through to qualified in specialty (QIS).
The steps of the pathway are:
entry of registered professionals into neonates
completion of QIS foundation level learning
completion of QIS specialist level learning
achievement of neonatal QIS status
continued education and professional development
What is expected of QIS educational programmes?
QIS education programmes must:
adhere to the knowledge and skills framework within this standard
align to the nationally agreed standards outlined in this document
be offered at education level 6 as a minimum (but may be offered at level 7 for those who wish to pursue masters’ level education)
exhibit innovation, inclusivity, diversity and flexibility in their design
enable learners to acquire the skills and theoretical knowledge required for safe and effective practice
be adaptable to evolving treatments, technologies, and care delivery models
align with strategic transformation plans in health and care systems highlighted by neonatal operational delivery networks (ODNs), integrated care boards (ICBs) and national transformation guidance
empower learners to critically review literature, research, and evidence so that it informs and allows them to critically evaluate care practice
disseminate current research to help improve clinical practice
Entry requirements and learning outcomes
To enter a neonatal QIS education programme, learners must be:
Nursing and Midwifery Council registered nurses or midwives or Health and Care Professions Council-registered professionals (provided that underpinning governance structures are in place)
employed in a neonatal setting for the duration of the programme
Most learners should start their pathway to QIS completion within a year of starting in a neonatal setting.
After completing a QIS education programme, all learners must be able to provide evidence-based cot-side care to neonatal patients as part of a multidisciplinary team (MDT) and work with families and carers to ensure wellbeing.
QIS programme outline
Universal elements
The following elements are fundamental to QIS education. Some are subjects in their own right and should be taught and assessed as such, but they must all also be reflected across all of the programme domains.
Family integrated care
Embedding the model of family integrated care (FICare) across all aspects of neonatal care and integrating families and carers as partners within the neonatal team. All members of the neonatal team are responsible for understanding their role in empowering and enabling families and carers to become capable and confident caregivers. True integration of families and carers in the provision of care paves the way to significant benefits to all parties: better outcomes, reduction in separation anxiety and improved bonding between the family or carer and the infant.
Psychologically and trauma-informed care
Embedding psychologically and trauma-informed care to promote feelings of psychological safety, control and choice. Good psychosocial support includes the whole neonatal team and is central to every interaction staff have with an infant and their family or carers.
Inequalities
Awareness of the inequalities in outcomes for the infants of women from ethnic minority groups and those experiencing deprivation; the ability to deliver individualised and personalised care and to advocate for infants and families from marginalised backgrounds.
Support and promotion of equality, diversityand inclusion; enabling staff to use the full range of their skills and experience to deliver the best possible patient care.
Interprofessional learning
Maximising opportunities for interprofessional experience and learning to support the adoption of a ‘one-team’ approach across the wider perinatal multidisciplinary team (MDT).
Culture
Creating a culture within teams that supports learning, psychological safety and the importance of ‘speaking up.’
Research and evidence-based practice
Application of current research, evidence-based practice and national and regional guidance.
Resources
Ensuring all resources are used efficiently, safely and sustainably.
Clinical aspects
Awareness of the following clinical aspects across all domains:
the impact of neonatal care on the long-term outcomes for infants and their families and carers
variations in care based on gestational age, diagnosis and/or co-morbidities
medicines management, pharmacology and the efficacy of all relevant medications
monitoring, investigation, assessment, and identification of deteriorating infants
Domains
The headings below provide an overview of the learning domains every neonatal QIS programme is expected cover. The detail of domain content is described in Section 2.
1. Personal and professional development
equality and diversity
effective communication and documentation
teamwork and compassionate leadership
clinical governance
safeguarding
legal and ethical principles
engagement and quality improvement
professional development
2. Overview of neonatal services
neonatal care pathway and levels of care
key principles of neonatal care
transport team
professionals working within neonatal or wider services
3. Fluid, electrolyte, nutrition, feeding and elimination management
embryology, anatomy and physiology
principles of feeding
growth
nutritional supplementation
role of the multidisciplinary team (MDT)
nutritional regimens
breastfeeding and breastmilk
alternative feeding methods
enteral feeding
conditions and complications that relate to nutrition and feeding
intravenous nutrition and care of indwelling lines
renal
upper glycaemic index (GI) output
lower GI output
glucose homeostasis
hyperbilirubinemia
bilirubin monitoring
phototherapy
fluid balance
exchange transfusion
4. Respiratory and cardiovascular care
respiratory care and conditions
cardiovascular care, monitoring and assessment
cardiac conditions
haematology
monitoring and assessment
cardiovascular instability
5. Neurological and infant neurodevelopmental care
embryology, anatomy and physiology
role of the multidisciplinary team (MDT)
infant neurodevelopmental care
family integrated care
pain, distress and discomfort
neonatal abstinence syndrome (NAS)
neurological conditions and management
intra ventricular haemorrhage (IVH) and periventricular leukomalacia (PVL)
hypoxic ischemic encephalopathy (HIE)
cerebral function monitoring (CFM)
seizures
infant neurodevelopmental care in intensive care
6. Thermoregulation, skin, hygiene, infection prevention and infection
thermoregulation
hygiene
skin
infection
strategies to minimise infection
intravenous (IV)/central line care
antimicrobials
role(s) of specialist personnel
7. Admissions, stabilisation, transfers and discharges
admissions
admission process
screening
core principles of infant transfer (intra- or inter-hospital)
inter hospital transfer
intra hospital transfer
documentation and communication
neonatal outreach
discharge
8. Surgical care
embryology, anatomy and physiology of the surgical infant
stoma care
condition specific care
post-surgical care
9. Palliative and bereavement care
neonatal specific pathways
communicating effectively
working with others in and across various settings
identifying and managing symptoms (holistic)
sustaining self-care and supporting the wellbeing of others
10. Psychologically informed neonatal care
psychologically informed neonatal care (PINC)
infant wellbeing on the neonatal unit
family and carer wellbeing on the neonatal unit
staff wellbeing on the neonatal unit
recognition of the individual needs and characteristics of families and carers
developing compassionate and psychologically informed neonatal teams
QIS education provision
Clinical experience
NHS trusts play a critical role in the training and development of learners who are undertaking a QIS programme. Experience in the neonatal setting should be arranged by the learner’s trust to ensure that they have adequate clinical experience to fulfil the programme requirements. Supernumerary status is required to ensure that learning opportunities are maximised. By meeting the national standards, trusts contribute to the effective delivery of neonatal QIS training programmes.
The neonatal environment is a constantly changing field, with emerging technologies and therapies. Learners need to develop capability and confidence in practice including gaining exposure to a range of experiences and opportunities to obtain, develop and apply related theoretical knowledge.
NHS trusts must:
ensure that learners are allocated clinical placement time and QIS study days
ensure sufficient numbers of practice supervisors and assessors qualified to support learners (including for completing final QIS sign off)
Trusts that are responsible for learners working in a special care baby unit or special care unit (SCBU/SCU) or local neonatal unit (LNU) must ensure learners complete dedicated supernumerary clinical experience of at least 150 hours in a neonatal intensive care unit (NICU).
Trusts that are responsible for learners working in a neonatal intensive care unit must ensure that learners have protected supernumerary time of at least 150 hours.
Trusts who are responsible for learners working in a neonatal intensive care unit must also offer the opportunity for learners to have a supernumerary placement in a unit of a different designation.
Some learners may need more hours allocated to achieve their competencies; this should be considered on an individual basis.
The learning environment
QIS education programmes will expose learners to different learning environments.
When considering the academic learning environment, all education providers must:
have robust educational governance and quality assurance arrangements in place
incorporate a variety of teaching and learning strategies that align with clinical practice
facilitate theory practice application to ensure learners have a holistic understanding of neonatal practice
provide opportunities for inter-professional learning and experience (for example, simulation training)
ensure teaching and clinical assessments are relevant and appropriate for all newborns, regardless of skin tones. Educational materials and clinical manikins should represent a diverse range of skin tones
When considering the clinical learning environment, trusts must:
Assessment plays a pivotal role in the identification of a learner’s level of capability. Effective and appropriate assessment supports the acquisition of the knowledge and skills needed to deliver high-quality care to neonatal patients and to facilitate empathy, therapeutic relationships, and family integrated care.
Clinical and academic assessment strategies should promote reflective practice to allow learners to critically analyse their experiences, enhance self-awareness, and provide opportunities for them to continuously learn and improve.
validity: accurately measuring intended knowledge and skills
reliability: providing consistent results across different assessors and occasions
fairness: evaluating all learners consistently and without bias or discrimination
inclusivity: creating an inclusive assessment environment that respects diversity and allows for reasonable adjustments where appropriate
practicality: considering specific circumstances and available resources
They must also:
be appropriately sequenced
reflect the domains and universal elements outlined within this document
A range of formative and summative assessments should be used throughout the programme to enhance the development of learner knowledge, skill and competence. Examples of suitable assessment practices include:
clinical assessments that incorporate and promote critical reflections and foster a culture of self-assessment and self-awareness
objective structured clinical examinations (OSCEs) or oral examinations (vivas). These can provide a structured opportunity to demonstrate clinical skills, communication proficiency, and critical thinking abilities in a controlled and interactive environment
portfolios that serve as comprehensive compilations of evidence, including case studies, reflective essays, personal development plans and clinical logs, allowing learners to demonstrate their achievements, experiences, and growth while promoting self-directed learning, critical thinking, and ongoing professional development
This is not an exhaustive list and education providers will be expected to determine which assessment strategies and methods are most appropriate for their programmes.
QIS educator roles
Collaborative partnerships between education providers, neonatal units and operational delivery networks (ODNs) will enable providers to develop courses that meet these QIS standards.
There are distinct educator roles that support the delivery of QIS programmes:
programme leads and organisers
session facilitators and subject matter experts
clinical nurse educators
practice supervisors and practice assessors
The programme lead or organiser
Programme leads/organisers should come from either a clinical education or academic background. They are responsible for maintaining the overall standard of the programme and must:
possess a neonatal QIS programme qualification
have significant neonatal experience
possess or be working toward a teaching qualification
have experience of facilitating and delivering neonatal education and training
have leadership or management experience
work in close collaboration with clinical facilitators, clinical areas and operational delivery networks (ODNs)
ensure that the programme content remains educationally and clinically current
ensure that subject matter experts involved in the delivery of the programme are aware of the programme requirements and the relevant learning outcomes and deliver high quality teaching
Session facilitators and subject matter experts
Session facilitators and subject matter experts are responsible for teaching specific subjects within the programme. They could be academics or clinicians from across the wider MDT. Session facilitators and subject matter experts must:
possess up-to-date expertise in the subject
have current credibility within their specialty area
Clinical nurse educators
Clinical nurse educators are responsible for supporting learners and their practice supervisors and assessors. Every neonatal unit must have a dedicated clinical nurse educator (National Neonatal Service Specification).
Dedicated support and development of the educator workforce (including succession planning) is a key priority to ensure sustainable education for the current and future workforce (Educator Workforce Strategy).
