Nurses taking on junior doctors' work: a confusion of accountability

Guidelines in lower-middle income countries

Guidelines include recommendations intended to optimize patient care; used appropriately, they make healthcare consistent and efficient. In most lower-middle income countries (LMICs), there is a paucity of well-designed guidelines; as a result, healthcare workers depend on guidelines developed in Higher Income Countries (HICs). However, local guidelines are more likely to be implemented because they are applicable to the specific environment; and consider factors such as availability of resources, specialized skills and local culture. If guidelines developed in HICs are to be implemented in LMICs, developers need to incorporate local experts in their development. Involvement of local stakeholders may improve the rates of implementation by identifying and removing barriers to implementation in LMICs. Another option is to encourage local experts to adapt them for use in LMICs; these guidelines may recommend strategies different from those used in HICs, but will be aimed at achieving the best practicable standard of care. Infrastructural deficits in LMICs could be improved by learning from and building on the successful response to the human immunodeficiency virus/acquired immunodeficiency syndrome pandemic through interactions between HICs and LMICs. Similarly, collaborations between postgraduate medical colleges in both HICs and LMICs may help specialist doctors training in LMICs develop skills required for guideline development and implementation.

Nurse-led care: The importance of management support

The focus of this paper is the importance of proper management planning and support to underpin the provision of nurse-led care. The author's record of research in this field has left her with a lasting impression that nurse-led services often fail to reach their full potential, at least in part because of inadequate management.

The main body of the paper consists of a brief account of a Department of Health-funded project, Exploring New Roles in Practice (ENRiP). In this three-stage study, members of the teams undertook a mapping exercise in a 20% sample of acute trusts throughout England to identify the emerging range and purpose of new roles for nurses and members of the professions allied to medicine (PAMs). The resulting database provided the sampling frame for 32 case studies to clarify the range of issues relating to the introduction of new roles. The database in its entirety also provided the population for a survey designed to establish the generalisability of the conclusions emerging from Stages One and Two. The research findings provided evidence on which to base a guidance document encapsulating the lessons learned during the project. The implications of its findings for management of nurse-led services are discussed and compared with advice given by the author in 1995 in the report Catching the Tide.

Primary care nursing: How can nurses influence its development?

Health service reforms emphasise the central place of the general practitioner in a primary care-led NHS, as at the same time aspects of primary care have been deregulated. Simultaneously, there is emphasis within nursing on individual accountability and professional judgement to allow responsiveness to demands for nurses to extend and develop their roles. This paper reviews the range and complexity of primary care nursing, to suggest that the profession needs to take account of the complex and heterogeneous nature of primary care nursing to develop regulatory frameworks which address the problems faced by primary care nurses at the grassroots.

Preparing nurses to initiate thrombolytic therapy for patients with an acute myocardial infarction - is there a consensus?

Within cardiac practice, one area that has seen much development involves the nurse assessing, diagnosing, and prescribing thrombolytic therapy for patients with a myocardial infarction. Alongside this, a variety of titles aimed at defining these new roles have emerged, but instead of clarifying the situation they have created more confusion about the actual characteristics and functions of nurses engaged in these innovative posts. In addition advice regarding the nature of preparation and training required to ensure the competency of nurses for these specific roles has been sparse and inconspicuous. As posts such as 'acute chest pain nurse', 'thrombolysis nurse', 'nurse-initiated thrombolysis' or 'nurse-led thrombolysis' increase and National Health Service targets tighten, it is timely to critically review the educational preparation for these roles for evidence of coherence. In particular, this paper analyses the literature in order to examine the content of educational programmes, teaching methods and assessment strategies in relation to preparing nurses to initiate thrombolytic therapy. The implications for those managing practice and the higher education sector are discussed. Finally, it is stressed that there is a need for national consultation relating to guidelines, standards and accreditation of practice schemes in this area of patient care.

Accounting for accountability: a discourse analysis of psychiatric nurses' experience of a patient suicide

Whilst the experience of a patient suicide is likely to have a significant impact upon the nurses who had been providing care, little work has actually explored this experience in any depth. In this article we explore how two psychiatric nurses construct and orient to accountability when talking of their experiences of a patient suicide. Discourse analysis was used to explore particular phases that the nurses oriented to in their accounts: scene setting; risk assessment; attributing for the suicide. Findings highlight the different, sometimes contradictory, ways the nurses attended to interactional concerns relating to implicit accountability and potential inferences of blame. Analysis of the nurses' talk can make a valuable contribution to understanding the nature and the impact of 'accountability' in a mental health setting and so help nurses and other professionals gain an insight into their practice. The results from this study suggest that as a consequence of internalising fundamentally unrealisable expectations regarding suicide prevention, nurses can hold themselves to blame raising significant concerns around their needs in terms of support, which may not be recognised. This paper also makes a valuable contribution to our methodological understanding and the value of using discourse analysis in this setting.

