Impact of Nurse Led Initiative and Consultancy
The philosophy of nurse-led initiatives is driven from a service redesign and clinical need standpoint rather than the patients experience and the changes in organizational culture. Shortages in the medical workforce means that nurses are increasingly called on to perform work previously done by doctors. This dearth in the nursing labor force means that healthcare assistants now do many tasks which nurses are trained to do. In the UK, Prime Minister Tony Blair first initiated the idea of the Consultant Nurse in 1998.
This new ‘super nurse’ was expected to have a similar status to that of medical consultants and for the first time expert nurses would be enabled to remain at the bedside and deliver improved services for patients. “Four key areas of responsibility were defined for Consultant Nurse posts: expert practice; professional leadership and consultancy; education and development; and practice and service development linked to research and evaluation. Key too was the expectation that the post-holder spend 50% of their time in clinical practice [2]. Furthermore, Consultant Nurses were to have been educated to Masters or Doctorate level and hold additional specialty-specific professional qualifications [1]. (Age and Ageing 2004; 33: 327–328. DOI: 10.1093/ageing/afh143. http://ageing.oxfordjournals.org/content/33/4/327.full.pdf, retrieved 28 April, 2011.)”
Nurse-led care has a variety of definitions. “Nurse led care can be usefully viewed as a continuum with, at one end, nurses undertaking highly protocol driven, focused tasks (cardioversion,2 colposcopy, smoking cessation) and, at the other end, responding to far more diverse challenges in terms of clinical decision making, such as first contact care and rehabilitation. The extent to which doctors’ work can be delegated effectively is likely to be influenced, in part, by the type and complexity of the associated decision tasks. (Cullum, Nicky et al. BMJ 330 : 682 doi: 10.1136/bmj.330.7493.682 (Published 24 March 2005.) http://www.bmj.com/content/330/7493/682.full, retrieved 28 April, 2011.)” “Through expert practice they can deliver service improvements that directly benefit patients; through professional leadership and consultancy they can influence the strategic development of services; through educating nurses and others they can raise awareness and change practice on a wider scale; and finally they can demonstrate their impact through research and evaluation. (Cullum, Nicky et al. BMJ 330 : 682 doi: 10.1136/bmj.330.7493.682 (Published 24 March 2005.) http://www.bmj.com/content/330/7493/682.full, retrieved 28 April, 2011.)”
The impact of Consultant Nurse posts can often prove challenging for both individuals and organizations. There has been remarkable disparity in how these posts have been set up and supported. For example, some organizations have handed over vast agendas to a single post-holder with the expectation that they can transform services on their own without support. “However research has shown [4] that Consultant Nurses have the potential to become isolated and fragmented from mainstream services unless the posts are well thought out, there are realistic expectations of what post-holders can achieve and they have adequate resources at their disposal. Organizational support is crucial to success both in terms of ensuring parity of resource with other consultant posts and in ensuring professional support from both nursing and medical colleagues. (Age and Ageing 2004; 33: 327–328. DOI: 10.1093/ageing/afh143. http://ageing.oxfordjournals.org/content/33/4/327.full.pdf, retrieved 28 April, 2011.)”
Despite the challenges faced by Consultant Nurses, they have already led several important service improvements: “leading on NSF targets; establishing nurse-led clinics and services, in particular around continence, falls, psychiatric liaison, early onset dementia, care home support, intermediate care, and a plethora of initiatives related to supporting and empowering vulnerable adults and their careers. (Age and Ageing 2004; 33: 327–328. DOI: 10.1093/ageing/afh143. http://ageing.oxfordjournals.org/content/33/4/327.full.pdf, retrieved 28 April, 2011.)” These nurses also have teaching and research obligations with local universities and many are pursuing postgraduate studies or have completed or in the process of finishing nurse prescribing courses. The potential of this role to be developed to lead new services need to be furthered explored. Recognizing professional boundaries as boundaries rather than obstacles will be essential to delivering high quality services.
“Close inspection of the clinical outcomes in the trial by Walsh et al reveals that patients who received nurse led intermediate care had better functional outcomes at discharge, although this did not reach significance. This lack of statistical significance is not the same as “no difference” in functional outcomes. A meta-analysis of 10 studies of nurse led intermediate care (which includes the Walsh trial) identified a statistically significant benefit of nurse led intermediate care on functional status at discharge, as well as reductions in the proportion of patients discharged to institutional care and in readmissions. This indicates that the increase in functional status may be clinically (and potentially economically) important and warrants further study. (Cullum, Nicky et al. BMJ 330 : 682 doi: 10.1136/bmj.330.7493.682 (Published 24 March 2005.) http://www.bmj.com/content/330/7493/682.full, retrieved 28 April, 2011.)”
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