Clinical nurse educators must:
receive support to help them pursue a teaching qualification as part of their professional development
hold practice assessor status and adhere to the standards for this role that are outlined below
ensure that all practice supervisors and assessors adhere to the standards outlined below
support or coordinate the provision of adequate numbers of practice supervisors and assessors
provide holistic support to learners
offer educational leadership and serve as a role model within the clinical environment
provide support and clinical education to learners to improve their professional practice
oversee and support the practice assessor in the final QIS sign-off of learners
coordinate and deliver practice-based education in collaboration with clinical and academic colleagues
liaise closely with the programme lead to support learners and improve professional practice
Practice supervisors and assessors
These standards acknowledge good practice principles for supervision and assessment within the Nursing and Midwifery Council Standards for Student Supervision and Assessment. The principles within this standard have been adapted and developed for the purpose of supporting learners undertaking QIS programmes.
Learners undertaking the QIS programme must be supported by practice supervisors and practice assessors. Practice assessors and supervisors should act as role models, promoting safe and effective practice in line with their professional code of conduct.
Practice supervisors must:
have current knowledge and experience of the clinical setting in which they are providing support, supervision, and feedback
have their status as practice supervisor approved by the clinical nurse educator
be adequately prepared to deliver effective supervision, contributing to learner development and assessment
communicate and collaborate with practice assessors and clinical nurse educators at relevant points in the programme to support learner achievement
understand the capabilities and programme outcomes they are supporting learners to achieve
promote a positive learning environment
highlight and facilitate learning opportunities to support learners to expand their knowledge and understanding
appropriately raise and respond to learner conduct and competence concerns
In addition to the list above, practice assessors must:
hold the neonatal QIS qualification and be approved by the clinical nurse educator to undertake the role of assessor
work in partnership with learners to establish practical and attainable goals and action plans
raise concerns with the education provider, clinical nurse educator, and/or manager, in line with the trust’s or education provider’s escalation process
appraise sources of evidence to inform a final QIS sign-off decision
support student progression through an effective partnership with the clinical nurse educator (with regular communication at relevant points in the programme)
Quality assurance and monitoring
Monitoring and evaluating the quality of QIS training is essential to maintaining standards, assessing effectiveness, promoting accountability and driving continuous improvement. Neonatal operational delivery networks (ODNs) are fundamental in supporting the quality assurance of local education provision. Neonatal ODNs have been recognised as being well positioned to understand regional nuances within workforce and education (NHS England). ODN workforce and education leads have a responsibility to review annual workforce data about training needs and to respond appropriately (National Neonatal Service Specification).
ODNs and education providers must work in partnership to ensure the delivery and sustainability of high-quality programmes that meet current and future workforce need.
Placement providers must:
support and empower learners to become well-rounded and competent professionals with the right skills and knowledge to provide safe and compassionate care
demonstrate a commitment to quality, ensuring that all placement provision has effective arrangements for educational governance to manage and improve the quality of education and training
ensure there is effective collaboration between education providers and key stakeholders to evaluate the effectiveness of the QIS programme while maintaining a productive working relationship
ensure educational governance processes effectively manage and improve the quality of education and training and ensure all key stakeholders understand them
have a comprehensive evaluation strategy for the QIS programme to ensure that it remains fit for purpose and ensure that feedback from all stakeholders, including learners, is central to this evaluation
have robust processes to annually audit the educational learning environment. These should provide a mechanism for continuous improvement of education and training based on collaboration between the education provider and placement settings
gain assurance from providers of sufficient numbers of practice assessors qualified to complete final QIS sign off for learners
have policies and processes to allow learners and practice supervisors or assessors to raise and escalate concerns, complaints and appeals. These help people to raise specific concerns about education and training (for example, issues with fairness or discrimination). All concerns must be investigated and responded to and feedback should be given to the individuals who raised the concerns outlining what action has been taken.
have robust academic quality assurance processes for marking, moderation, invigilation and assessment feedback that support consistency, parity and fairness for learners
have processes to support reasonable adjustments, promoting fairness for all learners
ensure that learners have access to and are encouraged to use resources to support their physical and mental health and wellbeing.
have governance arrangements that promote and support the development and sharing of equality, diversity and inclusion best practice
QIS domains – knowledge and skills framework
There are 10 domains, each setting out the knowledge and skills that must be included in QIS programmes in England. Each domain is divided into a ‘foundation’ and ‘specialist’ level. These are underpinned with Universal Elements (as per Programme Outline) which should run through the entire programme.
This document is split into ‘foundation’ and ‘specialist’ content to provide learners with levels of progression and programme providers with a suggested curricular structure for the QIS pathway. Future educational packages focused on specialist aspects of care for staff will complement the delivery of QIS and post-QIS – as part of their continuous professional development (CPD).
The domain descriptions below are organised under these headings:
underpinning knowledge: what learners need to know
skills: what learners need to be able to do
related equipment and resources: the equipment and resources the learner should be proficient in using. This will vary according to the unit and training and assessment should be conducted locally
Domain 1: Personal and professional development
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Equality and diversity
Learners should understand:
the value and benefits diversity brings and the reasons for promoting inclusion for all (including families, carers, colleagues and peers) across all settings
the diversity of the local population their unit serves, and the negative impact inequalities can have on care (and access to services) for infants and their families or carers
the principles of personalised, family-centred care based on what matters to families and how the expertise, capacity and potential of families and carers can support good care
the importance of ensuring all service users have equal access and reasonable adjustments are provided
awareness of the role allyship plays and of the importance of advocating for people from marginalised groups and raising awareness about issues affecting infants, their families and carers and colleagues
Equality and diversity
Learners should be able to:
champion equality and diversity
act as an ally within your team or clinical setting
champion underrepresented groups and seek ways to provide a fairer environment for infants and their families and carers, as well as colleagues
Effective communication and documentation
the importance of clear, easy to understand and accessible communication and how to provide it (including the use of multiple formats to enable access)
the importance of providing open and honest information to families and carers at an appropriate level and pace
the importance of advocacy within practice for infants, families and carers
the importance of ensuring that documentation reflects the needs of the infants and their families or carers and records any communication that has taken place
the principles of confidentiality and information sharing
the importance of communicating or escalating any changes or concerns to relevant team(s)
the impact of conflict in healthcare settings and of appropriate and timely management to reduce the risk of consequences for healthcare teams, individual staff, and, most importantly, infants and their families or carers
Effective communication and documentation
encourage and empower families and carers to become confident and knowledgeable in their infant’s care
support and empower families to ask questions and make suggestions, embedding the principles of family-integrated care (FICare) in all activities
contribute to the support of people in emotional distress (families, carers and colleagues) and provide relevant signposting and referrals to support services
respond appropriately and promptly to any questions or concerns raised
demonstrate safe and effective record keeping and data sharing principles
demonstrate timely escalation to senior colleagues (nursing, medical, allied health professional and psychological colleagues)
develop knowledge and skills to improve the recognition of potential conflict and early intervention to manage conflict between families, clinical teams, colleagues and others
Signpost families or carers to relevant health advocacy services, where appropriate
demonstrate the ability to effectively handover the care of an infant, using a structured approach
use communication tools such as SBAR within clinical practice
Teamwork and compassionate leadership
the importance of upholding standards and promoting good practice across teams and departments, and enabling infants, families, carers and colleagues to feel valued, respected and cared for
the key principles of effective multidisciplinary team (MDT) working (teamwork, communication, professionalism and mutual respect)
5 Cs of compassionate leadership: consciousness, curiosity, compassion, competence and courage
Teamwork and compassionate leadership
demonstrate an awareness of their own feelings and those of others and the impact of how they act on these feelings
work collaboratively within a multidisciplinary team (MDT) to ensure the clinical and holistic needs of infants, their families and carers are met
manage their time effectively and to prioritise and delegate
demonstrate emotional intelligence, self-awareness, self-regulation, reflection and empathy
Clinical governance
the key principles and processes of clinical governance and patient safety
accountability and your role as an individual in the effective use of clinical governance processes to maintain and improve patient safety
the key principles of openness and the duty of candour, prioritising compassionate engagement with those affected by patient safety incidents
the importance of learning from incidents to service improvement and quality improvement and the importance of seeking out the service user voice (families and carers) throughout the neonatal journey and post-discharge
Clinical governance
demonstrate clear understanding of the duty of candour in practice
work within organisational processes
escalate concerns, report incidents and risks
reflect on and embed their learning within their own practice
Legal and ethical principles
understand the key concepts of ethical decision making and the role of those providing cot-side care in ethical discussions, ensuring decision-making is family-centred and respectful of individual cultural differences
Legal and ethical principles
identify ethical issues within daily care and describe their role in supporting ethical decision-making
identifying and initiating the safeguarding process where there are concerns of harm (including staff and families or carers)
the need to demonstrate professional curiosity by questioning/challenging information, identifying concerns and making connections to enable a greater understanding of a situation
each individual healthcare professional working in the NHS, to ensure that the principles and duties of safeguarding children and adults are holistically, consistently and conscientiously applied
Safeguarding
demonstrate clear understanding of principles of safeguarding
identifying safeguarding processes where there are concerns of harm (including staff and families or carers)
work within organisational safeguarding processes
escalating concerns, reporting related incidents
Engagement and quality improvement
the roles of service improvement and service user engagement through co-production
Engagement and quality improvement
adopt approaches that support and empower service user engagement
Professional development
the importance of personal development
the need to take responsibility in maintaining skills and ensuring accountability
the importance of ongoing engagement with national and international practice to supporting professional development and high standards of care
Professional development
apply existing local, regional and national guidance to practice
adopt critical thinking in evidence-based practice and describe levels of evidence and their reliability
Specialist knowledge
Specialist skills
career opportunities beyond QIS
responsibility in maintaining high dependency (HDU) and intensive care skills and accountability
actively seek opportunities to maintain and further develop clinical skills, support other learners within the multidisciplinary team (MDT) and promote a positive learning environment
Domain 2: Overview of neonatal services
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Neonatal care pathways and levels of care
the structure of neonatal services
neonatal levels of care
the neonatal care pathways (for example, transitional care, outreach, hospice, transport)
Key principles of neonatal care
the impact of neonatal pathways, the transfer of infants between services and the impact this has on families and carers
key neonatal and perinatal organisations involved in supporting infants and families
the vital role that families and carers provide to support service improvement throughout their neonatal journey and post-discharge. Learners should know about and be able to signpost families and carers to local and national groups (such as maternity and neonatal voice partnerships, parent advisory groups, and relevant voluntary community and social enterprises)
Transport team
the transport team, in utero transfers, time critical transfers, and repatriation
Professionals working within neonatal and other services
the roles different professionals working within neonatal and other services have on care provision
the key principles of neonatal care and the interlinking roles of other professionals within the multidisciplinary team (MDT)
Learners should be able to:
describe the role of operational delivery networks (ODNs) within the neonatal care pathway
describe the neonatal levels of care: special care baby unit or special care unit (SCBU or SCU), local neonatal unit (LNU), and neonatal intensive care unit (NICU)
describe relevant resources and networks to support infants and their families and carers
identify and signpost people to relevant resources to support infants and their family or carers (recognising varying accessibility requirements and facilitating equal access)
Specialist knowledge
Specialist skills
the purpose and function of neonatal services at regional level
the national maternity and neonatal programme and its impact on neonatal care delivery (basic overview)
the current standards and frameworks that underpin neonatal care (for example, the British Association of Perinatal Medicine)
articulate the impact the neonatal journey mayhave on families and carers and the information and signposting that can support them
describe how the operational delivery network (ODN) fits into the wider system (the local maternity and neonatal system (LMNS) and the integrated care board (ICB))
describe the role of the neonatal transport team within regional neonatal services
Domain 3. Fluid, electrolyte, nutrition, feeding and elimination management
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Embryology, anatomy and physiology
the anatomy and physiology of the gastrointestinal system
gestational development – including the integration of suck, swallow and breathe reflex
identifying feeding readiness and supporting the transition from tube feeding to cue-based responsive feeding
Learners should be able to:
Embryology, anatomy and physiology
recognise indicators of normal and abnormal gastrointestinal function and report deviations (for example, stools and abdomen)
Principles of feeding
the importance of family-integrated care (FICare) in the provision of nutrition and feeding and appropriate sources of information and signposting when supporting families or carers with feeding choices
the principles of responsive feeding
early feeding strategies including mouthcare, non-nutritive sucking and supportive tube feeding
Principles of feeding
use a range of resources to appropriately advise and support families or carers
label and store all milk types correctly
recognise and support mothers in identifying infant cues and readiness for feeding
promote closeness and skin-to-skin contact between families and carers and infants to stimulate feeding behaviours
advise and support families and carers in sterilisation methods and equipment storage
support responsive feeding within their practice
employ appropriate non-nutritive sucking
complete all feeding-related documentation accurately
identify deviations from normal trends and escalate accordingly
The importance of growth measurement, documentation and the identification of concerns (weight, length, head circumference)
Growth
monitor and document growth (weight, length, head circumference)
Nutritional supplementation
the role of specialist formulas and supplementation
the role of probiotics and prebiotics
the key principles of reconstitution, labelling and storage of artificial feeds and supplements (including fortifier)
Nutritional supplementation
prepare specialist formulas, fortifier and supplements and administer correctly according to prescription
Role of the multidisciplinary team (MDT)
the role of other healthcare professionals in the multidisciplinary team (dietician, speech and language therapist, infant feeding lead)
the role of the multidisciplinary team approach in supporting early intervention and problem prevention
the importance of optimal nutrition in preterm and sick infants, when to escalate and who to escalate to when problems arise
Role of the multidisciplinary team (MDT)
initiate appropriate referral to specialist personnel; Dietician/ speech and language therapist/Infant feeding lead
Nutritional regimens
the importance of adequate nutrition and essential components
nutritional requirements depending on gestation (enteral regimes)
storage of nutrients (for example, glycogen, subcutaneous fat)
causes and consequences of electrolyte imbalance
the need for individualized feeding regimes following surgery
the range of infant formulas available (including pre-term and term formulas)
Nutritional regimens
calculate daily fluid requirements taking account of local guidance and acknowledging gestational or condition-specific requirements
monitor and document fluid balance
identify gestational feeding development and individualised, typical/atypical oral feeding behaviour. Record and report findings
Breastfeeding and breastmilk
anatomy and physiology of lactation, the breast and breastfeeding
Baby Friendly Initiative standards and their application to practice
the short and long-term benefits of breastmilk and breastfeeding for the infant and the mother
the differences between maternal own milk, donor human milk, and infant formulas, when and how they are used
human milk fortifiers
the theory and specifics of breastmilk expressing (hand and mechanical)
the importance of closeness and skin-to-skincontact
the assessment of expressionand supporting lactation
the assessment of readiness for breastfeeding – cues and coordination
positioning and attachment
the assessment of breastfeeding intake
supporting the infant and mother in the transition to breastfeeding
when to seek support and escalate concerns
the importance of correct breast or formula milk labelling and checking procedures
donor breastmilk processes(awareness of the processes and compliance)
situations in which breastfeeding may not be recommended (for example, maternal medication)
appropriate sources of information and signposts to employ when supporting families and carers
Breastfeeding and breastmilk
discuss the short and long-term benefits of breastmilk and feeding with families and carers to support informed decision making
identify potential and actual barriers to successful breastfeeding (for example, prematurity, separation, lack of support and societal issues) and troubleshoot and seek assistance if necessary
support the mother and infant in preparation for breastfeeding to optimise outcomes
support mother and infant in correct positioning and attachment
support mother and infant throughout breastfeeding
assess and document breast feed efficiency (observing latch, suck-swallow-breathe pattern and breast condition following feed)
manage top-up feeds appropriately
adhere to feeding plans and escalate for review as necessary
facilitate and support mothers in hand expressing within the first 2 hours of life (when possible)
help mothers with methods of expressing breastmilk, (hand and pump) and with optimising lactation
help mothers with appropriate timing and frequency for expressing
signpost mothers to agencies and organisations that support breastfeeding and expressing (internal, local, regional, and national)
manage stored expressed breastmilk to optimise the nutritional benefits for the infant and minimise waste
adhere to local process for donor milk
complete Baby Friendly Initiative (BFI) training
adhere to the checking process for milk before administration
Alternative feeding methods
principles of bottle feeding (side lying and positioning, coordination and fatigue)
the range of teats available
the principles of safe preparation and administration of bottle feeds in hospital and at home
the rationale for alternative methods of feeding such as cup and syringe feeding (under specialist guidance)
Alternative feeding methods
identify types of formula milk available
adhere to the international code of marketing of breastmilk substitutes
prepare and reconstitute formula milk correctly and demonstrate this to families and carers
select appropriate teats
help families and carers to understand how to safely make up and administer bottle feeds in hospital and at home
demonstrate appropriate infant positioning for bottle feeding (cradle hold, side lying)
demonstrate safe technique for the use of other feeding methods (for example, cup or syringe) in line with specialist advice
recognise, discuss and respond appropriately to infants at risk of feeding problems (for example, poor co-ordination or fatigue). Seek assistance and escalate as required
employ and facilitate responsive bottle-feeding strategies
Enteral feeding
the principles of nasogastric tube (NGT) orogastric tube (OGT) insertion and ongoing care
the principles of naso-jejunal feeding and ongoing care
The principles and clinical use of continuous feeds
safety (assessment of tube position, enteral syringes)
the principles of non-nutritive sucking (including family or carer consent)
the principles and correct implementation of alternative feeding methods supported by specialist multidisciplinary teams (MDTs)
Enteral feeding
explain the physiology and rationale for nasogastric tube (NGT) orogastric tube (OGT) placement to families and carers
prepare appropriate equipment in line with current National Patient Safety Alert guidance
prepare infant for intervention appropriately
measure tube length correctly
insert and secure gastric tube safely, observing infant physiological status throughout and responding appropriately
undertake gastric aspirate assessment and document and report findings appropriately
demonstrate when and how to escalate concerns with gastric aspirates or NGT or OGT placement or position
complete all documentation correctly
administer feed safely and observe physiological status throughout
provide appropriate neurodevelopmental support during tube feeds (oral stimulation and non-nutritive sucking (NNS), pacing, touch or comfort holding, attunement) and settling post-feed
recognise possible NGT or OGT displacement and demonstrate safe removal
provide support and information for families and carers regarding tube feeding, including supporting families and carers to tube feed their infant
Conditions and complications that relate to nutrition and feeding
the characteristics of intrauterine growth restriction (IUGR), associated risk factors and conditions
differences for IUGR/ low birth weight (LBW) and preterm feeding patterns
necrotising enterocolitis (NEC): aetiology, infants at risk, prevalence, identifying signs and symptoms
gastro-oesophageal reflux (GOR): aetiology and strategies to support the infant with reflux
congenital anomalies affecting feeds and nutrition (for example, cleft lip and palate)
chronic lung disease
cardiac and neurological conditions
genetic conditions and syndromes
surgical and structural conditions
the importance of breastmilk and buccal colostrum in surgical infants
Conditions and complications that relate to nutrition and feeding
identify signs and symptoms of neonatal gastro oesophageal reflux, report findings and implement a plan of care
identify the signs and symptoms of necrotising enterocolitis, report findings and implement a plan of care
Intravenous nutrition and care of indwelling lines
contraindications to enteral feeding
risks and benefits associated with use of peripheral venous lines
commonly used intravenous fluid regimes and their limitations; changing fluid and electrolytes needs in the first few days
the use of parenteral nutrition
Intravenous nutrition and care of indwelling lines
set up, maintain and discontinue peripheral intravenous nutrition
recognise and escalate complications (including extravasation and risk of over-infusion)
Renal
anatomy and physiology of renal and lower gastrointestinal structures
appropriate sources of information and signposts to use to support families and carers
normal parameters for urine output
gestational differences
the role of urinalysis
the role of diuretics
Renal
utilise appropriate personal protective equipment (PPE) and observe infection control procedures
measure urine output and calculate 24-hour fluid balance
demonstrate care of urinary catheter
collect and process urine samples correctly using non-invasive methods
accurate documentation of urine (including descriptive features)
identify when and how to escalate concerns
use a range of resources and appropriately advise and support families and carers
Upper gastrointestinal output
normal and abnormal gastric aspirates or loss
normal and abnormal vomits or loss
Upper gastrointestinal output
demonstrate awareness of local guidance regarding gastric loss replacement
accurately document (including descriptive features) all losses (aspirates/vomits/stool)
Lower gastrointestinal output
normal and abnormal stool output
gestational and age differences
stools in the first 24 hours of life
common conditions that have an impact upon stool output
common causes of constipation and immediate care strategies
Lower gastrointestinal output
demonstrate awareness of normal stoma losses
administer a glycerine chip as prescribed
Glucose homeostasis
aetiology and physiology of hypo/hyperglycaemia
infants at increased vulnerability
actions at birth to reduce incidence of hypo/hyperglycaemia
signs and symptoms
care interventions to support the hypo/hyperglycaemic infant
transition from IV to enteral nutrition (nasogastric tube (NGT), breastfeeding (BF), expressed breastmilk (EBM), formula)
maternal factors that impact glucose metabolism (for example, diabetes, obesity, medication)
when to seek support and escalate concerns
appropriate sources of information and signposts to employ when supporting families or carers
Glucose homeostasis
locate and discuss local guidelines for the management of hypo/hyper glycaemia
identify infants who are at increased risk
implement care interventions to support the vulnerable/hypo/hyper glycaemic infant
identify when blood glucose monitoring is required
coordinate care to minimise invasive painful procedures
prepare equipment and the infant’s, families’ and carers’ environment appropriately
collect and process the sample correctly and document results
use a range of resources and appropriately advise and support families and carers
support the infant transitioning from IV to enteral nutrition, titrating fluids and feeds accordingly and reflect families and carers feeding choices
identify and escalate concerns
Hyperbilirubinemia
physiology of bilirubin production, transport metabolism and excretion
conjugated and unconjugated bilirubin
physiological and pathological causes (including ABO and breastmilk).
significance of hyperbilirubinemia at under 24 hours of age
prolonged causes (total parenteral nutrition (TPN), gut surgery)
bilirubin encephalopathy and kernicterus
awareness of National Institute for Health and Care Excellence (NICE) guidance
approaches to visual assessment in all skin tones and recognising the limitations
relevance of maternal bloods
when to seek support and escalate concerns
Hyperbilirubinemia
holistically assess the infant for hyperbilirubinemia recognising limitationsdemonstrate awareness of the ongoing need for hyperbilirubinemia assessment and monitoring
Bilirubin monitoring
the principles of bilirubin monitoring and when to initiate
measurement options and limitations (considerations for different skin tones)
documentation (how to plot results)
treatment thresholds and trajectories and gestational differences
Bilirubin monitoring
identify and use appropriate bilirubin measurement techniques (transcutaneous bilirubinometer, serum bilirubin)
prepare the infant and families and carers for relevant procedures and actively engage them in positioning and comforting their infant (according to their comfort level)
use pain assessment and alleviation strategies throughout and after the procedure
choose appropriate equipment for the gestation of the infant
undertake the procedure and label and process the sample appropriately
identify, complete and accurately interpret gestational appropriate treatment threshold charts
Phototherapy
principles and physiology
modes of delivery and appropriate levels of treatment (for example, irradiance levels and intensity of treatment, depending on device used)
cot-side care (eye and skin care, exposure, thermoregulation)
side effects
fluids and feeding
the process of an exchange transfusion (basic awareness)
what sources of information and signposts are appropriate when supporting families or carers.