Clinical competence in myocardial perfusion scintigraphic stress testing: general training guidelines and assessment

The suggestion by the National Institute for Clinical Excellence (NICE) to more than triple the number of myocardial perfusion scintigraphy (MPS) procedures carried out by the NHS each year is a challenge both in terms of numbers of gamma cameras available to carry out the scans and qualified staff to supervise stress tests. In the past, exercise and pharmacological stress testing have been supervised only by doctors but, increasingly, this is taken on by suitably trained non-medical professionals such as nurses, radiographers and clinical technologists. The expansion of the numbers of non-medical professionals qualified to supervise stress testing will be key to meeting NICE's recommendations. This paper sets out how potential new stressors should be identified, what their training should cover and discusses the standards of competence they should meet. It provides guidelines for training non-medical stressors to perform a safe and efficient stress test during MPS and advice for maintaining competency.

Advanced nursing practice – the influences and accountabilities

The past two decades have seen a proliferation of new, advanced clinical roles for nurses in the UK which has resulted in much debate about the nature of advanced practice as these new roles involve many tasks that were traditionally considered the remit of doctors. This article critically analyses the professional accountabilities of working at an advanced level and the influences which are driving the NHS modernization agenda with particular reference to the role of the Community Matron. It concludes that advanced nursing practice presents an opportunity for the combination of the art of nursing and advanced tasks, but emphasizes that new roles must develop within a recognized framework which takes account of the educational, ethical and legal accountability issues and clarifies the scope and remit of roles for health professionals, patients and indemnifying agents.

The role of the advanced scrub practitioner

The roles of all healthcare professionals have changed considerably over the years and the nurse in particular has been affected. These changes have been influenced by the following guidance, Code of Professional Conduct (UKCC 1992) and Code of Professional Conduct (NMC 2004). Such changes involve the whole area of advancing roles in perioperative nursing, such as the nurse working as advanced scrub practitioner (ASP) (formally known as first assistant). Boss (2002) mentions that these new role developments are concerned with principles such as serving the interests of patients, providing holistic care, developing professional skills and knowledge and being accountable and responsible for your individual actions. Nurses acting as an ASP have many matters to contend with, such as autonomy, duty of care and other legal issues, and professional accountability. This paper explores these issues in more detail.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

BACKGROUND

Against the backdrop in the western world of increasing prevalence of chronic disease, active and informed patients and a policy emphasis on self-management, this English study explored health professionals' responses to expert patients.

OBJECTIVES

To:

DESIGN

A grounded theory approach was utilised with two concurrent data strands.

SETTING

A relatively affluent English county including community, primary and secondary care settings.

PARTICIPANTS

Via purposeful and theoretical sampling 100 health professionals (nurses, doctors, physiotherapists) and 100 adults affected by chronic disease participated.

METHODS

Focus groups, interviews and observation.

RESULTS

Nurses were found to be most anxious about expert patients when compared to other professionals, which appeared to be linked with a lack of professional confidence and unfounded fears regarding litigation. However, nurse specialists often provided a negative case for this. As a whole, nurses were most able to meet the emotional needs of patients, but apart from nurse specialists did not articulate this as a skill.

CONCLUSION

Apart from nurse specialists the majority of nurses appeared limited in appropriately facilitating self-management. It is suggested that this is linked to an ongoing nursing culture of patient as passive, an over-emphasis on empirical knowledge and a feeling of vulnerability on the nurses' part towards expert patients. The findings also indicate a rhetoric rather than reality of autonomous nursing roles within the chronic disease management agenda.

Rheumatology nurse practitioners' perceptions of their role

OBJECTIVES

To identify the current practices of rheumatology nurse practitioners and ascertain their perceptions of how their role could be enhanced.

METHOD

A cross-sectional questionnaire study of currently employed nurse practitioners in rheumatology in the United Kingdom (UK) was undertaken.

