The nutrition nurse specialist (NNS) role may be known by several different titles, including ‘nutrition support nurse’, ‘clinical nurse specialist for nutrition’ or ‘advanced nurse practitioner for nutrition’ (Boeykens and Van Hecke, 2018; Vasiloglou et al, 2019). The role is usually integral to a wider, multidisciplinary nutrition support team (NST) as recommended by several national bodies including the National Institute for Health and Care Excellence (2017) in the UK and the American Society for Parenteral and Enteral Nutrition (ASPEN) (DeLegge et al, 2010). An NST would typically include at least one consultant, NNS, pharmacist, and a dietitian, although larger centres are likely to have larger teams. The NST is responsible for the management of patients with complex nutritional requirements or those who need artificial nutritional support. NSTs have been shown to reduce costs and help ensure patients receive appropriate nutritional support (Kennedy and Nightingale, 2005; Gomes et al, 2018). Within the NST, introduction of an NNS has been shown to improve outcomes and reduce the incidence of catheter-associated bloodstream infection in patients receiving parenteral nutrition (Sutton et al, 2005). However, the specific role and tasks carried out by the NNS may vary between clinical settings and the needs of local services. Anecdotally, in secondary care the NNS role may be focused on nutrition screening and strategies to enable patients to eat and drink; with support for enteral tube feeding or parenteral nutrition where required. However, in the context of chronic or severe intestinal failure, the NST within secondary care hospitals may identify the need for parenteral nutrition but patients must then be referred to an intestinal failure tertiary referral centre for assessment and facilitation of this. In tertiary referral centres, specialist hospitals nominated within a geographical area to offer specialist services, the NNS role may be diverse.
Intestinal failure and parenteral nutrition
Intestinal failure is described as a reduction in gut function, to the extent that adequate absorption of nutrients and/or water and electrolytes is impeded, leading to the need for intravenous (IV) supplementation to maintain health (Pironi et al, 2016). There are various causes of intestinal failure including disease processes that may affect the quality of bowel function, such as Crohn's disease (Pironi et al, 2016). Extensive resection of the small bowel may lead to shortened gut length and short bowel syndrome, where there is an insufficient length of functioning gut to allow adequate absorption of nutrients and fluids (Pironi et al, 2016). Patients who are unable to receive adequate nutrition/hydration through eating and drinking or enteral tube feeding may require the use of parenteral nutrition (PN). PN is the delivery of nutritional substrates and fluids directly into the bloodstream, which allows a non-functioning gut to be bypassed. PN is commonly used in the acute setting as a short-term treatment for patients who cannot have oral/enteral nutrition for a number of days or weeks (Pironi et al, 2016). However, in some cases, patients may develop chronic intestinal failure and require PN or IV fluids for a longer period of time, such as months to years (Pironi et al, 2016). Patients requiring long-term PN or IV fluids may receive home parenteral nutrition (HPN), which in the UK is organised via NHS Specialised Commissioning Services. The most current data available, from the British Artificial Nutrition Survey on HPN, showed a point prevalence of patients on HPN and home IV fluids in the UK in 2015 of 1144 patients (Smith and Naghibi, 2016).
The intestinal failure tertiary referral centre where the authors work currently cares for a critical mass of more than 120 patients who require HPN or home IV fluids. Within the service, the NNS team use advanced clinical skills, are responsible for the day-to-day management of these complex patients, and have previously demonstrated improved patient outcomes in the management of IV central catheter rupture in patients with intestinal failure (Fletcher et al, 2021). Boeykens and Van Hecke (2018) described the role of the NNS based on collated information from proposed NNS competency frameworks. From this perspective, a review of current practice against these frameworks was warranted.
- To map, describe and critically analyse the role of the NNS within an intestinal failure tertiary referral centre service
- To compare the role of the NNS within the intestinal failure service against current NNS competency frameworks.