Phototherapy
identify and set up appropriate equipment
prepare and provide ongoing care for infants receiving phototherapy
support family and carers to navigate equipment etc., actively engaging them in positioning and comforting their infant
identify when phototherapy should be discontinued
consider exposure, eye and skin care, and thermoregulation
identify when and how to escalate concerns
demonstrate awareness of the ongoing need for hyperbilirubinemia assessment and monitoring
manage fluid and feeding
use a range of resources and appropriately advise and support families and carers
Specialist knowledge
Specialist skills
the current national feeding guidelines for the preterm (overview)
the impact of intensive care on long-term feeding outcomes
the benefits and regimens for trophic feeding
the expected growth patterns of the preterm infant
adequate calorific intake for growth
high risk-feeding regimens
parenteral nutrition (PN) constituents (micro and macro nutrients): administration, risks and benefits
the importance of fluid and electrolyte balance
the nutritional considerations for infants who are ‘nil by mouth’ (for example, necrotising enterocolitis)
the care principles, risks and benefits of central lines (umbilical vein/arterial lines, percutaneous venous long lines and peripheral arterial lines)
metabolic disorders
devise feeding plans in partnership with families and carers and review appropriately
insert and manage a naso-jejunal (NJ) tube
implement nutritional regimens for the high-risk infant
calculate intravenous nutritional requirements for the extreme preterm or sick infant
set up, maintain and discontinue intravenous nutrition via central access
titrate intravenous nutrition and other infusions accurately
recognise appropriate administration sites and contraindications of infusions
Renal and fluid balance
the importance of accurate fluid balance in the extreme preterm and sick infant, including considerations of additional fluid losses (for example, bloods sampling or flushes)
water homeostasis, reabsorption of electrolytes, excretion, and acid-base balance; sensible and insensible water losses in the newborn
the relevance of urinary pH or specific gravity
the relevance of glycosuria, leucocytes, haematuria or proteinuria
expected urine output and the causes of oliguria and polyuria)
acute renal failure – acute tubular necrosis(ATN)
the recognition and management of renal failure or fluid overload
situations leading to fluid restriction or liberation
awareness of haemodialysis methods
Renal and fluid balance
demonstrate accurate elimination and fluid output monitoring and documentation in the sick or extreme preterm infant
demonstrate care of urinary catheter
identify when to escalate concerns
identify concerning gastric aspirates and vomit and escalate promptly
use a range of resources and appropriately advise and support families and carers
Glucose homeostasis
the clinical situation in which infants may require insulin infusions
the role and action of administered insulin
Glucose homeostasis
care for the infant receiving insulin infusion
prepare, calculate and administer insulin infusions
prepare, calculate and administer increased glucose concentrations
Hyperbilirubinemia
haemolytic disease (risk factors, causes, and possible consequences including hydrops)
intensive phototherapy
intravenous immunoglobulin (IVIG)
cot-side care
Exchange transfusion
rationale and effect (dilutional, double or single volume)
process and methods
risks
cot-side care/role in exchange transfusion
Exchange transfusion
identify local guidance and the equipment required to undertake an exchange transfusion
observe and monitor throughout the process
demonstrate awareness of how to access blood units
complete pre-transfusion screening (if the infant is less than 5 days old)
use a range of resources and appropriately advise and support families and carers
Related foundation equipment
feed warmers
scales
infant measuring boards tool
pH strips
breast pumps and kits
sterilising equipment
feeding cups
nipple shields
bottles/ teats
equipment for supporting side lying (cushions, stools)
Breastmilk provision for preterm and sick neonates
Infant feeding
Domain 4. Respiratory and cardiovascular care
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Respiratory care and conditions
the embryology, anatomy and physiology of the respiratory system
how positioning can be used to optimise respiratory function
gestational differences
surfactant production and function
infants at greater risk of respiratory compromise
normal respiratory parameters and behaviours
holistic respiratory assessment and indicators of respiratory distress and deterioration(visual assessment, respiratory monitoring, basic blood gas interpretation, investigations)
how to recognise deterioration and ensure appropriate and timely clinical escalation
the principles of basic life support
oxygen therapy
the principles and cot-side care of non-invasive ventilation modes
the principles of humidity in respiratory therapy
the principles of nasal and oral suction
the importance of seeking support and escalating concerns
the principles of an accurate 24-hour oxygen saturation record (as part of discharge planning)
appropriate sources of information and signposting when supporting families and carers
Learners should be able to:
Respiratory care and conditions
use a variety of resources to provide relevant support and information for families and carers regarding respiratory care so that families and carers are actively engaged in all care activities
demonstrate awareness of respiratory differences between term and preterm infants
demonstrate awareness of clinical deterioration and escalation
identify signs of respiratory distress (respiratory rate, oxygen saturation, recession, grunting, nasal flare), intervening and auscultating appropriately
demonstrate the ability to set up, apply and provide ongoing care for a range of respiratory therapies (low flow regulators, high flow delivery systems, continuous positive airway pressure (CPAP), synchronized inspiratory positive airway pressure (SiPAP) and duo positive airway pressure (DuoPAP) delivery systems
demonstrate clinical application and interpretation of respiratory monitoring (alarm parameters, limitations and possible sources of error)
demonstrate basic pathophysiology and cot-side care of common respiratory conditions
undertake and document respiratory assessment
plan and implement nursing care of a baby at risk of apnoea of prematurity
respond appropriately to the apnoeic or desaturating infant
check resuscitation equipment correctly
demonstrate safe use of resuscitation equipment
employ positioning to optimise respiratory statusincluding the use of supportive equipment and demonstrate the ability to consistently position infants appropriately to safeguard airway and optimise respiratory function. Support kangaroo care (skin-to-skin contact) to ensure optimal comfort and stability
follow safe nasal and oral suction technique
discuss the rationale for and demonstration of the safe use of humidity within respiratory therapy
evaluate the effectiveness of care interventions on respiratory status
demonstrate basic knowledge of blood gases, identifying abnormal parameters and responsibilities for escalation and documentation
document, evaluate and report all aspects of respiratory care appropriately
discuss how to facilitate a 24-hour oxygen saturation recording and how to troubleshoot and escalate concerns
Cardiovascular care, monitoring and assessment
the embryology, anatomy, and physiology of the cardiac system including foetal circulation and adaptations at birth
the principles of cardiac monitoring and assessment
gestational appropriate parameters for heart rate, blood pressure, perfusion (including different skin tones)
the significance of deviations from the norm and cardiovascular instability
the importance of documentation and trends in data
Cardiovascular care, monitoring and assessment
demonstrate applied knowledge of normal cardiovascular parameters, including gestational differences
identify and utilise appropriate cardiac monitoring for low dependency infants with a range of care needs
set correct alarm parameters for health status and gestation and identify limitations and possible sources of error
identify physiological and visual indicators of cardiovascular instability and respond appropriately
document, evaluate and report all aspects of cardiac care appropriately and identify when and how to escalate concerns
Cardiac conditions
common congenital heart conditions (basic awareness)
Patent Ductus Arteriosus (PDA) and its role and impact (basic awareness)
Cardiac conditions
demonstrate applied knowledge of condition-specific cardiovascular parameters
provide relevant support and information for families and carers regarding cardiac care including preparation for investigations and procedure
Haematology
normal blood values (basic understanding)
anaemia of prematurity symptoms and causes
transfusion of blood products; indication, risks, process (basic overview)
when to seek support and escalate concerns
Haematology
discuss anaemia of prematurity and list the signs and symptoms of anaemia in the preterm or sick infant
participate in the safe administration of blood products
Specialist knowledge
Specialist skills
Respiratory care and conditions
relevant embryology, anatomy and physiology of the respiratory system
the pathophysiology of respiratory conditions
the impact of surfactant deficiency on respiratory status and treatment strategies
surfactant administration
holistic respiratory assessment and indicators of respiratory distress and deterioration (visual assessment, respiratory monitoring, blood gas interpretation and responsibilities, investigations)
airway positioning and management
additional considerations of saturation monitoring
the principles of supporting intubation procedure
the pharmacology of intubation pre-medication
the principles and cot-side care of invasive ventilation modes
the principles and practice of cot-side care for infants receiving nitric oxide
the principles of humidity
the principles of suctioning airway devices
clinical indications for respiratory physiotherapy referral and positional approaches to optimise airway function
the principles and cot-side care of an infant with a chest drain in situ
the importance of seeking support and escalating concerns
the principles of neonatal resuscitation
the pharmacology of medications used in resuscitation
the principles of safe extubation
the pharmacology of commonly used respiratory medications
appropriate sources of information and the signposts to use when supporting families and carers
the cardiac component of persistent pulmonary hypertension of the newborn (PPHN), respiratory distress syndrome (RDS), and acute hypoxia
awareness of the roles of the wider multidisciplinary team (MDT) and how to refer
when to seek support and escalate concerns
fluid compartments within the body
Respiratory care and conditions
undertake a systematic assessment (using the ‘ABCDEF’ approach) to prioritise and escalate care
actively engage families or carers throughout assessment, seeking their feedback and observations, supporting and empowering them to raise any concerns and ask questions
plan and implement care activities to optimise respiratory status, including handling and positioning
recognise respiratory compromise (observations, monitoring and behaviours) and provide appropriate support
evaluate the need for monitoring, taking into account the infant’s condition
support radiological investigations to optimise imagery
provide neonatal resuscitation in line with current national guidelines
participate in the preparation and administration of medications used within resuscitation
participate in the intubation process to support the infant, neonatal team and carers
participate in the preparation and administration of pre-medication for intubation
participate effectively in surfactant administration procedures and subsequent care
demonstrate emotional intelligence and compassion when supporting families and carers in relation to a resuscitation or acute care episode
participate and contribute professionally to the debrief process
demonstrate the ability to set up, apply and provide ongoing care for a range of respiratory therapies(oxygen therapy, conventional and high frequency oscillatory invasive ventilations, nitric oxide)
apply humidity within respiratory therapy
demonstrate effective airway positioning
maintain airway patency via suctioning techniques
demonstrate knowledge of blood gases, identifying abnormal parameters and responsibilities for escalation and documentation
identify indicators for respiratory physiotherapy and initiate the referral process
demonstrate care required for an infant requiring a chest drain (supporting insertion and removal and cot-side care)
demonstrate safe extubation processes
prepare and safely administer commonly used respiratory medications
utilise a range of resources, appropriately advise and support families and carers
Monitoring and assessment
the physiology of blood pressure (the impact of hyper/hypotension, trends and parameters in sick and preterm infants)
the potential impact of cardiovascular instability on cerebral blood flow
the principles of invasive blood pressure monitoring
The impacts of poor perfusion
the assessment of perfusion (capillary refill and toe or core monitoring)in different skin tones
the principles of pre- and post- ductal saturation monitoring
Monitoring and assessment
use the appropriate cardiovascular monitoring in response to clinical condition
undertake holistic, individualised cardiovascular assessment, respond appropriately to deviations from the norm and escalate appropriately
provide safe care of arterial lines
Cardiovascular instability
strategies for the management of cardiovascular instability (pharmacology, volume, blood products) indications, risks, and cot-side care
the impact of cardiovascular instability on other body systems
Cardiovascular instability
participate in the immediate care of and in meeting the stabilisation needs of the infant with cardiac compromise
demonstrate safe practice in the preparation, administration and cot-side care related to inotropes, blood products and fluid bolus
demonstrate safe practice in the calculation and titration of intravenous infusions for the fluid restricted infant
Cardiac Conditions
antenatally agreed place of birth and the importance of early communication with cardiac centre or transfer teams
