Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care

Patient safety in acute care: are we going around in circles?

This article provides a critical discussion examining why adult patients continue to unnecessarily deteriorate and die despite repeated healthcare policy initiatives. After considering the policy background and reviewing current trends in the data, it proposes some solutions that, if enacted, would, the authors believe, have a direct impact on survival rates. Health professionals working in hospitals are failing to recognise signs of physiological deterioration. As a result, adult patients are dying unnecessarily, estimated to be in the region of 1000 a month. This is despite international healthcare policy requiring practitioners to be appropriately trained to recognise the deteriorating adult patient and to intervene. A literature review centred on health policy for England from 1999 to 2015 was undertaken, with reference to international policy and practice. This article also draws on the authors' combined clinical experience, which is underpinned by relevant research and theory. The implications for nursing could be significant. Change is urgently required otherwise people will continue to die unnecessarily. Health professionals, healthcare organisations and international governments working together can prevent unnecessary deaths from happening within acute hospitals.

Clarifying Clinical Nurse Consultant work in Australia: A phenomenological study

The Clinical Nurse Consultant role in Australia is an Advanced Practice Registered Nurse Role (APRN). This role has been conceptualized from the discrete pillars of research, education, practice, system support and leadership, articulated in the Strong Model of Advanced Practice. This conceptualization has been manifested in job descriptions, workforce. planning and course design. This paper explored whether there was a more refined way of conceptualizing the unique 'value add' of the role. A hermeneutic phenomenological approach was employed to explore the lived experience of the role. It was identified that the pillars of education, practice, leadership and research are interconnected and expressed in the system work of the Clinical Nurse Consultant. The findings have implications for education and workforce planning.

Recognising the differences in the nurse consultant role across context: a study protocol

Background

The advanced practice role of the Nurse Consultant is unique in its capacity to provide clinical leadership across a range of contexts. However, the Nurse Consultant role has been plagued with confusion due to lack of clarity over function and appropriateness for purpose within health organisations across contexts. Changing health service delivery models are driving the emergence of new nursing roles, further clouding the waters related to role positioning and purpose. There is an urgent need for evidence of impact and demonstration of how Nurse Consultants contribute to health care outcomes. This study aims to gain a clearer understanding of the Nurse Consultant role and its impact in metropolitan and rural New South Wales (NSW) Australia.

Design

The proposed study employs a sequential mixed method design, underpinned by Realistic Evaluation, to explore how Nurse Consultants contribute to organisational outcomes. The ‘context – mechanism – outcome’ approach of realistic evaluation provides a sound framework to examine the complex, diverse and multifaceted nature of the Nurse Consultant’s role.

Method

Participants will be stakeholders, recruited across a large Local Health District in NSW, comprising rural and metropolitan services. A modified and previously validated survey will be used providing information related to role characteristics, patterns and differences across health context. Focus groups with Nurse Consultant’s explore issues highlighted in the survey data. Focus groups with other clinicians, policy makers and managers will help to achieve understanding of how the role is viewed and enacted across a range of groups and contexts.

Discussion

Lack of role clarity is highlighted extensively in international and Australian studies examining the role of the Nurse Consultant. Previous studies failed to adequately examine the role in the context of integrated and complex health services or to examine the role in detail. Such examination is critical in order to understand the significance of the role and to ascertain how Nurse Consultants can be most effective as members of the health care team. This is the first Australian study to include extensive stakeholder perspectives in order to understand the relational and integrated nature and impact of the role across metropolitan and rural context.

The impact on patient health and service outcomes of introducing nurse consultants: a historically matched controlled study

Background

The position of nurse consultant (NC) was introduced in Hong Kong by the Hospital Authority in January 2009. Seven NCs were appointed in five clinical specialties: diabetes, renal, wound and stoma care, psychiatrics, and continence. This was a pilot to explore the impact of the introduction of NCs on patient health and service outcomes.

Methods

The present paper describes a historically matched controlled study. A total of 280 patients, 140 in each cohort under NC or non-NC care, participated in the study. The patient health and service outcomes of both cohorts were evaluated and compared: accident and emergency visits, hospital admissions, length of hospital stays, number of acute complications, number of times of treatment or regimen altered by nurses according to patient’s condition, glycated haemoglobin A1c (HbA1c) levels, urea and urea-to-creatinine ratios, and number of wound dressings for patients in corresponding specialty units. A patient satisfaction instrument was also used to assess the NC cohort.

Results

The study showed that patients under NC care had favourable patient health and service outcomes compared with those under non-NC care. The NC cohort also reported a high level of patient satisfaction.

Conclusions

The study demonstrates that the introduction of NCs in specialty units may have a positive impact on patients’ health and service outcomes. The high level of patient satisfaction scores indicates that patients appreciate the care they are receiving with the introduction of NCs.

