Development of Nursing Roles – The UK Experience

1. Development of Nursing Roles – The UK Experience Christine Norton PhD, MA, RN Associate Dean (Research) & Professor of Gastrointestinal Nursing, King’s College London & Nurse Consultant, St Mark’s Hospital

2. Nurse Specialists • Rapid expansion of numbers • Mini doctor? Cheaper doctor? More available than doctors? • Pressures: junior doctors hours, demand for services (e.g. screening), political pressure, nurses more popular than doctors (??) • Quality of service • What is in the patients’ interests?

3. What is a quality service? • Different stakeholders • Patients: quality of clinical care, wait times, consultation length, respect & dignity, participate in decisions, information improves outcomes, informed choice, reassurance, enabled to cope • Managers: costs, audit, wait times • Colleagues: consultancy, shared care

4. Decision to expand nurse specialists • Cost? • Shortage of doctors? • Nurses – job satisfaction and promotion prospects • Improve patient care pathway (availability, wait times), quality of care, or patients satisfaction, ability to self-care

5. Confusing range of titles • Clinical Nurse Specialist • Nurse Practitioner • Advanced Nurse Practitioner • Nurse Consultant • At present in UK no central regulation, no defining qualification or training • “Not a specialist just because specialising” • If you are starting a new system, worth thinking about before you start • What education is required?

6. Training for Specialists • USA - Masters level preparation for Nurse Specialists • Problem for first pioneers • UK- some degree level courses / modules • UK: Masters (MSc) growing – will be required in future • Guidelines in a few situations e.g. BSG endoscopists - same training as doctors - 150 procedures.

7. Issues • Scope of roles • Training • Management • Audit / research • Costs • Ethical & legal issues • Interdisciplinary collaboration

8. Scope of nurse specialists • Clinical caseload • Clinical leadership and role model • Consultancy, policies, procedures etc • Education • patients, nurses, other professionals, public • Management • Research

9. Scope - Clinical • Assessment / history taking • Investigations (doing or ordering) • Patient teaching • Treatment: huge range of possibilities • Prescribing • Practical coping • Ongoing support • Patient’s advocate, service organisation

10. Nurse specialist – critical care • Increasingly nurse-run critical care units • Formalised roles (always did teach junior doctors what to do, now formally a nursing role) • Titration of drugs (open prescriptions) • Protocols – based on patient goals – nurse has discretion over drugs and fluid challenges • Central line insertion & IV drug administration

11. Nurse specialist – critical care • Set up technology: eg Ventilator set up & settings • Manage technology (eg haemofiltration) • Interpret data from technology (eg blood gases, ECG) and take action • Outreach for critically ill patient in general wards or emergency care (especially at night) – Site Practitioner typically assesses and decides if need to transfer to ITU or HDU

12. “Realising the potential of critical care nurses” (2002) • Shortage of nurses • Technological advancement: increased complexity of care • Levels of care (rather than location): • 0 = no risk • 1 = general ward, risk of deterioration • 2 = high dependency unit • 3 = intensive care

13. Critical care nurses • Often excessive workload • Increased infection risk • Increased mortality risk • Increased costs and length of stay • Geographical layout a big influence on nursing effectiveness • Level 2 may need more nursing time than level 3 (not unconscious) • Attributes of nurses (coping with unpredictability) crucial to patient outcomes

14. Effective practice: Endoscopy • 1975: Mayo clinic - nurse sigmoidoscopy • 1992: Flexible Sigmoidoscopy: doctors = nurses (Disario & Sanowski) • 1994: Nurses as accurate & safe in screening (and more returned for re-screen) (Maule, NEJM) • Only one prospective RCT (Schoenfeld, 1999): 20/21% polyps missed, depth insertion same • No study has found major differences doctors / nurses in performance or safety

15. Nurse Specialists in UK • All areas of care: • Primary care: first consult, prescribers, screening, much routine care • Accident and Emergency: nurse triage • Peri-operative nurse practitioners (especially role in enhanced recovery) • Procedures and tests (eg endoscopy – diagnostic and surveillance) • Chronic disease management

16. Nurse Consultants • Department of Health 1999 • “ Establishing consultant posts is intended to help provide better outcomes for patients by improving services and quality, to strengthen leadership and to provide a new career opportunity to help retain experienced and expert nurses in practice” • Responsibility for total patient care

17. Four core functions of nurse consultants • Expert practice (50%) • Professional leadership and consultancy • Education, training and development • Practice and service development, research and evaluation • No so different from nurse specialist?

18. My role as Nurse Consultant • Patients referred to me from surgeons, physicians, family doctors, nurses • I read letter, order tests, decide on treatment • My team of 5 nurse specialists assess and report back to me • I see “difficult” cases • No medical care or responsibility for my patients unless I decide to refer

19. Possible differences specialist / consultant • Ultimate clinical responsibility for care • Expert advice to outside bodies & individuals • New services and new ways of doing things • Spectrum from junior nurse specialist to senior consultant – continuum – career progression

20. Legal & ethical issues • Few legal limitations on what nurses can do • NMC (Code of professional conduct & Scope of professional practice) • Professionally accountable • Reasonable practice as judged by peers • Employers liability : for extended role (normally doctor): written job description & protocols, proof of competency, clear with clinical risk manager, must follow protocol if have one.

21. Dangers / drawbacks • Fragmentation of care • De-skill others • Generalists abdicate responsibility • Acceptance / overlap / resentments / ownership • Easy to spread too thin and be ineffective • Lack of career structure • Lack research base for practice and lack of evaluation

22. Evaluation - does Nurse Specialist make a difference? • Research / audit crucial • Patient numbers, waiting times • Patient clinical outcomes • Patient understanding • Patient satisfaction • Bed days, consultations, costs • Difficult to evaluate quality, care, coping • Outcomes multifactorial

23. Management • Corporate resource • Catalyst for change • Cross-boundary working / liaison • Protocols, guidelines, pathways for care • Need defined role in nursing structure to be effective • Need strong nursing management ownership & support

24. Problems • Lack of clarity in role • Lack of coherence and admin support • Expected to do too much (scope) • Difficult for existing colleagues to see you differently + “ownership” of patients • Lack of management support • Career structure

25. Conclusions • Evidence is consistent that nurses can take over many functions of doctors, as effectively and often with greater patient satisfaction • Opportunity to re-think and improve service • Think why, consult widely, plan carefully • Improve quality, not save costs • Keep patient as focus • Cope with dehumanising technology • Not a panacea! Cannot do everything! (Norton & Kamm, J. Royal Soc. Medicine, 2002)