common congenital cardiac conditions and patent ductus arteriosus (PDA)
pathophysiology
signs and symptoms
stabilisation
infusion pump height relative to the baby for inotropes and other short half-life drugs
treatment strategies
pharmacology
cot-side care
Cardiac Conditions
demonstrate safe practice in the preparation, the administration and the cot-side care related to cardiac medication (for example, prostaglandin E2)
use a range of resources to appropriately adviseand support families and carers
Domain 5. Neurological and infant neurodevelopmental care
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Embryology, anatomy, physiology
brain development including germinal matrix and cerebral blood flow and auto regulation)
nervous systems including role of cerebrospinal fluid (CSF)
the musculoskeletal system
normal neurological development (gestational differences): tone, posture, movements
development of the 5 main senses and the environmental impacts on these
birth injuries (including caput succedaneum, cephalohematoma, subgaleal haemorrhage, skull fractures)
The role of the multidisciplinary team (MDT)
the role of specialist personnel (including physiotherapists, speech and language therapists, occupational therapists, and psychological professions)
how to seek support and escalate concerns to specialist personnel
The role of multidisciplinary team (MDT)
demonstrate the local referral process to specialist personnel
Infant neurodevelopmental care
developmental risks associated with preterm birth (short and long-term impacts)
strategies to support bonding and their impact upon short and long-term wellbeing
the considerations for families of multiple birth
the importance of family and carer education and empowering families and carers with developmental care
infant behaviour and sleep and wake states
behavioural cues
positioning and the correct use of aids
appropriate handling (clinical and by family and carers)
comfort strategies
skin-to-skin contact (including the principles of infant transfer)
the differing sensory experience in utero and ex-utero
gestationally appropriate play
supporting for a language-rich environment (language, communication and interaction)
neurological assessment tools
when to seek support and escalate concerns
appropriate sources of information and signposts to employ when supporting families and carers
Infant neurodevelopmental care
actively engage families and carers to employ positive touch and wider comfort strategies
use a range of resources to appropriately advise, educate and support families and carers during neurodevelopmental care, empowering them to be partners in care
recognise and appropriately respond to sleep and wake states and to behavioural cues
employ strategies to support gestationally normal posture, movement and tone
promote and facilitate regular skin-to-skin contact and plan and support safe infant transfer
implement ‘wrapped’ care interventions
Implement side-lying nappy changes
promote bonding throughout care activities
use boundaries, positioning aids and incubator coversappropriately
plan and implement interventions to minimise the impacts of environmental stress and to evaluate effectiveness
facilitate gestationally appropriate play
identify when and how to escalate concerns, liaise and refer to specialist personnel
document developmental care in line with local practice
Family integrated care(FICare)
understand the rationale for and principles of family integrated care (partnership with families and carers, empowerment, wellbeing, culture, environment, staff and family and carer education)
Family integrated care (FICare)
provide education and support to families and carers, enabling them to be partners in care
advocate for families or carers and demonstrate behaviours that promote a supportive collaborative culture, empowering them to be active in the planning and delivery of care activities
signpost and promote peer and psychosocial support opportunitiestofamilies and carers
Pain, distress and discomfort
the anatomy, physiology of the central and peripheral nervous system and gestational differences
Normal behaviour in infants of different gestations (for example, tone, posture, movement, and sleep/awake states)
the differences between stress, distress, pain and discomfort in infants
the behavioural and physiological indicators of pain, distress or discomfort, including gestational differences
the range of care interventions that might cause pain, distress or discomfort
the short- and long-term impacts of pain, distress or discomfort
the importance of accurate and timely assessment of neonatal pain using assessment tools
non-pharmacological and pharmacological supportive strategies and the importance of timely implementation
the pivotal role of families and carers in supporting the infant in pain, distress or discomfort
appropriate sources of information and signposts to employ when supporting families and carers
when to seek support and escalate concerns
Pain, distress and discomfort
recognise the infant in pain, distress or discomfort
plan care to minimise painful experiences and promote rest and recovery and actively engage families and carers as advocates for their infant throughout this time
observe infant behavioural cues to pace interventions accordingly.
undertake pain assessment (utilising tool) and documentit
use non-pharmacological care strategies to promote stability and reduce pain, distress and discomfort
support families and carers as key partners in the management of the pain, distress or discomfortof their infant
provide relevant support and information for families and carers about neonatal pain, distress or discomfort and use a variety of resources to enhance the family integrated approach
use holistic assessments to advocate for the infant in pain, distress or discomfort and escalate concerns
implement pharmacological strategies as prescribed
evaluate the efficacy of non-pharmacological and pharmacological interventions to modify ongoing care appropriately
document care in relation to pain management
Neonatal abstinence syndrome (NAS)
basic aetiology of neonatal abstinence syndrome (NAS)
the signs, symptoms and behaviours
the impact of NAS on growth and development
the use of assessment tools and documentation
care strategies to minimise the adverse effects of NAS (pharmacological and non-pharmacological)
when to seek support and escalate concerns
specialist referrals to support areas of development (for example, neurobehavior and feeding)
the importance of developing effective relationships with families and carers to support their understanding of the infant’s complex needs
appropriate sources of information and signposts to employ when supporting families and carers
Neonatal abstinence syndrome (NAS)
assess the withdrawing infant utilising scoring tools and associated documentation
engage families and carers to employ positive touch and wider comfort strategies
implement a variety of non-pharmacological care strategies to support the infant with NAS and evaluate their efficacy
use assessment data effectively to advocate for the infant who requires adjustment to pharmacological support
identify when and how to escalate concerns
communicate with other agencies to support continuity of care
use a range of resources to appropriately advise and support families and carers
Specialist knowledge
Specialist skills
Neurological conditions and management
the aetiology and antenatal and perinatal factors contributing to neurological conditions
the treatment and outcomes of the most common neonatal neurological conditions(hydrocephalus and spina bifida)
the impact of physiological instability on cerebral blood flow and the developing brain
strategies to reduce the risk and severity of neurological injury
neurological observations and assessment tools
Neurological conditions and management
identify infants at risk of neurological injury
employ interventions to reduce the risk and severity of neurological injury
perform holistic neurological observations and escalate concerns
measure head circumference (hydrocephalus and spina bifida)
Intra ventricular haemorrhage (IVH) and periventricular leukomalacia (PVL)
pathophysiology
classification
the signs and symptoms
strategies to minimise the incidence and severity
treatment strategies
follow up and outcomes
Intra ventricular haemorrhage (IVH) and periventricular leukomalacia (PVL)
identify signs and symptoms
employ strategies to minimise fluctuations in cerebral blood flow
Hypoxic ischemic encephalopathy (HIE)
pathophysiology
classification
the signs and symptoms
the criteria for therapeutic hypothermia
the principles of therapeutic hypothermia
the care of the infant undergoing therapeutic hypothermia
outcomes
Hypoxic ischemic encephalopathy (HIE)
identify signs and symptoms of hypoxic ischemic encephalopathy (HIE)
demonstrate awareness of the criteria for therapeutic hypothermia
initiate cooling interventions
provide care to infants undergoing therapeutic hypothermia
Cerebral function monitoring (CFM)
awareness of cerebral function monitoring (CFM) and its uses
basic recognition of normal and abnormal CFM trace
the care of the infant receiving CFM monitoring
Cerebral function monitoring (CFM)
support the set up and application of cerebral function monitoring (CFM)
provide ongoing care for the infant receiving CFM
recognise normal and key abnormal CFM trace and escalate
Seizures
common causes
the signs and symptoms
investigations
common anti-convulsant therapies, side effects and monitoring
Seizures
identify and monitor infants at risk of seizures
recognise seizure activity and respond appropriately
provide care for an infant who is having seizures
safely administer anticonvulsant treatment and monitor its efficacy and side effects
Infant neurodevelopmental care in intensive care
the application of family-integrated care (FICare) within an intensive care environment
the preparation and facilitation of skin-to-skin contact for extremely preterm or sick infants
strategies to support bonding in the sick and extremely preterm infant
the environmental impacts of intensive care
the supportive positioning of extremely preterm or sick infants
neurodevelopmentally supportive handling
the roles of allied health professionals (AHPs) and psychological professionals within intensive care
Infant neurodevelopmental care in intensive care
facilitate family integrated care from admission to intensive care and actively engage families and carers with positive touch and wider comfort strategies
employ strategies to facilitate bonding and promote and facilitate regular skin-to-skin contact (when clinically appropriate)
plan and support safe infant transfer
employ strategies to support musculoskeletal development
minimise negative environmental stimuli
undertake safe preparation and facilitation of skin-to-skin contact for extremely preterm or sick infants
employ neurodevelopmentally supportive handling
collaborate with allied health professionals (AHPs) to support neurodevelopmental care
use a range of resources and appropriately advise and support families and carers to provide neurodevelopmental care
Pain, distress and discomfort
pain pathways, pain perception and modulation
intensive care factors influencing pain assessment (for example, intubation, sedation, muscle relaxation and neurological impairment)
pain assessment tool limitations
pharmacological supportive strategies in the intensive care setting
Pain, distress and discomfort
demonstrate awareness of pharmacological strategies, pain assessment tool limitations, and pain assessment in the sedated and paralysed infant
Neonatal abstinence syndrome (NAS)
the clinical situation where neonatal abstinence syndrome (NAS) may have an iatrogenic cause (for example, opiate infusions)
Neonatal abstinence syndrome (NAS)
identify infants at risk of iatrogenic neonatal abstinence syndrome (NAS)
Related foundation equipment
positioning aids
earmuffs
cot canopy
incubator covers
decibel monitors
reclining chairs
camp beds
kangaroo wraps
eye masks
locally employed pain assessment tools
non-pharmacological aids
locally employed NAS assessment tools
Related specialist equipment
cooling mattress
rectal temperature probes
cerebral function monitor (CFM) monitor
measuring tape
Domain 6. Thermoregulation, skin, hygiene, infection prevention and infection
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Thermoregulation
the anatomy and physiology of neonatal thermoregulation:
non-shivering thermogenesis
effects of low birthweight, differing
gestational ages
surface area (body weight ratio)
development of skin
subcutaneous fat stores
vasoconstriction
posture
brown adipose tissue stores
energy and O2 in heat production
central nervous system (CNS) response
hypo and hyper thermic parameters
the signs and symptoms of the infant with temperature instability
the impacts upon physiological state (short and long term)
cold and heat stress:
the energy triangle
4 types of heat loss
environmental impacts
clinical care and handling that may cause thermal stress (cold/heat)
bathing (appropriate clinical status, environment and preparation)
monitoring modes and appropriate clinical use:
axilla
central and toe
tympanic
central (including servo mode)
the range of thermoregulatory support (skin-to-skin contact, incubators, Resuscitaire or radiant heater, heated mattresses, the principles of humidity, the appropriate use of clothing and betting)
health promotion (sudden infant death syndrome (SIDS), appropriate clothing at home and in car seats, education of carers in thermal care monitoring and intervention in unit and at home)
appropriate sources of information and signposts to employ when supporting families or carers (the effectsoflowbirthweight atdifferinggestationalages, brownadiposetissuestores, energyand O2 in heat production)
Learners should be able to:
Thermoregulation
identify and use the correct temperature monitoring (as locally available) for low and stable high dependency infants with a range of thermal care needs (axilla, central and toe, tympanic and skin)
determine the frequency of assessment
document thermal care data
interpret thermal data as part of a holistic assessment, escalate concerns and identify sources of error
employ relevant strategies to minimise thermal impacts, maintain thermoneutrality throughout all care activities, and evaluate effectiveness and respond appropriately (commencing and maintaining humidity as required – environmental or respiratory)
use bedding and clothes appropriately for a low or high dependency infant being cared for with a cot, incubator, heated mattress or radiant heater.