Advanced nursing roles: a systematic review

In this systematic literature review, we analyzed and synthesized the literature on one specialized advance practice nursing role in three countries for the purpose of describing and comparing these roles, as well as discussing whether an international consensus of the advance practice nursing definition is possible. A systematic search on CINAHL and PubMed Medline was conducted in 2011 to search the literature on the nurse consultant in the UK, the clinical nurse specialist in the USA, and the clinical nurse consultant in Australia. The studies (n = 42) were analyzed and combined using qualitative content analysis method. The roles of the nurse consultant, clinical nurse specialist, and clinical nurse consultant were similar. The variation in the roles appears to derive from organizational or individual choices, not the country in question. The study process comprised a synthesized representation of one specialized advance practice nursing role. More work is needed to further define the concept of the advance practice nursing, as well as its implementation on other cultures beyond this review. Based on this review, an international consensus regarding the definition of advance practice nursing and its subroles is possible.

Differences between clinical specialist and advanced practitioner clinical practice, leadership, and research roles, responsibilities, and perceived outcomes (the SCAPE study)

AIM

To report a study designed comparing the roles, responsibilities, and perceived outcomes of Clinical Nurse Specialists, Clinical Midwife Specialists, and Advanced Nurse Practitioners in Ireland.

BACKGROUND

A clinical career pathway that encompasses progression from staff nurse or midwife through clinical specialist to advanced practitioner level was introduced in Ireland in 2000. Such roles are common internationally, but little evaluation has been conducted and few comparisons have been made between roles.

DESIGN

A mixed-method case-study design was used.

METHODS

Following Research Ethics Committee Approval, data were collected in 2009-2010, using non-participant observation (92 hours) of 23 Clinical Specialists and Advanced Practitioners, interviews with 21 clinicians and 13 Directors of Nursing or Midwifery. A survey was completed by 154 service-users.

RESULTS

A clear difference was seen between Clinical Specialist and Advanced Practitioners, with advanced practice roles providing improved service delivery, greater clinical and professional leadership, increased research, and a clear governance and accreditation structure. Clinical Midwife Specialists were rated at a similar level to Advanced Nurse Practitioners for certain aspects and rated more highly for 'continuity of care and carer'.

CONCLUSION

Advanced Practitioners do give a higher level of care, particularly at a strategic level. Existing Clinical Specialists should therefore be encouraged to develop their skills and education to achieve advanced practice level and more specialist and advanced practice posts should be instituted.

Being an effective nurse consultant in the English National Health Service: what does it take? A study of consultants specializing in safeguarding

AIMS

This study established key attributes and perceived strengths, weaknesses, opportunities and threats (SWOT) of nurse consultants specializing in safeguarding children.

BACKGROUND

The nurse consultant role in England spans four domains--clinical, leadership, education and research--and was intended to enable senior nurses to remain in clinical practice.

METHOD

ata identifying the time spent by the nurse consultants in the four domains was collated and a thematic content analysis of the SWOT of the role was ascertained from semi-structured interviews with nurse consultants (n = 4) and stakeholders (n = 6).

RESULTS

Strengths and opportunities in clinical (consultancy), leadership and educational functions were identified but some weaknesses and threats in terms of nurse consultant's contributions to research were also identified. The role was neither wholly strategic nor clinical. Role ambiguity meant that they were not always valued by managers, making the role potentially expendable.

CONCLUSIONS

Nurse consultants are pivotal within health-care organizations because they span clinical practice and leadership enabling them to support managers in strategic planning, commissioning and implementation of policy.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse consultants can support strategic practice development and influence quality and effectiveness service-wide. To succeed they must be understood, supported and nurtured by managers.

Evaluation of the impact of nurse consultant roles in the United Kingdom: a mixed method systematic literature review

AIM

This paper reports a mixed methods systematic review examining the impact of nurse consultant roles in adult healthcare settings, with a view to identifying indicators for demonstrating their impact on patient and professional outcomes.

BACKGROUND

Nurse consultants were introduced in England in 2000 with the intention to achieve better outcomes for patients by improving quality and services. Previous studies have investigated the impact of nurse consultants, but attempts to amalgamate this evidence have been methodologically limited. Since these reviews were published, the importance of demonstrating the contribution of nurse consultants has prompted new research. A robust review of the evidence is now required.

DATA SOURCES

A broad search strategy was adapted for eight databases. Grey literature was sought from various sources.

REVIEW METHODS

Quantitative and qualitative studies were included. Study quality was assessed using appropriate instruments. Cross-study synthesis combined the quantitative and qualitative findings in relation to the dimensions of impact identified. Measures of impact were mapped against a framework for assessing clinical and professional outcomes.

RESULTS

Thirty-six studies were included. The findings suggest a largely positive influence of nurse consultants on a range of clinical and professional outcomes, which map onto the proposed framework of impact. However, there was very little robust evidence and the methodological quality of studies was often weak.

CONCLUSION

Further robust research is required to explore nurse consultants' impact on patient and professional outcomes. The proposed framework for assessing impact could be used to guide future research and assist nurse consultants assess their impact.

An exploration of personal initiative theory in the role of consultant nurses

The aim in this paper is to investigate the contribution personal initiative theory makes in understanding the consultant nurse role. The role was introduced in the UK in 2000 to improve patient outcomes, clinical leadership and retention of experienced clinicians. A larger study used a multi-method approach to collect quantitative and qualitative data from focus groups, interviews and a questionnaire administered nationally at two time points. Findings from longitudinal telephone interviews with 30 consultant nurses are the focus of this paper.