RESULTS

200 questionnaires were distributed and 118 nurses responded. Ninety-five respondents met the inclusion criteria for undertaking an advanced nursing role. Typical conditions dealt with included: rheumatoid arthritis (96.8%); psoriatic arthritis (95.8%); osteoarthritis (63.2%); ankylosing spondylitis (62.8%); systemic lupus erythematosus (51.6%); and scleroderma (34.7%). Drug monitoring, education, counselling of patients and arranging basic investigations were routinely performed by more than 80% of respondents. A smaller proportion performed an extended role that included dealing with referrals, research and audit, the administration of intra-articular injections, and admission of patients. Specific attributes identified as being necessary for competence were: knowledge and understanding of rheumatic diseases (48.4%); drug therapy (33.7%); good communication skills (35.8%); understanding of the roles of the team (27.4%); working effectively (23.2%) as part of a multidisciplinary team; assessment of patients by physical examination (28.4%); teaching (26.3%), research (17.9%); organizational skills (14.7%); and the interpretation of investigations (9.5%). Factors that could enhance their role included: attendance at postgraduate courses (30.5%); obtaining further qualifications (13.7%); active participation in the delivery of medical education (41.1%); training in practical procedures (31.6%); protected time and resources for audit and research (11.6%); formal training in counselling (11.6%); and implementation of nurse prescribing (10.5%).

CONCLUSION

Nurse practitioners already have a wide remit and play an invaluable part in the delivery of modern rheumatology services. An extended role could improve patient care and enhance nursing career pathways in rheumatology.

Nurse consultants: organizational influences on role achievement

AIMS

This paper reports on organizational influences on nurse consultant post holders. The influence of individual characteristics has been the subject of another paper.

BACKGROUND

Nurse consultant posts were set up in the United Kingdom from the late 1990s onwards and, therefore, there has been little opportunity to report on evaluations of these innovative initiatives.

DESIGN

A cross-sectional design, using a convenience sample, was adopted.

METHODS

Ten nurse consultants working in a variety of settings and specialties participated in in-depth, tape-recorded interviews. The data were analysed using the Framework approach.

FINDINGS

Support systems were important influences on nurse consultants' role achievement levels. These took the form of internal trust networks, nurse consultant forums and links with higher education institutions. Post holders both gave and received support and acted to empower other nurses. Thus, relationships were vital to successful role integration. The culture and structures of the National Health System were also a powerful influence in terms of local and national modernization policies, and participants had to be careful in their choice of strategies to deal with the traditional medically dominated culture.

CONCLUSIONS

The new nurse consultant role is challenging and innovative, but a major area of contention is how much post holders are expected to take on work previously done by doctors rather than developing their nursing role. Organizational support and commitment are needed if nurse consultants are to maximize the benefits of this innovation.

RELEVANCE TO CLINICAL PRACTICE

The findings show that new nursing roles are not always easily accepted in multidisciplinary settings and that holders of such post need to have the appropriate previous knowledge, skills and personal characteristics, as well as the ability to negotiate their way through organizational influences.

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses: a questionnaire survey

Occurrence of problems with, refusals of orders and contemplated refusals of orders for risky procedures by nurses in Dutch hospitals and views on the safety of performance was studied using postal questionnaires (600 physicians and 3200 nurses, response 60--71%). Of the respondents, 11--30% experienced problems with and (contemplated) refusals of orders for risky procedures in the previous 12 months. Gynaecologists and internists most frequently mentioned problems concerning the practical performance of the procedure (44% and 30%, respectively). The reason for a problem or a contemplated refusal most frequently given by nurses was that they disagreed with the medication policy (34% and 35%, respectively). The reason for a refusal most frequently given by the gynaecologists, internists, and nurses was that the nurses themselves were of the opinion that they did not have the necessary authorisation (95%, 67%, and 62%, respectively). With regard to certain procedures, the views of professionals are more strict than the current legal regulations.

How graduate nurses use protocols to manage patients’ medications

AIMS AND OBJECTIVES

The aim of the study was to determine how graduate nurses use protocols in their medication management activities. The objectives were to: examine the extent of adherence to various protocols in relation to medication activities and determine how the ward environment impacts on graduate nurses' use of protocols to manage patients' medications.

BACKGROUND

Protocols help newly qualified nurses integrate new knowledge into practice and promote effective decision-making Design. A descriptive prospective qualitative design was used. Methods. Twelve graduate nurses involved in direct patient care in medical, surgical and specialty wards of a metropolitan teaching hospital participated in the study. Participant observations were conducted with the graduate nurses during a two-hour period when medications were being administered to patients. In-depth interviews were conducted with each nurse immediately after observations and demographic data were collected on participating nurses and patients in their care, including all medications prescribed. Protocols associated with medication management activities for the clinical settings were also transcribed.

RESULTS

Six themes were evident from the data: availability and use of protocols, scrutinizing patients' identity before medication administration, double-checking certain medications before administration, writing incident reports, following specific policies and timing the administration of medications.

CONCLUSION

Graduate nurses adhered to protocols if they were perceived not to impede with other nursing activities. Participants were also more likely to follow protocols if they felt encouraged to make their own decisions and if there was a decreased likelihood that disciplinary action would be involved.

RELEVANCE TO CLINICAL PRACTICE

Experienced health professionals should encourage graduate nurses to comply with medication protocols and to make clinically reasoned decisions about medication activities. By providing peer support and acting as role models, experienced health professionals can also demonstrate to graduate nurses how effective protocol use is an important component of quality patient care.

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses

Occurrence of problems with, refusals of orders and contemplated refusals of orders for risky procedures by nurses in Dutch hospitals and views on the safety of performance was studied using postal questionnaires (600 physicians and 3200 nurses, response 60-71%). Of the respondents, 11-30% experienced problems with and (contemplated) refusals of orders for risky procedures in the previous 12 months. Gynaecologists and internists most frequently mentioned problems concerning the practical performance of the procedure (44% and 30%, respectively). The reason for a problem or a contemplated refusal most frequently given by nurses was that they disagreed with the medication policy (34% and 35%, respectively). The reason for a refusal most frequently given by the gynaecologists, internists and nurses was that the nurses themselves were of the opinion that they did not have the necessary authorisation (95%, 67%, and 62%, respectively). With regard to certain procedures, the views of professionals are more strict than the current legal regulations.

Exploring nursing roles: using physical assessment in the respiratory unit

The role of the nurse continues to change, with the point where nursing stops and medicine begins becoming increasingly blurred. Arguably, the main driver for this change could be the recent reduction in junior doctors' working hours. However, modern nursing is ripe for innovation and nurses are taking on more and more tasks and skills that were traditionally part of the doctor's remit. One example is physical assessment, which has very little evidence to support its use in any setting. Analysis of the utilization of physical assessment in the respiratory unit indicates that although it could facilitate earlier recognition of peri-arrest symptoms, its usage highlights training and legal issues. Furthermore, this article will explore whether the continual adoption of tasks, such as physical assessment, constitute mere role extension, with nurses becoming physicians' assistants rather than advanced autonomous practitioners.

An exploration of the ethical dimensions pertinent to gaining consent for thrombolysis

--This paper explores some of the pertinent ethical principles involved in gaining consent in thrombolysis, relevant to both nurses and paramedics. --It describes ethical concerns regarding this practice. --Two key themes that have been explored are around the issue of autonomy and paternalism. --With nurse-initiated thrombolysis gaining momentum, an awareness of key ethical dimensions is fundamental.

A framework for the introduction and evaluation of advanced practice nursing roles

AIM

This paper describes a participatory, evidence-based, patient-focused process for advanced practice nursing (APN) role development, implementation, and evaluation (PEPPA framework).

BACKGROUND

Despite the growing demand for advanced practice nurses, there are limited data to guide the successful implementation and optimal utilization of these roles. The participatory, evidence-based, patient-focused process, for guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA) framework is an adaptation of two existing frameworks and is designed to overcome role implementation barriers through knowledge and understanding of APN roles and environments. The principles of participatory action research directed the construction of the new framework.

CONCLUSIONS

The process for implementing and evaluating APN roles is as complex and dynamic as the roles themselves. The PEPPA framework is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems. Engaging environmental stakeholders as participants in the process provides opportunity to identify the need and shared goals for a clearly defined APN role. The process promotes increased understanding of APN roles and optimal use of the broad range of APN knowledge, skills, and expertise in all role domains and scope of practice. The steps for planning and implementation are designed to create environments to support APN role development and long-term integration within health care systems. The goal-directed and outcome-based process also provides the basis for prospective ongoing evaluation and improvement of both the role and delivery of health care services.

Reserved procedures in Dutch hospitals: knowledge, experiences and views of physicians and nurses

The Individual Health Care Professions Act came into force in The Netherlands in 1997, introducing a mixed system for the regulation of the practice of medicine. One of its components, the reserved procedures regulations, was studied in hospitals to gain insight into the knowledge, experiences and views of physicians and nurses with regard to these regulations. Questionnaires were sent to representative samples of 250 gynaecologists, 350 internists, and 3200 nurses, response rates were 65, 60 and 71%, respectively. Almost all respondents were aware that physicians are authorised to perform reserved procedures on their own initiative (93-99%), and 48-63% knew that nurses are not authorised to do this. A substantial percentage of the nurses performed reserved procedures on their own initiative (17-53%). A majority of gynaecologists and internists presumed that the hospital had ensured the proficiency of the nurses to perform reserved procedures (58% resp. 65%), while 82% of the nurses determined their own proficiency for each procedure. Most respondents felt that the reserved procedures regulations offer adequate protection for patients (58-72%). Although recommendations are made for improvement, the functioning of the reserved procedures regulations in hospitals is considered to be moderately positive.