locate and discuss local, network or national policy and guidelines relating to thermal care
educate and support families and carers about thermal care and use a variety of resources to engage families or carers with managing thermal care
use a range of resources and appropriately advise and support families and carers about:
sudden infant death syndrome (SIDS)
appropriate clothing at home and in car seats
thermal care monitoring and interventions (in unit and at home)
Hygiene
underpinning principles of developmentally appropriate hygiene care
Hygiene
engage families and carers with using positive touch and wider comfort strategies
provide developmentally appropriate hygiene care, including:
assessment of umbilicus/eyes/skin/stoma
bathing
relevant hygiene regimes (such as mouth care and eye care)
nappy care
Skin
anatomy and physiology (skin and immune system)
common neonatal infections
its role in infection prevention
gestational differences
possible causes of iatrogenic skin injury
skin assessment tools for different skin tones
understanding of broader skin care products and their suitability for infants
principles of wound care (wound sites, extravasation injury)
common skin infections in different skin tones
Skin
undertake regular head-to-toe assessment of skin integrity in different skin tones
employ strategies to minimise pressure injury
identify pressure injuries (using appropriate scoring system) in different skin tones and modify care accordingly
referral to a local tissue viability service
identify commonly used skin dressings and when they are appropriate
Infection
sources of infection
routes of transmission (vector, nosocomial)
the timing of presentation (congenital, early, late and onset)
common infections (bacterial, viral and fungal)
the signs and symptoms of local infection and systemic sepsis-escalation in different skin tones
the identification of risk factors and ‘red flags’
tools used to determine the risk of early onset infection in newborn infants
short- and long-term impact on outcomes
Infection
undertake:
effective hand washing
donning and doffing personal protective equipment
clean procedures
aseptic non-touch technique (ANTT) and sterile procedures
routine infection control actions (in line with local policy):
damp dusting
the storage of milk (formula and expressed breastmilk)
feed preparation (including additives)
the use of single use or single patient use equipment
the decontamination of equipment
identify signs and symptoms of infection in an infant and when and how to escalate concerns
initiate and maintain barrier nursing procedures
undertake screening swabs in line with local policy
support the multidisciplinary team (MDT) with specimen collection (for example, lumbar puncture)
conduct observations and document them using a recognised early warning tool, escalating concerns as appropriate
identify sepsis protocol in their area and recognise red flags
access and discuss local infection control policies and related guidelines
Strategies to minimise infection
hand hygiene
appropriate use of personal protective equipment
barrier nursing
differentiation between clean and aseptic non touch technique
disinfection/sterilisation techniques
appropriate milk storage and feed preparation
environmental considerations
routine infection and colonisation screening (swabs and specimens)
equipment (single use, single patient, reusable)
local cleaning procedures
septic screen
Strategies to minimise infection
identify infants at risk of early and late onset infection
Intravenous (IV) or central line care
the underpinning principles of IV or central line care
Intravenous (IV) or central line care
undertake site assessment and use relevant scoring systems
assess the integrity of dressings and fixation methods and initiate changes appropriately
deliver relevant cot-side care
identify the signs or symptoms of the concerning or deteriorating infant and use scoring systems
identify departmental and trust infection control personnel
use a family integrated approach to educate and support families and carers to understand susceptibility to infection, participate in infection prevention, recognise signs of infection and manage care or escalate when discharged
Signpost family and carers to information and resources
Antimicrobials
commonly used antibiotics, antivirals and antifungals
indications
side effects
The roles of specialist personnel
the local infection control and prevention team
Specialist knowledge
Specialist skills
delivery room strategies
extreme prematurity and effects upon thermostability
skin physiology of the extreme preterm and trans-epidermal water loss (TEWL)
thermal management of the infant who is undergoing intensive care procedures
supporting thermal care during transfers (intra- and inter-hospital)
impact of humidity on thermal stability (environmental, respiratory)
monitoring modes and appropriate clinical use:
central and toe
central – (including servo mode)
rectal
infections associated with intensive care (invasive procedures, ventilation associated pneumonia)
increased vulnerability of the preterm infant and sick infant
importance of rapid recognition and response to deterioration
impact of systemic infection (for example, disseminating intravascular coagulation (DIC))
basic principles of microbiology
tole of specialist personnel (including the role of the microbiologist)
correctly identify and use thermal care delivery room strategies and equipment (as locally available)
implement thermal care strategies to support the transition from delivery suite to neonatal unit
apply and manage environmental and respiratory humidity in the extreme preterminfant
employ proactive thermal care strategies for the infant receiving intensive care to maintain thermoneutrality
evaluate the effectiveness of thermal care strategies and interventions and respond appropriately
identify when and how to escalate concerns
Support the infant appropriately and advocate for them throughout the infection screening
carry out assessments and provide care for infants with indwelling central and peripheral catheters
assist the neonatal team during invasive procedures
Related foundation equipment
temperature monitoring (axilla, skin, toe)
incubators
heated mattresses
trans warmers
cots
radiant heaters
Resuscitaire
humidifiers for respiratory therapy
feeding equipment.
