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

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?

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

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

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?

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 procedures.

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

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

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

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

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

“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

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

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

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

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

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?

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

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

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.

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

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

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

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

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)