A team mind-mapping exercise was carried out with members of the NNS team and the NST during April 2021. Mind mapping is a creative process that involves breaking complex concepts into constituent parts. The free, branching nature of a mind map encourages word association and broadens critical thinking (Willis and Miertschin, 2005; Santiago, 2011). No specific time limit was specified to complete the exercise but it was anticipated that team members might spend up to 30-60 minutes on the exercise. The authors ensured that all team members understood the mind-mapping technique and encouraged all participants to use a pen and paper where possible to enable free thinking.
Nurse specialist perspective
All members of the NNS team individually used mind mapping to critically explore and record their perception of their role and key tasks. A group discussion then took place to review individual mind maps and to expand the mind-mapping exercise by adding words or phrases to the maps that emerged in discussion.
Members of the multidisciplinary NST were asked individually to use mind mapping to critically explore and record their perception of the role of the NNS within the wider team and the intestinal failure service. Each member then emailed their results to the first author.
Words and phrases from the mind maps were listed. From the list common themes, such as governance, assessment and prescribing activities emerged. Words and phrases were then listed for each group of mind maps under common themes.
Themes identified by the NNS team were then compared with the proposed competency frameworks described by Boeykens and Van Hecke (2018), Colagiovanni and Fletcher (2010) and DiMaria-Ghalili et al (2016).
In total, 13 mind maps were completed in the exercise. Team demographics are shown in Table 1
Table 1. Team demographics
|Nutrition nurse specialist team
|Nutrition support/intestinal failure team
|Nutrition nurse specialists n=7
|Nutrition support team (excluding nurses) n=6
|Years within specialty mean: 9.1; range: 4–17
|Years within specialty mean: 14.8; range: 2–27
Common themes identified between the mind maps of the NNS team and NST are described in Table 2 with examples provided from team members' mind maps. It can be seen that there were a number of common threads, including training and education and knowledge and expertise, identified by both groups.
Table 2. Common themes Identified, with examples of skills and activities show in mind maps
|Nutrition nurse specialists perception
|Multidisciplinary team perception
|Teaching and education
|Independent non-medical prescribing
|Knowledge and expertise
|Point of contact for patients
HPN=home parenteral nutrition; IF=intestinal failure; IMCA=Independent mental capacity advocate; IV=Intravenous; MDT=multidisciplinary team; MSc=Master of Science degree; NST=nutrition support team; PEG=Percutaneous endoscopic gastrostomy; PhD=Doctor of Philosophy degree; PN=parenteral nutrition
In addition to those shown in the table, the NNS team identified activities corresponding to themes of communication, counselling, collaboration and resource development (such as patient information resources). In contrast, the NST identified a separate set of activities carried out by the lead nurse, including budget management and strategic management that are not shown in common themes.
Additional comments from the NST
NST members emailed their mind maps back to the NNS for analysis. Comments additional to the mind maps that were included in emails are detailed below.
‘This is only a few of the vital things … so much more!’
‘Apart from being all round super stars that I couldn't do my job half as well without your expertise, knowledge and skills.’
‘Overall, I would say that you guys are the heart of the service and the team. Without you, there is no way that the medical staff could provide the service … You keep the consultants and patients happy. You are all enabled with a wealth of knowledge and expertise and are true experts in clinical nutrition.’
Comparison with published frameworks
A high-level comparison of NNS-identified practice themes with three current NNS competency frameworks is shown in Table 3. The purpose of this was, first, to demonstrate where competency frameworks converge in the broad areas of practice covered within the NNS role, and, second, to compare these broad areas with the themes and phrases identified in the NNS mind-mapping exercise.
