REVIEW OF THE CLINICAL NURSE/MIDWIFE CONSULTANT ROLE WITHIN HUNTER NEW ENGLAND HEALTH

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1 FEATURE ARTICLES REVIEW OF THE CLINICAL NURSE/MIDWIFE CONSULTANT ROLE WITHIN HUNTER NEW ENGLAND HEALTH Vicki Parker University of New England, New South Wales, Australia Hunter New England Local Health District, New South Wales, Australia Michelle Giles Centre for Practice Opportunity & Development (CPOD) Hunter New England Local Health District, New South Wales, Australia Abstract Background: Advanced practice nursing and midwifery roles are integral to the provision of high quality health care across a range of clinical contexts and health care sectors. The continued relevance and importance of these roles requires that they be systematically evaluated and revised where necessary to ensure maximum effectiveness and career satisfaction for incumbents. Aim: The aim of this study was to better understand how the Clinical Nurse Consultant (CNC)/Clinical Midwife Consultant (CMC) role is distributed, enacted and integrated within service delivery programs and units across contexts within the Hunter New England Local Health District (HNELHD). Method: This study employed mixed methods incorporating an online survey of CNC/CMCs; and, focus groups with all stakeholders including CNC/CMCs, nursing and service managers and clinical leaders. Quantitative data were analysed using categorical, factor and regression analysis and qualitative data were coded and themed to provide a description of experiences, concerns and issues. Results: Seventy three per cent of the total (n=192) HNELHD CNC/CMC workforce completed the online survey in full; and, 26 CNC/CMCs, 20 managers and 16 stakeholders participated in eight focus groups across the Local Health District. Qualitative findings indicated that Consultants are recognised and valued as clinical leaders who are central to the delivery of high quality care. However, there was concern expressed regarding role clarity and expectations. Most stakeholders focussed on the clinical leadership capacity of the role, identifying the role as dynamic in nature, constantly responding to changes in policy and practice, and service delivery needs. Conclusion: Diversity in the role is necessary to match the diversity of health care contexts and differing models of care across and within the Local Health District. Competing demands as well as the need for engagement across a range of disciplines, sectors and groups add to the challenges experienced by the Consultants and to the growing complexity of the role. Introduction Employment of nurses and midwives, as the largest health workforce group, consumes a significant component of the Australian health care budget (both Federal and State). The size of this cost means that the contribution of nurses and midwives has and will continue to be scrutinised both from within the professions themselves and from outside by government bodies and other planning and funding agencies. Hence there is increasing pressure to articulate and strengthen the roles played by nurses and midwives within the multidisciplinary health workforce. At the same time there is increasing concern over the capacity of the future workforce to meet the growing demand for healthcare arising particularly from the dual problems of an ageing population and an ageing health workforce (AIHW, 2011). Advanced practice nursing and midwifery roles are integral to the provision of high quality care across sectors. Whilst much attention has been focussed on the roles of Nurse Practitioner (NP) and Independent Midwife, less attention has been given to the role of Clinical Nurse Consultant. This article describes research conducted to examine the role of the Clinical Nurse Consultant (CNC) and Clinical Midwife Consultant (CMC) within the Hunter New England Local Health District (HNELHD). Background The advanced practice role of Nurse or Midwife Consultant is characterised by incorporation of a number of advanced practice criteria, for example clinical expertise, education, research and leadership (Por, 2008). Domains of practice identified in the NSW Health Clinical Nurse Consultant award policy directive (NSW Department of Health, 2005) include Clinical Service and Consultancy, Clinical Leadership, Research, Education and Clinical Services Planning and Management. Such roles exist, albeit with different titles across Australia and in other countries. A review of the literature identified only a small number of studies to date that have evaluated this role. The review by Guest et al. (2001) in the United Kingdom (UK) aimed to: analyse the emerging role of Health Visitor Consultant in practice; conduct an audit of the Consultant workforce and assess problems; levels of satisfaction; and, identify the types of contexts in which the role was being enacted. The role components encompass: practice leadership and consultancy; education; service and practice development; research; and, evaluation functions (Guest, Redfern et al., 2001). Their research method included survey, analysis of accounts and incidents, and role network analysis using in-depth interviews with Consultants, as well as observation and interviews with members of the Consultants role network. Data were collected from 153 Consultants and their networks. The value of this study s finding for current purposes may be limited by its focus on implementation and the number of roles in transition. However the concepts and processes used have relevance for contemporary examination of the role in Australia. These include the concept of role pattern 6

2 engagement that describes the level to which each of the above components is included in the role. The patterns identified in this UK study were high involvement in all domains, dual focus, single focus, medium involvement and low involvement. The same team of researchers (Guest, Peccei et al., 2004) conducted further research to explore the impact of the role on patient care and the leadership component of the role. This second study highlighted the difficulties of attribution of impact on patient care to the Consultant role. Although Consultants in this study believed that they had a positive impact, this impact was seen to be through indirect means such as support of other staff, advice and championing change. In spite of a requirement to spend 50% of their time providing direct care, only 43% of Consultants were able to achieve this. The researchers concluded that this requirement is less appropriate for some roles. Overall leadership was reported as the activity in which Consultants were engaged in most, with 15% of respondents reporting heavy engagement in required components of the role. Eleven per cent reported that they were heavily engaged in none of them. Using a cross-sectional design, Woodward, Webb and Prowse (2006) examined Nurse Consultants characteristics and achievements, together with organisational influences in the UK. The findings of this study highlight the power of culture and hierarchical social structures and the importance of support structures and networks. Their finding that nurses are not well accepted in multidisciplinary settings is concerning. This highlights the importance of organisational support and the development of social capital. These authors recommended minimising the management component of the role and strengthening the research component. Also in the UK, McSherry, Mudd & Campbell (2007) evaluated the perceived role of the Nurse Consultant using the 360 degree technique involving three Consultants and 30 health professionals who responded to the survey. As with other studies, participants identified a range of personal qualities that characterise Consultants, for example being supportive, accessible and approachable. A significant finding of this study was that participants felt they had insufficient information and hence disparate expectations of the role. In an effort to better understand the role of advanced practice nurses in Canada, DiCenso & Bryant-Lukosius (2010) produced a decision-support synthesis that integrated the findings from a qualitative study of stakeholders and an extensive literature review. Their study focused on three types of Advanced Practice (AP) roles, notably Clinical Nurse Specialist, Primary Care Health Practitioners and Acute Care Nurse Practitioners. The Nurse Specialist role in Canada is similar to the Consultant role in NSW. CNSs are RNs with graduate education, who have expertise in a clinical nursing speciality and they perform a role that includes practice, consultation, education, research and leadership (DiCenso & Byrant-Lukosius, 2010) A speciality area is defined loosely and may include population groups, settings, disease, and type of care or problem. DiCenso and Byrant-Lukosius concluded that in spite of a growing consensus related to the purpose of the roles, inconsistencies exist in how the role is perceived and practiced. They highlighted the need to establish mechanisms to support scope of practice for APs, to raise awareness, to clearly define the roles and to sustain administrative leadership to support implementation of the roles (ibid, 2010, p.4). In NSW, the review conducted by Chiarella, Harford & Lau (2007) utilised the Irish National Council for the Professional Development of Nursing and Midwifery (NCPDNM) questionnaire, which was developed for a similar review in Ireland in The NCPDNM questionnaire canvasses the demographics of the cohort, both personal and role-related; their reporting structures, both clinical and professional; the bridges and barriers to the establishment of their roles; and the resources available to them in order to function in their roles. However the review of Chiarella et al., (2007) was not specific to the Consultant role, but also included the NP role. Key recommendations from the review by Chiarella et al., (2007) included: the need to clarify the elements of the various overlapping roles in order to ensure best fit in terms of workforce planning; career development and capacity building for senior clinical nurses; consideration of the surrounding infrastructure that supports senior clinical nursing roles; clarification of the research component of the Consultant role, with a recommendation that the focus be on research application and utilisation. There appears to be no follow up to these recommendations in the form of further debate or action towards implementation. In their examination of the Consultant and NP/MP roles, Chiarella et al. (2007) drew on the model developed by Daly and Carnwell (2003) to describe practice that ranges in focus across a continuum from the individual to community and practical to strategic. Although specific to the Wentworth Area Health Service and small in its sample size (n=24), the 2007 study conducted by O Baugh, Wilkes, Vaughan & O Donohue (2007) focused specifically on Consultant engagement in the domains outlined in the NSW policy directive of the Nurse Consultant award (NSW Department of Health, 2005). Their survey findings highlighted consistent performance of clinical service and consultancy and clinical services planning and management (irrespective of Consultant grade), but found little evidence to confirm fulfilment of the leadership domain and even less involvement in research. The authors concluded that the functions statements in the award are ambiguous and verbose and not easily translated into practice. Whilst these reviews provide some guidance there appears to be very little recent literature, apart from Chiarella et al. (2007), and O Baugh et al., (2007) that focuses specifically on the NSW model. There are studies that examine the role in specific contexts such as critical care (Dawson & Coombs, 2008); neonatal intensive care (Dawson 2001) and palliative care (O Connor & Chapman, 2008). The O Connor and Chapman study highlights the complex and diverse nature of the role and how essential the role is in coordinating and accessing services for clients. Context The advanced practice roles of the Clinical Nurse Consultant (CNC) and Clinical Midwife Consultant (CMC) were introduced in NSW in 1986 (Chiarella, Harford et al., 2007). Since that time, the roles have developed in line with significant increases in demand for health care and consequent health service reform. In January 2010 Hunter 7

3 New England Local Health District had a total of 193 Consultants in their workforce, 185 CNCs and eight CMCs, of which 83 were grade one, 71 were grade two and 39 were grade three (NSW Health CNC Higher Grades Public Hospital Nurses (State) Award Domain Guidelines for grade descriptions). The number of Consultants has increased from 163 in 2007 to 193 in During this time there has been a concomitant increase in the numbers of NP positions (n=31), and the introduction of the Clinical Nurse Specialist (CNS) grade 2 position (n=37). Purpose and Aims This research was conducted to clarify how the Consultant role is distributed, enacted and integrated within service delivery programs and units across the LHD. An intended outcome of the research was to inform further activities designed to provide support to CNC/CMCs and managers and to build capacity and strengthen the utility of the role in context. The primary aims of the research were to: identify the current nature and scope of Consultants practice; identify patterns of role engagement; identify Consultants networks and relationships; identify attitudes and values of Consultants, and those of other stakeholders about the role; examine the various ways in which the Consultant s role is enacted in context and accords with the NSW Public Health System Award Domain Guidelines (NSW Health, 2011). Method A mixed approach, incorporating quantitative and qualitative methods was used. Ethics clearance was sought and granted through the HNELHD Human Research Ethics Committee. Data were collected for a six month period from February 2010 to July 2010 via online survey and online discussion, targeting the CNCs; and focus groups were conducted with relevant stakeholders. The survey was a modified version of that used by Guest et al., (2001) in the UK, which they used to evaluate the role of the Clinical Nurse Consultant and Health Visitor and consisted of 43 items with Likert scale, multiple choice responses, and four open-ended questions. Questions were based on key constructs including Consultant characteristics, job characteristics and opportunities, role engagement and work patterns, role networks and supports, and role performance, behaviours and attitudes. Eight focus groups were held in a number of locations across the LHD, four were held with Consultants, two with managers and two with other stakeholders such as service directors, network directors and medical directors. Focus groups aimed to build on survey data and gather an in-depth understanding and examples of the nature and contributions of the role as well as tensions and difficulties experienced by Consultants. Quantitative analysis included categorical analysis, factor analysis and regression analysis to identify factor predictors. Qualitative data were coded and themed to describe experiences, concerns and issues. Results Although 96% (n=184) of Consultants responded to the survey, only 73% (n=140) completed the survey in full. Of the 184 respondents, 95% were CNCs and eight (5%) were CMCs. Twenty-six Consultants, 20 managers and 16 stakeholders participated in eight focus groups, and 22 Consultants contributed to the online discussion. The manager group included Nursing and Midwifery Unit Managers, and Nursing and Midwife Managers. The stakeholder group comprised Service Managers, Directors of Nursing and senior staff specialists. Three interviews were held with individual stakeholders who were unable to attend scheduled focus groups. Overall, the role of the Consultant was found to be diverse and in many instances dynamic, responding to changes in practice, population needs and innovation, government directions and funding availability. Generally roles become more complex and more diffuse in line with grade (1, 2 or 3) but this was not always the case. Values and Views About the Consultant Role The position is more than the job description, each individual brings unique skills and attributes and there needs to be scope for incumbents to make the job their own within service need and guidelines. Manager Consultants are recognised and valued by managers and other stakeholders as actual and potential clinical leaders who are central to the delivery of high quality, evidence-based interprofessional health care, co-ordination of service delivery/patient and family care; and co-ordination of support and development of staff across a range of specialties and contexts. One stakeholder summarized the value of the role as follows:... where a CNC can come along and look at the best practice, look at where you need to deliver it to and make it work, many of the other roles that exist, can t do that. They purely deliver a program and that s I think the true value of the CNCs across the local area, the role that they provide but also across the health department community roles where you apply similar strategies... //.. So I think there s an enormous value in the CNCs being able to relate (to issues) across the spectrum but having the experience, the knowledge, the capacity, to then get the best things to happen in a (particular but realistic) way. Manager All participants shared concerns regarding the role clarity and expectations, knowledge about the role and its function, misappropriation of the role, and the difficulties associated with integration of role domains. Consultants themselves identified that they had good clarity about their own role. They were unclear, however about other Consultants roles within and outside their own service or specialty areas. Managers and stakeholders were clear about what they expected from the role, but these did not always match the expectations of Consultants. In the focus groups Consultants reported that they believed clinicians and others were not always aware of their role and therefore did not always engage with them in beneficial ways. There was some disagreement amongst stakeholders in relation to a number of issues, in particular, the imperative for Consultants to be in close proximity to the client care interface, the importance of and the need to protect the role, and also the degree to which the role should be LHD-wide or confined as a local resource. 8

4 Stakeholders highlighted that the Consultant role is most successful when the service within which they are situated is well resourced, well managed and functioning effectively. Gaps in the service platform erode the role of the Consultant and reduce their level of functioning and therefore the impact on patient and service outcomes. There were many reported instances where Consultants were required to help fill gaps in response to the inability of the service to meet existing and or escalated activity and shortfalls in staffing. Nature and Scope of the Role By far the largest numbers of Consultant positions are closely linked to the tertiary level services within the Newcastle metropolitan area. Most others work out of the larger hospital centres at Tamworth and Taree. Some positions are designated as LHD positions (having a requirement that some or all aspects of their role operate across the whole of the HNELHD). Others are located within specific units, sites and services. The average age of a Consultant in metropolitan areas is 46 and 49 in rural areas. There is low turnover in the roles particularly in rural areas, with the number of years Consultants have been employed in their current position ranging from one month to 28 years (mean of eight years). Over 60% of respondents have been in their current role for six years or more. Thirty per cent of Consultants have a Master s degree as their highest qualification. One person holds a PhD and three others are currently enrolled in PhD programs. Seventy nine per cent of Consultants are employed full-time; however there is a small number of part time and shared appointments. Consultants, together with managers and stakeholders, reported via the survey and focus groups that their work is: evolving; increasingly interdisciplinary in direction if not operation; across the interface of community and acute care; some positions have more than one clinical focus (IV and wounds, sexual health and TB); other positions are closely aligned with clinical services. There are also positions in transition to NP as well as short term project or disease specific roles. Those who are employed under the award category of Clinical Nurse Consultant work in positions which have different titles. For example, some are Consultants for a designated service, while others are Care Coordinators or Case Managers. Role Engagement Consultants were asked to estimate the percentage of time they spent within their role in each of the following six categories of health service delivery: prevention/promotion and protection; primary health; ambulatory care; emergency care; acute care; rehabilitation and extended care. The majority of respondents (83% of all respondents and 91% of grade 3) spent time across more than one of the above categories; 37% (n=52) of all respondents and 36% (n=13) of grade 3 respondents spent time across four or more areas of health service need. The most common category identified was Prevention/Promotion/Protection where 64% (n=89) of respondents spent some time and 14% spent over 50% of their time. In the grade 3 group, 30% spent some time across five or six of the areas above in the course of their employment activities. Variation exists in relation to the degree of involvement in direct care, staff and service support, inter-disciplinary and intradisciplinary decision-making and consultancy; and service development and management of human and other resources. It is this variation that creates blurring and lack of distinction from other role and award categories, in particular CNS grade 2, service or nurse manager, nurse or clinical educator and NP. Figure I. below illustrates overall HNE Consultant role activity and engagement across two continuums. The horizontal line indicates the degree of mobility, complexity and expected change in the role, and the vertical line indicates orientation to either clinical and consumer focus, or service and operations focus. heavily involved with provision of information and education to staff; directed towards development and dissemination of client information and client education ; involved in direct client interaction; intradisciplinary and interdisciplinary. A number of Consultants and stakeholders highlighted the importance of flexibility and the changing nature of the role, for example: my role actually involves that flexibility.. //.. meeting the needs of what the current issues are. So my original role and my original job description look nothing like what I am now. Consultant Another reported feature of the role was a shift in emphasis from hospital inpatient focus to community-centred prevention and early intervention. There is also some evidence to suggest that this is driven in part by involvement in the Clinical Networks and Streams (HNELHD, 2012). Variation occurs in the degree to which the role is recognised and operates at unit, service, network and stream and district level. