Nurse Consultant And Their Role, A Critique

In order to critically analyze the role of a consultant nurse the author feels it is important to look at the definition of a nurse consultant role, discuss and examine events leading to the existence and development of such roles (history) and finally the impact on quality of patient care of a consultant nurse. The author's current area of practice- a nine bedded adult intensive care unit, where no such role currently exists. However, the author will examine the potentialities of such a role, the possible benefits to patient care and barriers which may be encountered by a consultant nurse in this environment. The model use on the analysis of such a role will be the Manley's 1997, see appendix 1.Author will use research in order to identify key aspects the role would be likely to encompass, and then analyze and evaluate the advanced/consultant nurses role and conceptual framework will be applied. Discussion will also include possible legal and professional implications of the role and how it may be affected in the current climate of the NHS of ever changing and diversifying roles in order to meet patient demands.Nurse consultant is an expert practitioner and professional leader able to assess information and mange change, someone who is capable of understanding and solving complex problems, able to shape the agenda for the future. (DOH, 2000)Since 1972 The Briggs Report (cited by Bowler and Mallik, 1998) recognized an overlap between nursing and medical roles, and where these duties were performed by nurses they were termed 'extended roles.In 1977 the DHSS (cited by Last, 1992) stated that the clinical nursing role may be extended by delegation from a doctor and in response to an emergency. Nurses had to gain certificates of competence in order to perform tasks referred to as extended roles, leaving minimal scope for nurses to take control of decisions necessary for patient care delivery (Bowler and Mallik, 1998). Thus nurses' expanded roles at this time appeared to be task orientated, and served the needs of doctors rather than necessarily those of patients.In 1992 the publication of the Scope of Professional Practice (UKCC, 1992) appeared to redress the balance, removing the need for certification and placing patient need at the centre of development of nursing practice. It stated simply that; 'Practice must be sensitive, relevant and responsive to the needs of individual patients and clients and have the capacity to adjust, where and when appropriate to changing circumstances....the range of responsibilities which fall to individual nurses should be related to their personal experience, education and skill' (UKCC, 1992). However, coming as did between the publication of the New Deal for Doctors (NHSME, 1991, cited by Hind et al, 1999) and The Calman Report (DoH, 1993), which respectively initiated reduction of junior doctors hours and shortening of specialist training, scope understandably created considerable tension within the nursing profession (Finlay,2000). Many were concerned about the 'medicalisation' of nursing and the loss of its intrinsic value (Edwards, 1995). It was feared that in medical terms, the interpretation of 'good' may be to the advantage of medical care and the interests of the physician, but at odds with the interests of the patient and nursing (Castledine, 1996). Tolley, (1994) while acknowledging the benefits of scope in ending confusion relating to task and extended roles, warned that nurses must take on new roles to improve patient care and diversify practice, rather than as a means of gaining power or status.The scope of practice appears to give nurses more freedom in practice. Koefmann and Woods (1995) described how scope enabled nurses in one trust to move the boundaries of care in almost unlimited ways, for example, the setting up of nurse led clinics. With the removal of need for certification and the placement of onus on individual nurses to decide in what ways to expand their practice, certain legal and professional issues are raised. These will be discussed later in further detail.In accordance with scope, a range of new roles for nurses have since evolved in response to the major changes in UK healthcare and therefore service delivery, national policies and moves to more patient focused care (Spilsbury and Meyer, 2001). Indeed, nurses could be said to have a formal responsibility for exploring way in which quality healthcare can be improved under the auspices of clinical governance (Levenson and Vaughan, 1999).More recently both 'Making a Difference' (DoH, 1999) and the NHS Plan (DoH, 2000) promote and encourage continued development of the nurses role. However, despite government and professional bodies continued promotion of expansion of nursing roles and support of advanced nursing practice, definition of advanced practice has not been forthcoming. Tume and Bullock (2002) quote the UKCC's failure to define advanced nursing practice as the reason for the diverse interpretation of these roles in practice. Neenan (1997) bemoans the UKCC's refusal to be more explicit in defining the role of the advanced practitioner in the acute setting, though acknowledging their reason being not wishing to stifle potential development. Sutton and Smith (1995) reject the notion of the medical model at the centre of specialist nursing and stress that the truly advanced practitioner focuses their efforts on their clients' and situations which enhance positive outcomes for the client. They are at once intuitive, reflexive and empowering practitioners that use their expanded roles to foster a sense of the individual and focus wholly on achieving excellence in caring.Manley (1996) recognized two schools of thought regarding advanced nursing roles; one relating to the acceptance by nurses of roles previously considered to be those of doctors, and the other, the theory to which she subscribes, associated with the advancement of nursing rather than medical practice. She sees the purpose of such posts being multi-dimensional, promoting and developing clinical nursing to strategic and policy levels whilst creating a culture where nurses strive for more effective patient and healthcare services. Manley, (1997) through the plethora of terms and the diversity of expanded roles in practice, developed a conceptual framework in order to try and operationalise the advanced practitioner/consultant nurse role in the acute setting.She saw the role as comprising of four integrated sub roles; these are expert practitioner, educator, researcher and consultant. Together with numerous skills and processes and the contextual prerequisites for this role to function result in developed and empowered staff, development of nursing practice and a transformational culture, all of which then contribute to quality services, see appendix 1A study by Hind et al (1999) found considerable support for role expansion in the critical care setting among both medical and nursing staff. They found expansion of role was likely to include activities such as cannulation, venepuncture, ordering blood tests and x-rays, performing physiotherapy, cardioversion and intubation. Goldman (1999) decided to focus her research on skills she felt represented extended roles in ICU - weaning patients from ventilation, extubation, use of Swan-Ganz catheters, defibrillation and management of haemofiltration therapies. 83% of respondents felt role extensions in these areas had benefited patient care.The consultant nurse would have to be aware of the risk of medicalisation of her role and make efforts to ensure role expansions are made within the context of multi-disciplinary care and with the primary benefit being improved patient care (Tume and Bullock, 2002). Working with existing teaching staff and programs, the consultant nurse would need to facilitate practice and staff development of both ICU nurses to take on the role of outreach nurses, and by empowering the ward-based staff with knowledge and skills, quality care could be delivered regardless of the location (Coombes and Dillon, 2002).A qualitative study by Woods (1998) into the nature and focus of the role of the advanced nurse practitioner in critical care found that a core of nursing skills and practices remained an integral part of their day-to-day work. She believes this finding goes some way towards counteracting the suspicion that advanced nurse practitioners are simply being used as physicians' assistants, as suggested by Castledine (1996). In the author's clinical area there is more than adequate medical cover, and therefore theoretically there would be no need for the consultant nurse's role to develop in order to take on traditionally medical roles for the wrong reasons. It could therefore, if combined with Manley's conceptual pre-requisites, be an ideal environment to capitalize on the role for the improvement of patient care, service provision and the education and support of other staff. The nurses consultant could identify by audit which of these skills, if performed by nurses would be beneficial to patient care, and so develop staff and practice in these areas.Hospital based care is becoming increasingly more acute and complex, and recent documents reviewing adult critical care services have defined the need to provide 'critical care without walls' (DoH, 2000). One way in which consultant nurses in critical care are responding to these changing healthcare needs and government policies is through the development of critical care outreach teams (Tume and Bullock, 2002). These were developed in response to research which showed higher mortality rates for ICU patients' admitted from ward areas compared with those admitted from theatre or accident and emergency. This was believed to be due, in part, to delays in recognizing patient deterioration and sub optimal treatment (Singer and Little, 1999). One two centered study identified that up to 41% of ward patients were transferred to critical care too late to significantly improve patient outcome (McQuillan et al, 1998). When considering these findings it is clear how development of an outreach service could directly and significantly impact on patient care.Led by the nurse consultant, the service could aim to decrease the incidence of preventable cardiac arrests, support and empower ward staff and improve recognition and management of acutely ill patients, as suggested by Adam (2002). The setting up of a critical care outreach service would involve many of the aspects of the consultant nurses role as set out by Manley (1997). Initial and continual audit of the service would be required in order to assess need, recourses and measure its impact on patient outcome. It would involve working across professional and organizational boundaries, an approach fundamental to supporting quality service improvements (Coombes and Dillon, 2002). Initially, collaborative relationships between ward and ICU staff would need to be developed. However, if the change was led and managed sensitively it could lead to improved communication and intraprofessional understanding and recognition. Thus. to the breaking down of barriers that exist between ICUs and ward areas, not only in the study by Coombes and Dillon (2002) but also in the author's clinical area, potentially leading to the transformational culture envisioned by Manley.As well as requiring many of the attributes associated with the role of the consultant nurse, leading a critical care outreach team, and PERT would provide the nurse consultant with a unique position to observe hospital wide patterns of care, providing a global perspective on how acute clinical care is delivered (Coombes and Dillon, 2002). If, like many nurse consultants, s/he acted as an adviser to the NHS at regional and national level, this would provide a direct link between strategic level decision making and hands on expert patient care, so benefiting both patients and the nursing profession (Adam, 2002).The role of the consultant nurse in the author's clinical area could be considered particularly useful in its relative infancy, or indeed, from its inception. The role would help to establish best practices and provide strong leadership required to manage the two very different groups of staff combined by the amalgamation of two separate units with different policies and procedures. The management in the author's clinical area, though open to suggestions, is not clinically based and is, therefore, often slow to recognise and so attempt to address issues that may arise in practice and management, acting as a catalyst in changing policy where appropriate, assuming s/he had the organisational authority attributed to the post.As well as initiating and contributing to research on the unit, the nurse consultant could provide valuable support to course students and assist staff with their own research/dissertations, while also acting as a resource base for all staff at all levels. The enormity of such a role is difficult to comprehend, and with so many diverse and time-consuming demands placed upon them, could one individual fulfill such a role? There is currently a teaching sister in this unit that can carry out some of these tasks. Taking in the consideration that this unit is currently changing in to a fast track unit author feels that there is very little that such a role will be able to ad to patient care,A health circular, Nurse, Midwife and Health Visitor Consultants suggests that 50% of a nurse consultant's time should be spent in clinical practice (NHS Executive, 1999), a particularly difficult balance to achieve when there are clearly so many demands on them (Adam, 2002). The core functions of the role are enormously time-consuming and it is difficult to see the nurse consultant being able to research and audit effectiveness as well as delivering Trust wide educational policies (Adam, 2002).A study by Williams et al (2001) also found that the emphasis placed on clinical practice made it difficult for advanced practitioners to contribute to other activities such as research, teaching and improving standards of care. They noted that this highlighted the multifaceted nature of the role and raised two possibilities. One that the role is so demanding that the individual cannot fulfill all that is required and the nurse will inevitably concentrate on some aspects rather than others. The alternative is that the disparate elements of the specialist role identified by research may in fact be part of an integrated whole, and although attempting to separate it may be useful in explaining it to others, it may not reflect the ways in which advanced practitioners experience their work (Williams et al, 2001). Manley (1997) recognizes this, explaining that though her sub roles are presented as separate entities within the conceptual framework, in practice