Decisions by nurses in acute care to undertake expanded practice roles

Since 1992, expanded practice has been an important issue in the career progression of the qualified nurse. Its contemporary relevance in the early years of the 21st century is underpinned by recent and ongoing national initiatives to blur the boundaries between healthcare providers, and to regulate practice at a higher level. This article reports the findings of a survey and in-depth, semi-structured interviews conducted with nurses from across the UK, which explores their views and experiences in terms of decisions regarding whether or not to undertake expanded practice roles. Insights are gained in a variety of domains of expanded practice including preparation for the role, competency verification, perceptions of accountability and liability, effects on patient care, role refusal and utilization of evidence to underpin expanded practice. These reported views and experiences have important implications for current practice and future research.

Regulating the health care workforce: next steps for research

This article explores the recent ferment surrounding professional self-regulation in medicine and other health professions. It reviews the academic literature and sets out an agenda for research. The first section considers definitions, acknowledging the particularly complex regulatory maze in UK health care at present, in which professional self-regulation is only one part. The second section reviews academic writing, currently dispersed among the disciplines. 'The logic of light touch regulation', a feature of the 19th century establishment of the General Medical Council, can perhaps shed light on present debates. Alongside the intense political spotlight on regulation in the wake of the Bristol case, consumer-led research and consumer pressure to rethink the principles of regulation has emerged. This is examined in the third section. Finally, themes for research are advanced. First, there is a need to explore the changing relationship between the state and professions and implications, not only for the professions but for health care more broadly. Second, calls for a new professionalism need to be given clearer content. Third, the moves towards more lay involvement in regulatory bodies need study. Fourth, questions of human rights and professional registers must be explored. Fundamental questions of what professional self-regulation can hope to achieve and where it fits in relation to government ambitions as a whole, remain unresolved. Alongside the work programme of the new overarching regulator, there may well be scope for a new style of public enquiry covering the whole territory of regulation.

A discharge protocol for the postanaesthetic recovery unit

Despite guidelines from the Royal College of Anaesthetists, some hospitals still do not have a formal discharge policy. The author of this article works within an operating department in the dual role of anaesthetic and recovery sister and has a particular interest in discharge criteria for postanaesthetic recovery patients. She suggests that a discharge protocol, developed in a multidisciplinary setting, should be in place in the postanaesthetic recovery unit.

Nurse consultants as higher level practitioners: factors perceived to influence role implementation and development in critical care

This paper discusses the main factors perceived to influence higher level practice in critical care drawing upon personal experience as a critical care nurse consultant. Implementation and development of the role towards a higher level of practice has been influenced--both positively and negatively--by policy, legislative, organisational, cultural, professional and individual factors. Discussion focuses on professional, policy and organisational issues because--on reflection--these are the main factors that have facilitated and inhibited role implementation and development towards a higher level practice in the United Kingdom. Relevant research exploring advances in nursing practice in critical care, and how this has influenced the development of higher level practice in relation to the nurse consultant role, will also be discussed.

Towards a nurse-led service?

In recent years, there have been many changes in nursing, particularly in specialist areas. In the 1990 s, posts emerged in secondary care with the titles of nurse practitioner, advanced practitioner and nurse consultant. Nurse practitioners diagnose, refer, prescribe and provide complete episodes of care for clients with undifferentiated health problems. Nurse practitioners are undertaking the roles of junior doctors within neonatal units and pre-admission clinics, whereas other nurse practitioners work across the primary-secondary care interface and can prescribe following protocols for conditions such as asthma and hypertension. In units where specialist fertility practitioners demonstrate a higher level of clinical decision-making, the role of nurses has developed as their experience has been recognized. Nurses are able to monitor and improve standards of care through supervised practice, clinical nursing audit, developing and leading practice, contributing to research, teaching and supporting professional colleagues. This article will focus on the changes in fertility nursing over the years, which have placed nurses in a position to provide a holistic service for subfertile individuals. Motivated and experienced nurses within the area of fertility are fundamental to high quality patient care, and they can deliver a seamless service from primary to tertiary care, with appropriate support services made available when and if required.