sterilisation procedures
fridge/freezer temperature management
Related specialist equipment
Thermal elements of Resuscitaire utilised at delivery
Thermal elements of transport mode
Rectal probes and monitoring
Plastic thermal covering
Domain 7. Admissions, stabilisation, transfers and discharges
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Admissions
embryology and foetal development, including multiple pregnancies
adaptation to extrauterine life
maternal health factors that impact the infant
obstetric issues contributing to neonatal admission
preparing families for admission (pre-birth)
health inequalities and their relationship with maternal and neonatal care
risk factors for preterm delivery
perinatal optimisation strategies
avoiding unnecessary admissions (for example, ATAIN)
the range of criteria for admission to neonatal care
additional considerations for families of multiple birth
Learners should be able to:
Admissions
locate and discuss related policies and guidelines
Admission process
preparation for admission (environment, equipment, team roles and responsibilities)
holistic assessment of a low dependency infant (history, visual, handling, vital signs)
when to seek support and escalate concerns
data collection and documentation at admission
appropriate sources of information for families and carers and signposting to relevant services for at point of admission
Admission process
identify any additional support or resources that may support families and carers on admission (for example, finance, transport, accommodation and interpreters)
prepare the environment and use equipment required for the admission of a special care or high dependency infant
communicate effectively with the multidisciplinary team (MDT) during the admission process
conduct an appropriate holistic initial assessment of the infant, assimilating data from a variety of sources and responding appropriately
prioritise actions to respond to the infant’s status
identify when and how to escalate concerns and recognise their own professional boundaries
participate in a team approach to admissions and support colleagues
complete the relevant documentation
use a range of resources to appropriately advise and support families and carers during admission and orient them to the special care (SC) environment
recognise infants and families that are vulnerable or have existing safeguarding concerns
identifying and initiating the safeguarding process where there are concerns of harm (from families/carers, staff etc)
referring to relevant professionals in line with local and national safeguarding guidance
use opportunities and interventions to support bonding and attachment during the admission process
check all resuscitation and safety equipment
Screening
examinations and screening:
newborn infant physical examination (NIPE)
newborn blood spot (NBS) screening
retinopathy of prematurity (ROP) screening
hearing screening
infection screening
hip ultrasound
cranial ultrasound
the rationale for screening programmes
the nationally recognised processes and methods of screening
the information to provide families and carers when gaining consent
preparation of equipment and the infant’s, families’ and carers’ environment and equipment
supporting the infant and family during screening
the key specialist personnel
supporting the professional undertaking the screening
documentation
awareness of local and national support groups
when to seek support and escalate concerns
the most commonly seen neonatal genetic disorders and their management and prognoses
the most commonly seen neonatal metabolic disorders and their management and prognoses
where applicable:
relevant anatomy and physiology
pathophysiology
risk factors and prevention
classification
treatment options
possible short-term effects and long-term outcomes
Screening
provide relevant information and signposts to families and carers, using a variety of resources and communication methods to support the consent process for screening programmes
prepare equipment
support the infant and their family or carers throughout the screening process
assist the professional doing the screening
coordinate care to minimise pain and distress for the infant
identify when and how to escalate concerns
collect and process samples correctly
complete documentation
Core principles of infant transfer (intra- and inter-hospital)
stabilisation before transfer
planning and preparation:
communication (team, families and carers, receiving area)
equipment
key safety aspects
destination preparedness
the importance of recognising personal abilities and professional boundaries
the impact of intra- and inter-hospital transfers on families and carers and strategies for support
potential problems during transfer and troubleshooting strategies
the impact of transfer on unit workload and the importance of teamwork
Core principles of infant transfer (intra- and inter-hospital)
locate information about local transport teams
locate guidance for the preparation of infants for intra- or inter-hospital transfer
check and prepare transport equipment
communicate with the receiving team to ensure preparedness
prepare the infant for transfer
undertake an intra-hospital transfer
prepare additional items for transport (for example, personal belongings and mother’s milk)
undertake a comprehensive verbal handover using a structured approach
complete all transfer documentation
use a range of resources to appropriately advise and support families or carers throughout the transfer process
offer support and resources to the attending transfer teams
recognise individual abilities and professional boundaries
demonstrate appropriate moving and handling techniques during transfer activities
Inter-hospital transfer
reasons for transferring to another unit (surgery, escalation, repatriation, capacity)
clinical situations requiring time critical transfers
the role of the transport team
network guidance
the importance of timely referral to the transport team
Intra Hospital transfer
the reasons for transferring within hospital (admission, escalation and de-escalation of care within the unit, transitional care, investigations)
the use of key transfer documentation
Documentation and communication (transfers)
structured approaches for verbal handover
when to seek support and escalateconcerns
appropriate sources of information and signposts to employ when supportingfamilies or carers whose infants are being transferred
communication with other professionals before admission and on admission (for example, community midwives, health visitors)
Neonatal outreach
the role and function of outreach services within the neonatal care pathway
local service provision and specialist personnel
local criteria for outreach
Neonatal outreach
identify key features of neonatal outreach services that support the infant and family throughout neonatal care
identify local unit criteria for outreach services
locate local guidelines aimed at helping families and carers to prepare for transfer to outreach care (where relevant)
liaise effectively with local outreach services to support the ongoing care of infants, families and carers
Discharge
the importance of starting the discharge process early and of incorporating planning within daily nursing care to empower families
the purpose of a discharge planning meeting and the procedures for initiating one
the range of services and equipment that may need to be coordinated before discharge (Basic Life Support (BLS), medicines, outreach, home oxygen)
the importance of health promotion opportunities before discharge
the local discharge criteria
the possible ongoing care needs of the preterm infant and family after discharge and liaising with relevant teams (including outreach, surgical outreach, and specialist nurses)
the appropriate sources of information and signposts to employ when supporting families and carers whose infants are approaching discharge
when to seek support and escalate concerns
the circumstances in which discharge processes may include safeguarding considerations
the follow-up pathways and early interventions or outcomes relevant to continuing a developmentally appropriate care approach after discharge
supporting transition to home (working with outreach team or paediatric services)
follow-up processes
Discharge
prioritise timely discharge planning when nursing the low dependency infant
use all local care plans and checklists to support families and carers in preparing for discharge
coordinate and participate in a discharge planning meeting
teach families and carers the required infant care skills before discharge
discuss all current and relevant health promotion communications with families and carers
advise families and carers about how to comfort a crying infant and how to cope. Signpost them to relevant resources and services
access supportive community resources (for example, breast pump hire and breastfeeding peer support groups)
contribute to local referral processes that support infants, families, and carers who require outpatient or community care
initiate local referral processes for infants who require home oxygen
identify families with ongoing additional social needs and liaise with key referral personnel (for example, social workers, safeguarding leads or foster families)
complete all discharge documentation in line with local guidance, facilitating a safe and comprehensive handover of care to the wider multidisciplinary team(MDT)
input information to data collection systems accurately
use a range of resources, appropriately to advise and support families or carers
Documentation and communication (outreach and discharge)
key documentation and communication actions that ensure a comprehensive handover of care to the wider multidisciplinary team (MDT)
data collection processes and systems
communication with other professionals within pre-discharge planning (for example, community midwives and health visitors)
Specialist knowledge
Specialist skills
the implications of right place of birth for the following infants: preterm, surgical, cardiac
preparation for an intensive care admission (environment, equipment, team roles and responsibilities)
the practical implications of attending the delivery of and admitting multiple births
holistic assessment of a high dependency or intensive care infant (history and visual)
resuscitation at birth as per Resuscitation Council UK guidance:
principles of neonatal resuscitation
the importance of appropriately stocked and checked safety equipment
escalating concerns (method dependent upon level of urgency)
documentation (the importance of contemporaneous record keeping)
supporting the family during resuscitation
preterm optimisation at birth
the role of delivery room cuddles
the importance of efficient and well organised early care and admission processes
the role of the multidisciplinary team (MDT) in the admission and stabilisation of a sick or preterm infant
appropriate sources of information and signposts to employ when supporting families and carers
locate and discuss related policies and guidelines
prepare the environment and use the equipment required for the admission of an intensive care infant
demonstrate resuscitation skills (appropriate to role) and support the resuscitation process in line with Resuscitation Council guidance
correctly employ relevant monitoring or equipment to support the resuscitation and admission process
support preterm optimisation interventions at birth
undertake holistic initial assessment of the preterm or sick infant, assimilating data from a variety of sources
prioritise actions in response to infant status
identify when and how to escalate concerns and recognise their own professional boundaries to optimise outcomes
communicate effectively throughout the resuscitation, stabilisation and admission processes
work with wider nursing team to support admissions and transfers; recognising impact of unit acuity
complete all relevant documentation
use a range of resources, appropriately to advise and support families and carers during admission and orient them to the high dependency or intensive care environment
facilitate opportunities and interventions to support bonding and attachment during the intensive care admission process
Related foundation equipment:
incubators
monitoring:
temperature (axilla, skin, toe)
electrocardiograms (ECGs)
saturations
Resuscitaire
heel lancets
local transport equipment (basic awareness of location, checking procedures and responsibilities)
computer access and training to complete key data capture
Domain 8. Surgical care
We recognise that further specialist education will be required for staff working in surgical centres. The objective of this domain is to address the learning needs of neonatal nurses across all unit designations in relation to surgical care.
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Embryology, anatomy, physiology of the surgical infant
the clinical presentation of common neonatal conditions that may require surgical intervention, including:
abdominal wall defects
cardiac
diaphragmatic hernia
ear, nose and throat (ENT)
inguinal hernia
intestinal obstruction
necrotising enterocolitis (NEC)
neurological
trachea oesophageal fistula and oesophageal atresia (TOF and OA)
urology
the wider multidisciplinary team (MDT) in the care of the infant who requires surgery (for example, Transport, surgical link nurses, surgical centre, stoma nurse)
appropriate sources of information and signposts to employ when supporting families and carers before and after surgery
the use of training materials and relevant teaching resources
care of an infant requiring surgery (basic introduction)
Learners should be able to:
Embryology, anatomy, physiology of the surgical infant
identify common conditions requiring surgery in the neonatal period and highlight the impact of the condition on the infant, families and carers
demonstrate awareness of the general principles of care for an infant requiring surgery (pre- and post- operative care)
promptly escalate the infant who has concerning gastric aspirates or vomit
identify and promptly escalate red flags for conditions that may require surgical review
promptly action changes to an individualised plan of care
undertake basic surgical wound care assessment and management
recognise the need for post-operative pain assessment and management, including pharmacological and non-pharmacological strategies
use a range of resources to appropriately advise and support families and carers
Stoma care
the relevant anatomy and physiology of lower gastrointestinal conditions that may require formation of a stoma
different types of stomaand appropriate care
altered anatomy and physiology in stoma formation and the implications of stoma site
the principles of cot-side care for the infant with a stoma (for example, perfusion, fluid balance, skin integrity, assessment, stoma bag management)
immediate post-surgical care of the stoma
when to seek support and escalate concerns (within the unit, within the trust or to regional specialist personnel)
appropriate sources of information and signposts to use when supporting families and carers)
Stoma care
locate and discuss local stoma guidelines and supporting information
use a range of resources to appropriately advise and support families and carers to provide stoma care
use appropriate personal protective equipment and observe infection control procedures
change a stoma bag as per the individual plan and support parents, families and carers with stoma care in preparation for discharge (as appropriate)
assess and document the nature, characteristics, colour, consistency and volume of stoma output
assess the skin integrity of stoma site and provide skin care in line with local guidance
recognise deviations from the norm and identify when and how to escalate concerns
Specialist knowledge
Specialist skills
maternal histories associated with congenital abnormalities that may require surgical intervention
prenatal management and foetal medicine related to conditions that may require surgery (basic awareness)
the importance of timely escalations and reviews to outcomes
the importance of medication management in infants with conditions that may require surgical intervention
how to recognise and provide immediate care for and stabilisation to infants with conditions that may require surgical intervention, including:
abdominal wall defects
cardiac
diaphragmatic hernia
ear, nose and throat (ENT)
inguinal hernia
intestinal obstruction
necrotising enterocolitis (NEC)
neurological
trachea oesophageal fistula and oesophageal atresia (TOF and OA)
urology
the importance of close liaison with regional services (surgical and transport)
the stabilisation of babies with the acute abdomen or OA and their preparation for transfer to surgical centres (these are babies that often come from district general hospitals (DGHs)
the use of Replogle tubes in stabilising OA infants for transfer
the surgical management and outcomes of necrotising enterocolitis (NEC)
potential short and long term sequalae
awareness of surgical complications:
haemorrhage
wound
anastomosis
stoma
infection
requirement for specialist feeding and nutritional needs (please refer) to domain 3
the role and functions of specialist personnel (for example, paediatric specialty surgeons, specialist surgical nurses, stoma care nurses)
when to seek support and escalate care
provide care as part of the neonatal team at delivery and provide ongoing stabilisation for the infant with common conditions that may require surgery
promptly action changes to individualised plans of care
ensure timely referral and effective communication with the surgical centre and the transport team
prepare infants, families and carers for transfer to the surgical centre
use a range of resources to appropriately advise and support families and carers
liaise with the relevant multidisciplinary team (MDT)
Condition specific care
care for infants with tracheoesophageal fistula or oesophageal atresia before surgery (including Replogle tube insertion and ongoing cot-side care)
undertake a holistic assessment of an infant with bilious aspirates or vomiting and escalate appropriately for review
identify an infant with inguinal hernias or testicular torsion and appropriately escalate concerns
provide tracheostomy care
Post-surgical care
the principles of care for the infant with a tracheostomy
the principles of care for an infant with a trans-anastomotic tube (TAT)
the potential need for nutritional plans and dietetic referral
the complex feeding issues of infants before and after surgery
speech and language referral
medicine management, discharge planning and parental training
Post-surgical care
offer relevant parental training in preparation for discharge (for example, stoma care, specialist nutritional care, wound care and safety netting)
the uncertainty of the neonatal journey and that families or carers can experience grief without the loss or death of their baby
Learners should be able to:
Neonatal pathway
sensitively care for infants with an uncertain future and their families and carers (with support and guidance from senior staff and/or a psychological professional)
Communicating effectively
the importance of emotional intelligence throughout all communications
the importance of memory making for families
Communicating effectively
support families and carers with memory making (tangible and non-tangible), enhancing and nurturing the families and carers experience
Working with others in and across various settings
local policies and procedures that support palliative and end-of-life care
the role of the children’s hospice
the key principles of safeguarding infants with palliative and end-of-life care needs
Working with others in and across various settings
discuss indicators of safeguarding concerns
seek support and escalate concerns as required
Identifying and managing symptoms (holistic)
common reactions and mental health issues and strategies to support wellbeing for infants and for families or carers who are experiencing grief and/or loss
Identifying and managing symptoms (holistic)
listen and respond to individual families’ and carers’ needs, signposting and referring as appropriate
Sustaining self-care and supporting the wellbeing of others
how their own behaviours, beliefs and practices may influence others.