Three consultant nurses were selected as case studies to examine the potential of personal initiative theory when applied to new nursing roles. The activities of two of the three demonstrated a high level of personal initiative in the job. They persisted in overcoming problems faced in improving practice. The third scored lower: she emerged as a reactive conformist and less likely than the other two to pursue initiatives of her own.

Personal initiative theory has potential as a framework for evaluating the consultant nurse role, although further research is needed to test it. The longitudinal analysis revealed a determination to stay in the job and overcome difficult challenges when consultants show initiative and are making progress in achieving change.

Investigating the role and impact of expert nurses

This literature review was conducted to identify the attributes of an expert nurse and the direct and indirect impact they have on patient care, health-care organisations and nursing. Given the loss of expert nursing posts as a result of NHS deficits, there is an urgent need to differentiate between a range of expert nursing roles and how these contribute to positive patient and health outcomes and organisational efficiency. The focus of the literature search was on developments in the UK and the results indicated that ambiguity and confusion exist around the terminology and definitions associated with expert nurses. Research shows that expert nurses have a positive impact on patient care and organisational efficiency. However, a lack of clarity leads to a dilution of expert nursing roles and nurse expertise. There is a need for national guidance on the skills required of expert nurses and the necessity of considering the formal protection of nursing titles.

Revitalizing academic-service partnerships to resolve nursing faculty shortages

Vacancy rates of nursing faculty are on the increase as fewer educators are being prepared and nurses at the bedside are in short supply. Advanced practice nurses--uniquely suited to provide clinical education for undergraduate and graduate students--are underutilized. However, without release time, preparation as educators, ongoing support from education and administration, and remuneration for providing both evidence-based education and evidence-based patient care, they can hardly be expected to assume additional responsibilities. This article reviews academic-service partnerships, noting a general lack of published efficacy and cost-effectiveness data, and highlights 21st-century innovations for academia and service to share resources for the benefit of all stakeholders--especially patients and students.

The current role of the consultant nurse in critical care: consolidation or consternation?

BACKGROUND

The consultant nurse role emerged into the National Health Service in 1999, presented against a backdrop of practice and service modernisation. As with any innovative development, the role was originally subject to much scrutiny with regards to impact and outcome. However, six years after its initial introduction, continued focus and support on this role is less visible. This paper presents a follow-up review of the role and function of consultant nurses in critical care, using an original survey tool that underpinned Dawson and McEwen's work in 2003. From the results of the current study, key changes in role are identified and areas for further development are highlighted.

AIMS

To provide a contemporary profile of the consultant nurse in critical care. To identify changes in the consultant nurse role from 2003 to 2006.

METHOD

A national email survey of all known critical care nurse consultants in post in the United Kingdom was undertaken in October 2006. Using a validated survey tool originally used in 2003, a return rate of 73% (n = 47) was yielded.

RESULTS

Biographics of this survey reveal a static consultant nurse population with increasing length of tenure in post (mean = 60.2 months). There is no substantial increase in the size of the cohort since 2003. Postholders demonstrate advanced academic skills through higher degrees (94%) and carry a national and international profile through presentation and publication portfolios (92% national and 53% international presentation, 62% multi-authored publication, 47% single authored publication). The core role that consultant nurses in critical care engaged in is practice and service development (mean involvement score = 3.65), with expert practice holding least mean involvement scores (mean involvement score = 2.67). There is evidence of increasing use by these posts for strategic input at organisational/trust level.

CONCLUSIONS

This paper has identified ongoing strengths and limited developments of the consultant nurse in critical care role. Whilst it is clear that core role functions have not dramatically changed, there are demonstrable shifts towards more strategic engagement within Acute Care Trusts. This has brought about concerns regarding overall management of the role, and sustainability of postholders to balance this ever-increasing portfolio. It is also clear that there has been little new investment in this key leadership role, and this raises concerns as to the perceived contribution that experienced clinical nurses bring to a currently financially and operationally driven health service agenda.

Developing a new model of care for patients with chronic musculoskeletal pain

AIM

To evaluate the impact of a nurse consultant in developing a new model of care for patients with chronic musculoskeletal pain.

BACKGROUND

Patients with chronic musculoskeletal pain experience fragmented care and long waits to have their symptoms assessed [Clinical Standards Advisory Group (2000) Services for Patients with Pain. Department of Health, London]. A nurse consultant post was created to implement a chronic musculoskeletal pain service and prevent inappropriate referrals to other services.

METHODS

Seven peers participated in a semi-structured, qualitative, audio-taped interview to evaluate the impact of the nurse consultant's role. Data were analysed using content analysis. A retrospective audit of 60 patients was conducted to determine utilization of hospital services following attendance at the pain clinic.

RESULTS

Two main themes were identified from the interview data included: (1) the influence of the nurse consultant in implementing a chronic pain service and (2) the clinical leadership skills of the nurse consultant. The audit demonstrated that majority of patients (n = 53) were utilizing less hospital specialities.

CONCLUSION

The nurse consultant's role was pivotal in the implementation of the chronic pain service.