Skill mix, doctors and nurses: substitution or diversification?

This commentary surveys the current arguments for and against modifying the work of doctors and nurses by placing the main viewpoints - substitution and diversification - within the policy background, particularly that of the UK. We discuss the forces for modification: cost effectiveness, professional development, quality improvement and pragmatic management and how each provides a stand-point for evaluation of the issues. Policy makers and managers in the health sector should be aware of the rather fragmented evidence base for doctor-nurse substitution and should consider skill mix changes only when they are clear about: purpose, evidence base, acceptable risks, accountability and quality assurance. Doctor-nurse substitution is not necessarily cost effective, nor is it unfailingly a gain in nurse professionalism or in quality of care. Of the management perspectives available - advocacy, skepticism or pragmatism - the current evidence and policy base favours pragmatism over evaluations of the rightness or wrongness of a general policy.

Decision-making in primary care: outcomes from a study using patient scenarios

BACKGROUND

Various documents emphasize the importance of new roles and new ways of working to modernise delivery of health service and improve the public's health. In particular nurse practitioners are seen as crucial in the modernization process.

AIM

This paper reports the outcomes of a study conducted in 1998 to ascertain the differences, if any, in the decision-making processes of nurse practitioners and general practitioners for diagnosis and treatment when given the same patient scenarios.

METHODS

Information processing theory together with 'think aloud' approach were used to understand the cognitive processes of the 22 participants, 11 general practitioners and 11 nurse practitioners, in the study. A reference model was developed for each of the six scenarios of the study; three medical photographs were also used. The data were analysed using NUD*IST computer software.

RESULTS

The outcomes of each scenario are presented and comparisons are made with general practitioners. The results show that there were more similarities than differences in the decision-making processes of the two groups. Hypothesis evaluation appears to be the critical component in the decision-making process. Explanations given by the two groups at the end of their 'think aloud' procedure justify their diagnoses and treatment/management plans.

CONCLUSIONS

The research adds to existing evidence that encourages health care providers to use nurse practitioners more flexibly and to develop service-based approaches to the delivery of health care as set down in government policies. It also adds to the body of literature using information processing theory because it demonstrates that the two groups use similar decision-making processes to arrive at similar diagnoses and treatment options.

Role ambiguity in nursing: undergraduate students' struggle for direction

An experience common to many undergraduate nursing students, particularly whilst on placement in the clinical area, is a sense of aimlessness, lack of direction and standard role, and an overall ambiguity about what nursing is and does. Research in the nursing literature contributes to and supports the concept of the lack of clarity of the nursing role. Whilst the discourse of nursing is diverse and covers many aspects of nursing, a number of core issues may be seen to emerge. These contribute to form a concept that may be identified as the ambiguity of nursing. This paper identifies those issues and represents this concept of role ambiguity. These issues include the concept of caring and the apparent lack of clarity over what this actually is in a nursing context.

Assessing the skills for family planning nurse prescribing: development of a psychometrically sound training needs analysis instrument

RATIONALE AND AIMS

Family planning nurses have been identified for early development for prescribing authority in the United Kingdom (UK). Currently, no psychometrically founded training needs analysis instrument exists that can reliably assess the nature and extent of the specific educational provision required for this role. This paper is concerned with the development of an instrument capable of defining the development needs for family planning nurse prescribing.

METHODS

A national survey was conducted with 388 family planning nurses, using a modified training needs analysis instrument. Respondents were required to assess the importance of 40 tasks, firstly for the role of the family planning nurse (FPN), and again for the role of the family planning nurse prescriber (FPNP). The data from each set of ratings were separately factor analysed using orthogonal Varimax rotations and Cronbach's alpha was computed for each factor.

RESULTS

Six factors emerged from the family planning nurse ratings ('professional development', 'managing patient consultations', 'critical appraisal', 'clinical information giving and professional accountability', 'collaborative working and current National Health Service (NHS) issues' and 'dispensing of drugs') and nine factors emerged from the FPNP ratings ('research and practice development', 'prescribing and professional accountability', 'management/leadership', 'clinical decision making and risk assessment', 'advanced health assessment', 'critical appraisal', 'referral processes', 'core nursing skills' and 'dispensing of drugs'. This suggests that the role of the FPNP is more extended and, moreover, that the two roles are configured very differently but in a way that makes logical and coherent sense within existing research and government policy. This indicates that the instrument is valid. Moreover, all but two of the factors had a Cronbach's alpha score of >0.7 and so can be considered reliable.