Table 3. Comparison of identified broad practice themes against current competency frameworks
|National Nurses Nutrition Group (NNNG), UK
|Vereniging van Voedingsen Infusie Verpleegkundigen (VVIV)*, Netherlands
|American Society for Parenteral and Enteral Nutrition (ASPEN), USA
|Similar Identified themes through NNS mind-mapping exercise
|Identify nutritionally at-risk patients
|Requesting and Interpreting investigations
|Analyse nutritional and fluid requirements
|Participate in care or manage patients on home enteral and parenteral feeding
|Trouble-shooting and problem-solving
|Route and device selection
|Selection of appropriate enteral and parenteral devices and management of these
|Ongoing patient management
|Make care procedures in line with evidence-based guidelines
|Implementation (including co-ordination of care, health promotion and health teaching, consultation and prescriptive authority and treatment)
|Nurse-led clinic, MDT clinic, telephone helpline clinic
|Recommendation of appropriate nutrition support therapy, mode of delivery and administration rates
|Independent non-medical prescribing
|Management of patients receiving home parenteral nutrition (HPN)
|Expert coaching and guidance
|Evidence-based practice and research
|Decision making, consent and ethics
|Ethical decision making
|Education and training
|Provide ongoing education and support for healthcare professionals, patients/families and care givers
|Teaching and education
|Management and service development
|Clinical and professional leadership
|Quality of practice
|Identify potential barriers to self-manage nutritional therapies
|Professional practice evaluation
|Policies and procedures
|Development of resources
Having previously scoped the available literature, the authors believed practice within their intestinal failure tertiary referral centre extended beyond that of currently published data on the role of the NNS. Undertaking the mind-mapping exercise allowed exploration and description of the role in detail. There are disadvantages with the use of mind maps, including inconsistency in the level of detail between users and that they may be too complex and difficult for others to follow (Davies, 2011). Nevertheless, this technique has been shown to improve reflection and critical thinking in a number of scenarios—for example, Kernan et al (2018) demonstrated the effective use of mind mapping in identifying research topics with undergraduate students. Mind mapping has also been used as an active learning strategy in nurse education (Rosciano, 2015), and in teaching English as a foreign language (Al-Zyoud et al, 2017). In the context of the current piece of work, the mind maps that were created elicited words and phrases beyond the broad concepts described in job descriptions and published competency frameworks.
Collaborative working is a key principle of the NNS role (DiMaria-Ghalili et al, 2016), so the perceptions of the NST on the role of the NNS team were a particularly important aspect of this exercise. Although the role of the clinical nurse specialist may be welcomed by patients, there may be barriers and a lack of engagement for nurses when contributing to an MDT (Wallace et al, 2019). However, it is important for nurse specialists to have the support of the MDT and an identified role within this (Mitchell, 2018). Comparing the mind maps within the NNS team and between the NNS team and NST demonstrated a good deal of commonality. It was encouraging to see that the work carried out by the NNS team is recognised by the MDT and that colleagues seem to have a similar understanding of the NNS role and contribution to the wider service as the NNS themselves. The additional comments provided by some NST members were unsolicited and not part of the mind-mapping exercise. However, they have been included here as it was clear from the comments that the NNS team are valued and integral to the service.
The National Nurses Nutrition group (NNNG) developed a competency framework for nutrition nurse specialists (Colagiovanni and Fletcher, 2010). This competency comprises seven clinical competencies and three non-clinical competencies as described in Table 3. This framework was developed in accordance with the Knowledge and Skills Framework (KSF), which was the career development tool that was launched as part of the new payscale system in the NHS, ‘Agenda for Change’. The purpose of the KSF was to link nurses' pay to career progression and competency (Gould et al, 2007). The purpose of the NNS competency is to enable individuals to understand what is expected of them in their role, identify their personal development needs and to enable them to provide evidence of their progress for their appraisal process.
The competencies are divided into broad themes and are then further described at three levels. The first level is that of a proficient NNS (Band 6). This is the level many NNSs within a team may be expected to achieve. The second level is the competent NNS (Band 7). At this level, NNSs are expected to manage patients with more complex needs and to also have additional skills such as independent non-medical prescribing. The final level is the expert nurse (Band 8), which is a team leader or advanced role. The level to which NNSs are required to work will vary according to the service needs and priorities of their NHS trust.
The mind-mapping exercise described above revealed an overlap between the proficient nurse and competent nurse roles. The mind maps demonstrated that the Band 6 nurses regularly work to the competency level of the Band 7 as described in this framework. This includes Band 6 NNSs who are independent non-medical prescribers and who are able to carry out expanded practice in the repair of central venous access devices, for example. As an intestinal failure tertiary referral centre it is perhaps not surprising that the development of skills beyond those described for Band 6 nurses in the NNNG competency is essential for the day-to-day running of the authors' service. Although this level of skill development and autonomy is likely to enhance job satisfaction and aid staff retention (Tang and Hudson, 2019), this exercise has provided the opportunity to review the team structure and consider additional investment in terms of pay bands and promotion within the team.