they are overlapping and reciprocal. She argues that it is the multi-dimensional nature of the role that is the key in developing clinical nursing to have greater impact at strategic and policy level.A potential barrier to fulfillment of the educator sub role was identified by Bowler and Mallik (1998). They found that some senior nurses adopt an elitist position in relation to junior staff. If this attitude was fostered by the nurse consultant, it could be argued that by failing to empower junior nurses, s/he would be withholding development and maintaining expert power, thus supporting the hierarchical systems which are encouraged within the present grading structures (Bowler and Mallik, 1998). S/he would also be in conflict with Manley's model in which an open, non-hierarchical management is a pre-requisite for the role to be realized. If by contrast and elitist attitude was displayed by other senior staff on the unit, the nurse consultant would need to collaborate with all staff to create a shift in power relations and the breakdown of hierarchical relations - as Manley points out, however much practical and theoretical expertise the individual may have, on their own they are of little value. The potentialities of the role can only be fully realized in a conducive context, where the basic ingredients exist (Manley, 1997).Legal and professional implications are another area that must be considered with the development of nursing practitioner/consultant nurse roles. With the publication of the Scope of Professional Practice (UKCC, 1992) came the placement of onus on individual nurses to exercise their own professional judgment on role expansion, whilst continuing to practice within the guidelines set out by the Code of Professional Conduct. This states 'You are personally accountable for your practice...' and 'You have a duty of care to your patients' and clients, who are entitled to safe and competent care' (NMC, 2002). Any expansion of practice will therefore require acknowledgement of accountability by the practitioner and require competency (Carver, 1998). Whilst scope allowed more flexibility in role development for nurses, its approach could also lead to legal complications (Goldman, 1999). If, for example, in the course of his/her duty an advanced practitioner/consultant nurse undertakes a task normally performed by a doctor, in law his/her level of competence will be measured against the skills and knowledge of a doctor, as The Bolam Test denotes, the patient is entitled to a reasonable standard of care irrespective of who performs it (Diamond, 1995).Interestingly the General Medical Council (GMC) sanctions delegation to nurses if the doctor is sure the nurse is competent (GMC, 1995) and states that the doctor retains ultimate responsibility for the patient's care (GMC, 1992). However, with the nature of advanced nursing roles such a task may potentially be undertaken as a result of an autonomous decision by the nurse, so in such cases rendering this guideline irrelevant. It must also be remembered that accountability is the one element that cannot be delegated (Huber, 1996) and where issues may appear conflicting all professional guidelines ultimately refer back to the Code, which states that 'you are personally accountable for your practice....regardless of advice or directions from another professional' (NMC, 2002).Lunn (1994) asserts that legally, nurses are expected to adapt to new methods and techniques in the course of their employment. This is expanded on by Rowe (2000), who states that knowledge and ability to practice must be constantly enhanced in order for nurses to be truly accountable and to deliver optimum nursing care and failure to do this would actually constitute a break of the Code. Accountability for these developments must be accepted by nurses and should be welcomed, as without it nursing could not claim to be a profession and patients' would have no rights. Provided the central principal of protecting patients' is adhered to, the practitioner can enjoy developing his/her own practice (Rowe, 2000).As the role is only potential it is difficult to accurately assess to what extent it would impact on patient care in the author's clinical area. It would depend not only on the numerous aspects conceptualized by Manley but also critically on the background, motivation and personality of the individual. However, if the role was realized to its full potential it appears the impact on quality of patient care could be considerable and far-reaching. Quality of care would be effected both directly, through the role's strong emphasis in expert clinical practice, so also providing a role model, and indirectly through development of staff and practice and through the initiation and management of change to direct service provision to meet the needs of patients'. The example of setting up a critical care outreach service and PERT led by the nurse consultant could result in the