CONCLUSIONS

The results indicate that the modified instrument is valid and reliable and therefore can be used with confidence to assess the training needs of FPNPs. In addition, the factors have outlined a cogent definition of the role of the FPNP, which can be used both to inform educational programmes and to assess their efficacy.

The extended role of the nurse--opportunity or threat?

Nursing practice is undergoing changes that are both exciting and controversial. The UKCC Scope of Professional Practice has encouraged nurses to re-evaluate their practice and, as a result, nurses from various fields have expanded their roles to meet the changing needs of patients and the profession. Published evidence shows that nurses can be as effective as doctors within these expanded roles, but that there is a danger that gender issues will cloud the debate because of the assumption that all nurses are female and all doctors are male. This problem is especially evident when female nurses perform an extended role involving male patients, although female doctors are in a similar position and work with the same patients without undue comment. The roles of doctors and nurses should complement each other, and all practitioners should work for the benefit of patients in their care, rather than defending traditional roles and hierarchy. There is confusion surrounding accountability of nurses who work in an extended role between the medical and the nursing profession, and both the Royal College of Nursing and the British Medical Association need to clarify the situation. This article looks at the arguments for and against the extended role of the nurse specialist and discusses current opinions within the nursing and medical fields. The article also describes how nurses at Midland Fertility Services have successfully extended their role to encompass ultra-sound-guided oocyte retrieval and surgical sperm recovery.

Legitimation of nurses' knowledge through policies and protocols in clinical practice

Health care professionals use policies and protocols in varying ways to guide their clinical activities and to promote quality patient care. The critical ethnographic case study upon which this paper is based, involved a research group comprising six registered nurses who worked in a critical care setting. Research methods included professional journalling, participant observation, and focus group and individual interviews. This paper examines the power relations at play between doctors and nurses, and among nurses, and the ways in which nurses used policies and protocols as a means of mediating communication. While policies and protocols provided nurses with legitimacy of their knowledge in the clinical arena, doctors tended to rely on their past experience and background to inform their knowledge and activities. For nurses to believe that they provided valued and collaborative input in patient decisions, they actively sought out written evidence through policies and protocols to confirm and support their knowledge. Policies and protocols of critical care activities provided nurses with expected standards of care, which they used to legitimize their knowledge and to communicate with doctors about 'undesirable' medical decisions. The doctors valued their professional authority and autonomy over policies and protocols, while nurses used these written guidelines to assert power and demonstrate resistance. Policies and protocols do not exist in isolation; they occur within a complex network of power relations that create tensions in clinical practice. In challenging these tensions, it is important that nurses and doctors establish a fine balance between using policies and protocols to provide directions for practice, and to allow sufficient latitude and flexibility in addressing the complexities of patient care.

Educating the infection control team - past, present and future. A British prespective

This review sets out to explore how education and training provisions for members of the Infection Control Team (ICT) have developed alongside their roles and in response to changes in the British National Health Service. It focuses on the Consultant in Communicable Disease Control, the Infection Control Doctor and the Infection Control Nurse in the United Kingdom, but also briefly considers approaches adopted by other countries. Future developments should include maximizing information technology for delivering teaching materials, shared learning and improvements to pre-registration curricula for both doctors and nurses.

Clinical risk and collective competence in the hospital emergency department in the UK

The hospital emergency department (ED) is a risky environment, often subject to litigation for negligence. Risk is defined as an avoidable increase in the probability of an adverse outcome for a patient. With the aim of identifying the sources of risk, this study carried out participant observation and collected critical incidents in two EDs in the UK for a period of 30 months. Active failures included delay in beginning investigations or treatment, failure to obtain diagnostic information, misinterpretation of diagnostic information and the administration of inappropriate treatment. Three latent conditions underlay these failures: patients' unrestricted access to the ED, cognitive errors by individual members of staff and a strict horizontal and vertical division of labour. An analysis of the incidents resulting from the third latent condition identified a contradiction between the division of labour and working conditions in the ED. The paradigm circumstances under which this contradiction can result in active failures are described. The management of risks arising in this way could be improved by developing a workplace culture in which 'sapiential authority'--authority derived from experience, special access to information or being at hand in an emergency--is recognised in addition to authority derived from a formal status. However, as long the contradictions between the division of labour and working conditions remain, accidents should be considered normal events.