Two international competency frameworks were identified. The former Vereniging van Voedings en Infusie Verpleegkundigen (VVIV) (Association for Nutrition and Infusion Nurses) in the Netherlands, which has since merged into a larger body, developed a competency framework in 2004.
Translation issues meant it was not possible to access the complete framework (VVIV, 2004) therefore the authors referred to the summary of the framework described by Boeykens and Van Hecke (2018). With a similar structure to the NNNG competency there are core competencies in this framework (see Table 3). The requirements for NNSs are very similar to the NNNG framework. These demonstrate fundamental skills that are necessary in order to fulfil this role such as assessment, interpretation of results and education. Interestingly, this framework suggested a Master's degree in nursing is recommended to be able to achieve the competencies identified. This suggests NNSs in the Netherlands may need evidence of more clinical and academic experience before applying for such posts. In contrast, the progression to a Master's degree is often seen as a developmental opportunity for Band 6 and Band 7 nurses in the UK.
The American Society for Parenteral and Enteral Nutrition (ASPEN) published its standard of Nutrition Care Practice in 2016 (DiMaria-Ghalili et al, 2016). ASPEN (2022) defines standards as ‘a benchmark representing a range of performance of competent care that should be provided to assure safe and efficacious nutrition care’. ASPEN envisions a healthcare system where all patients receive safe and high-quality nutrition care in which they recognise the role of the nutrition support nurse in achieving this. Unlike other frameworks, ASPEN (DiMaria-Ghalili et al, 2016) describes competencies for general nursing practice and compares these with the expanded requirements of a nutrition support nurse and nursing speciality practice. This format extends the scope of the framework beyond that of specialist nurses. However, in contrast to the VVIV framework, there is no suggestion of an academic requirement for specific roles.
The themes identified in the current mind-mapping exercise were largely consistent with themes within all three frameworks discussed. The similarity in the standards or competencies across all three frameworks shows there are fundamental aspects to the role of the NNS, such as education and patient assessment. The scope of the role varies depending on the environment the nurse works in. DiMaria-Ghalili et al (2016) discussed that although nurses in the USA can no longer certify as nutrition support nurses, they often specialise within a specific area of nutrition support care such as infusion therapy or home care. In the UK, NNSs may have roles that are predominately related to enteral nutrition, parenteral nutrition or a combination of the two.
In the context of the current mind-mapping exercise, it is likely that many nutrition nurses will recognise elements from Table 2 within their own practice. Aspects such as enteral feeding tube management or parenteral nutrition may be common to many NNS roles. However, some services, such as tertiary services, may benefit from expanded roles within NNS teams.
The expanded role of the NNS may include competencies such as independent non-medical prescribing and insertion of central venous access devices (CVADs). An early innovation in the role of the NNS was demonstrated in a nurse-led CVAD insertion service, which was shown to cut costs and improve patient care (Hamilton, 2005). Within the authors' intestinal failure service, CVAD insertion is not part of the NNS role; instead, there is a separate nurse-led IV access team who lead on peripherally inserted central catheter (PICC) and CVAD insertions for all specialities. However, within the intestinal failure service the NNSs have expanded skills to enable repair of CVADs in patients receiving HPN. Repair of a CVAD in this patient group was shown to be safe, effective, to increase the longevity of the CVAD and demonstrate cost savings (Fletcher et al, 2021).