Sustaining self-care and supporting the wellbeing of others
demonstrate an awareness of their own feelings and the impact of their actions on others
listen and respond to families’ and carers’ needs, signposting and referring as appropriate and seeing support and escalating concerns when required
awareness that some infants may deteriorate and need to transition to end-of-life care
the legal and ethical aspects of end-of-life care and the withdrawal of survival focused treatment
the importance of individualised care for the dying infant and their family that takes account of:
cultural diversity
spiritual or religious beliefs
variations in behaviours and preferences
language and communication styles
memory making
agencies supporting families throughout the bereavement process
support networks
family composition and dynamics
life experiences
maternal health (post-natal)
Neonatal pathway
support the team and the family or carers if the infant deteriorates and needs transition to end-of-life care
participate in ethical discussions with emotional intelligence
sensitively care for the dying infant and the family or carers
Sensitively care for the infant who has died and the bereaved family or carers in accordance with local and national bereavement protocols (with support and guidance from senior staff)
seek support and escalate concerns as required
liaise with support services and agencies to support the family of dying infants and ensure individualised needs are met
demonstrate insight into how the unique experiences, preferences and dynamics of families may affect the care approach required
Communicating effectively
positive patterns of communication when delivering bad or unwanted news or information to families and carers
the role of the nurse as an advocate for the infant and family throughout palliative and bereavement care
Communicating effectively
communicate sensitively during difficult conversations or when breaking bad news
initiate and lead individualised planning for end-of-life care in line with families and carers’ wishes
Working with others in and across various settings
the professional roles and responsibilities within an multidisciplinary team (MDT) relating to the delivery of palliative and end-of-life care
local and national policies, procedures and reporting requirements following the death of an infant
the concepts of parallel planning and advance care planning within palliative care
the circumstances in which an infant postmortem may be required and when the coroner should be informed
the criteria and process for infant organ donation
Working with others in and across various settings
participate in individualised and parallel planning for end-of-life care in line with the families’ and carers’ wishes
sensitively care for infants with an uncertain future and those diagnosed with a life-limiting condition and care for their families and carers (with support and guidance from senior staffand/or a psychological professional)
initiate and lead advance care planning discussions with the family
be aware of choices available about location post death (hospital, hospice or home)
sensitively care for dying infants and those with palliative care needs and care for their families and carers
identity processes of caring for and maintaining the optimum condition of the body of an infant who has died
identify procedures for preparing the body for the mortuary and postmortem
support the team and families and carers relating to organ donation
Identifying and managing symptoms (holistic)
how to recognise deterioration and ensure appropriate escalation in line with the end-of-life care plan
key concepts of bereavement, grief, and loss and how these may be manifested by families and carers
Identifying and managing symptoms (holistic)
initiate ongoing support for families and carers, including signposting or referring to local and national agencies
Sustaining self-care and supporting the wellbeing of others
their own experiences of delivering and their interactions with those receiving care and the team delivering care. Learners should have opportunities to reflect on and discuss this.
the impact of infant death on a neonatal unit
Sustaining self-care and supporting the wellbeing of others
consider and support needs across the wider neonatal unit (including other families and carers who may be affected or impacted)
support the team, families and carers in situations where there are difficult or challenging discussions for infant(s) transitioning to end of life care
Related specialist equipment
consideration of care of the baby’s body after death. This may be in a side room within a hospital or home (using a portable air conditioning unit or cold cot) or in a cold bedroom at a local children’s hospice
Programme leads should promote additional local, regional or national education resources related to this domain.
Domain 10. Psychologically informed neonatal care (PINC)
Underpinning knowledge
Skills
Foundation knowledge
Foundation skills
Learners should understand:
Psychologically informed neonatal care (PINC)
the aims of psychologically informed neonatal care (PINC)
relational care and containment, the potential effects of trauma and the importance of trauma-informed care
the creation of a psychologically informed environment
the importance of PINC supporting the principles of family-integrated care (FICare)
Learners should be able to:
Psychologically informed neonatal care (PINC)
contribute to the development of a psychologically informed environment
employ strategies to reduce the impact of admission and the neonatal environment on family life
support family and carers who are experiencing loss and grief
listen and respond to individual family member’s or carer’s needs and signposting or referring as appropriate
promote a partnership approach to care and decision making
facilitate memory making with families and carers from admission
support practices that promote the caregiver and infant dyad, recognising individualised needs
consider the needs of siblings, extended family and wider support networks within care
discuss indicators of safeguarding concerns and instigate local processes to support family and carers
provide support mechanisms for the family and carers following an emergency or incident
respect and support the individual needs of each family member or carer:
cultural diversity
spiritual or religious beliefs
language and communication styles
support network
family composition and dynamics
life experiences
Infant wellbeing on the neonatal unit
the importance of the caregiver-infant dyad in supporting infant wellbeing and development
the development of the brain in a social context
the importance of interaction in buffering the effects of pain and toxic stress
the impact of the neonatal experience on the infant
family responses to neonatal admission
the relationship between families and carers and infant trauma
how to support mechanisms of healthy interactions, between families, carers and infants
Family and carer wellbeing on the neonatal unit
the impact of trauma (both infant, family or carer) and associated feelings of constant sense of threat
the sense of family/carer being empowered in their role as caregiver, feeling connected to their infant and understanding co-occupations (tasks, or occupations, that require the participation of both a caregiver and the infant)
how to attend to families and carer needs
the multiple ways of showing distress
the importance of providing an opportunity to regulate their emotion; relate (with others) and reason (achieve a state in which they can think clearly)
access to a psychological professional
how to support specific needs of families or carers (for example, language, access to information, and logistical, practical or financial issues)
Staff wellbeing on the neonatal unit
that working in a neonatal environment can be stressful and staff need to feel cared for
stress induced psychological and physical reactions
the mental and physical effects of repeated stress
long-term psychological consequences
the prevention of distress following a traumatic event
the support that is available
Recognition of the individual needs and characteristics of families and carers:
cultural diversity
spiritual and religious beliefs
language and communication styles
support networks
family composition and dynamics
life experiences
Specialist knowledge
Specialist skills
Developing compassionate and psychologically informed neonatal teams
developing compassionate and psychologically safe teams and systems, including:
the development of relational care and containment
trauma informed care and psychologically informed environments
the mental health needs of staff, families and carers and how to support them, including
psychological trauma
the management of risk (including referral to neonatal psychological professionals and community services)
the purpose of huddles, debriefs and reflective spaces and a nurse’s role within these
verbal and non-verbal communication strategies
Developing compassionate and psychologically informed neonatal teams
support team members in distress
participate in huddles, debriefs and reflective spaces
engage professionally with any medical/ethical conversations
Programme leads should promote additional local, regional or national education resources related to this domain.
Appendix 1: Background to the development of the standards
Staffing standards set by the Department of Health and Social Care (DHSC) in 2009 require at least 70% of nurses in a neonatal service to be qualified in specialty (QIS).
Over the past 10 years the Royal College of Nursing (RCN) and BAPM (British Association of Perinatal Medicine) have published national documents to support the development of the neonatal nursing workforce. Since the publication of these documents, neonatal education and training requirements have continued to evolve and, as a result, there is disparity in the content and delivery models of QIS programmes across the country. This disparity reduces the transferability of knowledge and skills between units and trusts and creates discrepancies in expectations among the workforce that affect the consistency of care provision.
In 2016, NHS England published a 5 year forward view for NHS maternity and neonatal services Better births: Improving outcomes of maternity services in England. The report highlighted several challenges facing the neonatal workforce and recommended a dedicated review of neonatal services. In response, the Neonatal Critical Care Review (NCCR) was commissioned and made several key recommendations, including development of the neonatal nursing workforce. The 3-year delivery plan for maternity and neonatal services (2023) said NHS England would invest in a number of activities to support the recruitment and retention of neonatal staff and the Long Term Workforce Plan set out the need to grow the workforce, embed the right culture, improve retention and reform the way the NHS workforces trains and develops staff for the future.
After the publication of the NCCR recommendations, Health Education England (HEE), conducted a review of neonatal qualified in specialty (QIS) training. As part of this, HEE commissioned RSM UK Consulting to evaluate Neonatal QIS programme provision across England. The resultingNeonatal qualified in specialty education and training review highlighted:
a lack of standardisation of QIS skills and knowledge across operational delivery networks (ODNs).
a lack of professional regulation and insufficient monitoring of content and assessment across programmes
The report contained 9 recommendations, and the national standards contained in this document have been developed in response to recommendations 1 and 2:
one agreed standard across all ODNs in relation to programme content and the knowledge and skills to be developed by learners
an agreed minimum level of practical experience within QIS programmes, which is structured in a way that enables learners to ensure sufficient experience is gained across different levels of unit and allows for the consolidation of learning
Stakeholder engagement
NHS England took an iterative approach to developing these standards with the support of neonatal nurses, allied health professionals (AHPs) and colleagues from the psychological professions. Key stakeholders included clinical nurse educators and practice educators, unit managers, neonatal operational delivery network (NODN) lead nurses, workforce and education leads, national neonatal organisations and charities, national service user groups, service providers and academic lecturers and QIS programme leads. The University of East Anglia (UEA) supported the early phases of the work.
Regulatory and professional bodies including the Nursing and Midwifery Council (NMC), Neonatal Nurses Association (NNA), British Association of Perinatal Medicine (BAPM) and the Royal College of Nursing (RCN) also contributed.
QIS working group
These standards were developed by a national QIS working group whose support, guidance, and clinical expertise have been essential. Working group members included Diane Keeling, Jessica Talbert, Kate Lamming, Kelly Harvey, Marie-Anne Kelly and Susi Hill.
In addition to this working party, our NHS England Workforce Training and Education directorate colleagues, (particularly the Maternity and Neonatal programme teams) and representatives from the British Association of Perinatal Medicine (BAPM) and the Neonatal Nurses Association (NNA), have also played an important part in the development of this work.
Appendix 2 – Endorsements
These standards have been endorsed by:
Neonatal Nurses Association
British Association of Perinatal Medicine
Royal College of Nursing
This resource has been endorsed by the Royal College of Nursing until 25 July 2025. Endorsement only applies to the professional content of the resource.
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Introduction: My name is Sen. Ignacio Ratke, I am a adventurous, zealous, outstanding, agreeable, precious, excited, gifted person who loves writing and wants to share my knowledge and understanding with you.
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