Managing the unmanageable? Nurse Executive Directors and new role developments in nursing

This paper offers a unique insight into the factors affecting the functioning of the Nurse Executive Director(s) and their views on the realities of nursing management in the new National Health Service in England. It is based on the findings of the Exploring New Roles in Practice (ENRiP) project which was carried out for the Department of Health. As part of this project interviews were undertaken with Nurse Executive Directors from a 20% sample of acute hospital trusts in England. The interviews were designed to explore the Nurse Executive's perceptions of the process of new role development. The findings highlight a tension between the drive for professional development and the pragmatics of service delivery in a health care system which lacks dedicated funding for nursing development. It was evident that most Nurse Executives vacillated between responding either in an ad hoc way to internal and external pressures or leading and supporting managed development.

The Scope of Professional Practice: A literature review to determine the document's impact on nurses' role

Following the UKCC's publication of The Scope of Professional Practice (Scope) in 1992, it commissioned a study to investigate the document's impact. As part of the study, a review of the literature relating to Scope and its application was undertaken. Given the association of expanded practice using Scope, with new nursing roles and titles, the British and American literature relating to clinical nurse specialists and advanced practice was included in the review. This was undertaken because of the considerable influence from America on developments in this area in Britain.

The extended role of the nurse: the United Kingdom perspective

There has been considerable discussion and debate in the United Kingdom regarding the role and function of the nurse. This article outlines the main tenets of the debate, namely the extended/expanded role and function, and gives a brief overview of the situation to date. Professional guidance from the United Kingdom Central Council for Nurses, Midwives and Health Visitors is explored and the implications this has for the nurse in the exercise of accountability. The legal implications of the nursing function in an expanded role capacity is discussed, in particular in relation to legal accountability, with reference to existing case law. Recommendations are made for the development of the expanded role.

A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments

OBJECTIVE

To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments.

DESIGN

Randomised controlled trial.

SETTING

Orthopaedic outpatient departments in two hospitals.

SUBJECTS

481 patients with musculoskeletal problems referred for specialist orthopaedic opinion.

INTERVENTIONS

Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists).

MAIN OUTCOME MEASURES

Patient centred measures of pain, functional disability and perceived handicap.

RESULTS

A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238).

CONCLUSIONS

On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.

A specialist nurse: an identified professional role or a personal agenda?

Specialist nurses have existed for many years. Initially denoting a nurse with extensive clinical experience, implicit within nursing's professional agenda for attaining 'specialist' status since the 1960s has been the requirement to achieve a high degree of 'specialist' knowledge through post-basic education. Despite the professional agenda, much confusion surrounding definitions of specialist nurses prevails. In recent years this confusion has been compounded in the United Kingdom by the introduction of advanced nurse practitioners alongside existing clinical nurse specialists. This paper suggests that health care professionals' perceptions of a 'specialist' are subjective, grounded in their own experiences. Drawing on a study which examined relationships between paediatric oncology outreach nurse specialists and other health care professionals, two types of personal agenda from which perceived 'specialist' status evolves are described: (1) 'needs-driven agendas', and (2) 'peer-driven agendas'. When 'specialist' status is accorded to paediatric oncology outreach nurse specialists, 'specialist' knowledge is derived from: formal qualifications, hands-on technical skills, previous 'specialist' work experience, in-depth medical knowledge and/or insight into families' dynamics. The relative contribution each of these makes towards constructing a 'specialist' depends on the experiences of individual health care professionals and the varying work locations and professional backgrounds of paediatric oncology outreach nurse specialists.

Exploring the expanded role of nurses in critical care

This paper reports on a small research study that explored the perceptions of staff in an intensive/coronary/high-dependency care unit on the expanded role of nurses in critical care. The research was undertaken in two phases. In the first phase, focus groups and interviews of nursing and medical staff were used as methods to explore their perceptions. Data were analysed by thematic content analysis and generated four categories: specialized skills; maintaining competence; how far nurses can go; and training and education. Using verbatim examples from the participants, these categories are described. In summary, it was found that both doctors and nurses were in favour of nursing role developments, and for the nurses this was driven by their desire to meet the patients' needs. In a smaller second phase, a questionnaire was developed based on information gained in the first phase. It was utilized to seek the views of all the nursing staff on specific role-expansion activities. Findings revealed substantial support for developing the role of critical care nurses in a number of activities: cannulation; venepuncture; ordering blood tests and X-rays; performing physiotherapy; inserting arterial lines; performing elective cardioversion; thrombolysis treatment and intubation. This research study has yielded important information. However, it is recognized that, whilst these roles may be new to this particular critical care unit, there are many other units where they may already be common practice. Whenever new roles are developed, it is important to evaluate their effectiveness in measurable terms and regular audit is advisable. Further research is therefore recommended on both the development and evaluation of new roles in critical care.