The development of the nurses' role in areas such as non-medical prescribing has also proven to be beneficial. Nurse prescribing was introduced in the UK in 1986 (Scrafton et al, 2012). Initially, this additional skill was limited to community-based nurses with a limited formulary. However, with the advancement of nursing skills and competencies over the years independent nurse prescribers now have access to most drugs in the British National Formulary and practise according to the competency framework described by the Royal Pharmaceutical Society (2021). The number of nurse prescribers has also increased over the years, with statistics from the Nursing and Midwifery Council (NMC) register showing there were more than 96 029 prescribers in 2021 (NMC, 2021). Latter et al (2005) found nurse prescribing was positively received by patients and staff in the community setting as this showed benefits in terms of access and timeliness of treatment. In the current mind-mapping exercise, independent non-medical prescribing was identified as a specific theme by both the NNS team and NST. This is a key element to the role, with the NNSs within the intestinal failure service being responsible for the day-to-day management of HPN and inpatient PN prescribing, with the support of the medical consultants if required. Prescribing is recognised within the NNNG framework as a skill in Band 7 or above roles; however, within the authors' service, Band 6 NNSs are also prescribers.
Telephone consultations became critical during the COVID-19 pandemic as patients were able to continue with their healthcare regimen but also adhere to government advice on staying at home (Wolthers and Wolthers, 2020). A nurse-led telephone clinic/hotline was identified within the current mind-mapping exercise by both the NNS team and NST, which has been a core part of the NNS intestinal failure service for many years before the COVID-19 pandemic. The telephone clinic allows patients rapid access to advice from an NNS. In addition, it enables nurse triage and direction of care for HPN patients who call to report complications, such as CVAD rupture or symptoms of CVAD-related sepsis. Nurse-led telephone triage and clinics have been shown to reduce hospital admissions (Calvetti et al, 2022) and improve patient satisfaction (Jimènez Torres et al, 2021). This aspect of practice sits within the assessment theme of the identified frameworks. However, in terms of the intestinal failure service, the authors would suggest that the level of decision making and autonomy demonstrated within the nurse-led clinic may be different from that practised in non-tertiary services.
It is clear that an effective NNS team within a tertiary intestinal service needs to demonstrate advanced knowledge of intestinal failure and nutrition support in order to expand nursing practice and meet the needs of patients. This enables NNSs to act with professionalism in the role and make autonomous, evidence-based decisions with confidence (NMC, 2017).
Implications for nursing
Specialist nursing teams have the opportunity to evaluate their practice and service provision beyond the scope of their existing job descriptions. The mind-mapping technique is an approach to exploring current practice and, importantly, provides a basis for further investment in nursing teams.
Nurses are advocates for patients and should strive to improve the care patients receive (NMC, 2017). In order to identify areas for improvement, nurses need to be able to critically evaluate their current practice and meet the expectation for innovation and improvement within healthcare services (NMC, 2017).
Alongside identifying improvements, it is equally important to recognise positive elements of the service that work well. As nurses we often focus on the negatives and look at how to correct these rather than emphasising the positive and life-changing work we do every day for the patients under our care.
The mind-mapping exercise identified key areas of practice recognised by both the NNS team and NST. Some areas of practice are likely to be familiar to NNSs in many areas. However, other areas of practice are likely to be specific to expanded roles required within a tertiary intestinal failure service, such as repair of CVADs and independent non-medical prescribing of PN. The exercise further demonstrated that the NNS team is integral to and valued by the wider NST.
Competency frameworks are useful in identifying broad themes and areas of practice within the nutrition nursing role. Limitations of frameworks must be recognised, including that it is difficult for these to reflect rapid advancements in the role. Each NNS service is likely to have individual requirements to meet local needs. Therefore, the authors would suggest that NNSs may use practice frameworks as reference points to determine current and future roles.
The use of mind mapping for service review can be adopted by other specialist nursing teams to compare their role against published competency frameworks. It aids in identifying areas for improvement within the service but, in the context of the current exercise, may also be a tool for positive feedback and team recognition.
- The role of the nutrition nurse specialist is diverse
- National and international competency frameworks may not identify the advanced nursing skills carried out by some practitioners
- Specialist nursing teams have the opportunity to evaluate their practice and service provision beyond the scope of their existing job descriptions
- The mind mapping technique is an approach to exploring current practice and, importantly, provides a basis for further investment in nursing teams
CPD reflective questions
- Use the mind-mapping technique to explore your role
- Are you aware of any national or international competencies that you could evaluate your role against?
- Think of other approaches that can be used to map your service and evaluate practice