breaking down of barriers between clinical areas and increased collaboration between staff, as well as directly effecting patient outcome and providing a direct link between practice and management at all levels. The undertaking of, contribution to and support of other staff in research projects would further contribute to nursing practice and staff development and so to quality of patient care.Taking in consideration the fact that the unit is small, the fact that there is one modern matron off side, a teaching sister in the unit, the good skill mix of staffing within the unit, the fact that the unit is now changing in to a fast-track unit, and finally that there is a nurse consultant within the trust for ITU who is currently working on policy development, as well as fact that financially it will be a big investment in such a role, by description the enormity of this role may not appear practically achievable; it seems unlikely that one individual could create such an impact on quality of patient care. However, the essence of nursing is often difficult to describe and therefore, the true nature of such a diverse and dynamic role is even more challenging to capture and convey. In practice the sum of the roles' aspects appears to be greater than its parts and so its integrity and true nature appear to be compromised by attempting its analysis.Appendix 1, Manley's Model.REFERENCESCastledine, G. 1996 The role and criteria of an advanced practitioner British Journal of Nursing 5, (5), 288-289Adam, S. 2002 The role of a nurse consultant in expanded critical care Nursing Times 98, (1), 34-36Briggs, A. 1972 Briggs Report: Report of the Committee on Nursing HMSO/DHSS, LondonBowler, S. and Mallik, M. 1998 Role extension or expansion: a qualitative investigation of the perceptions of senior medical and nursing staff in an adult intensive care unit Intensive and Critical Care Nursing 14, 11-20Carver, J. 1998 The perceptions of registered nurses on role expansion Intensive and Critical Care Nursing 3, 82-90Coombes, M. and Dillon, A. 2002 Crossing boundaries, re-definining care: the role of the critical care outreach team Journal of Clinical Nursing 11, 387-393Diamond, B. 1995 When the nurse wields the scalpel British Journal of Nursing 4, (2), 65-66Department of Health, 1993 Hospital Doctors: Training of the Future. The report of the Working Group on Specialist Medical Training Lancaster, Health Publications UnitDepartment of Health, 1999 Making a Difference: Strengthening Nursing, Midwifery and Health Visiting Contribution to Healthcare London, DoHDepartment of Health, 2000 Comprehensive Critical Care Review: A review of Adult Critical Care Services London, The Stationery OfficeDepartment of Health, 2000 The NHS Plan - a plan for investment. A plan for reform London, The Stationery OfficeDepartment of Health and Social Security Joint Working Party, 1997 The Extending Role of the Nurse, Legal Implications and Training Requirements London, DHSSEdwards, K. 1995 What are nurses' views on expanding practice? Nursing Standard 9, (41), 38-40Finlay, T. 2000 The Scope of Professional Practice: A literature review to determine the documents impact on nurses' role Nursing Times Research 5, (2), 115-126General Medical Council, 1992 Professional Conduct and Discipline: Fitness to Practice London, GMCGeneral Medical Countil, 1995 Good Medical Practice: Duties of a Doctor London, GMCGoldman, H. 1999 Role expansion in intensive care: survey of nurses views Intensive and Critical Care Nursing 15, 313-323Hind, M., Jackson, D., Andrews, C., Fulbrook, P., Galvin, K. and Frost, S. 1999 Exploring the expanded role of nurses in critical care Intensive and Critical Care Nursing 15, 147-153Huber, D. 1996 Leadership and Nursing Care Management Loncon, WB SaundersKoefman, K. and Woods, M. 1995 Developing a new deal for nurses Nursing Standard 9, (44), 33-35Last, T. 1992 Extended role of the nurse in ICU British Journal of Nursing 1, (13), 672-675Levenson, R. and Vaughan, B. 1999 Developing New Roles in Practice: an Evidence Based Guide Sheffield, University of SheffeldLunn, J. 1994 The Scope of Professional Practice from a Legal Perspective British Journal of Nursing 3, (15), 770-772McQuillan, P. et al 1998 Confidential inquiry into quality of care before admission to intensive care British Medical Journal 316, (7148), 1853-1858Manley, K. 1996 Advanced practice is not about medicalising nursing roles Editorial Nursing in Critical Care 1, (2), 56-57Manley, K. 1996 A conceptual framework for advanced practice: an action research project operationalising an advanced practitioner/consultant nurse role Journal of Clinical Nursing 6, 179-190National Health Service Executive 1999 Nurse, Midwife and Health Visitor Consultants: Establishing Posts and Making Appointments Leeds, NHS ExecutiveNational Health Service Management Executive 1991 Junior Doctors; the New Deal London, NHSMENeenan, T. 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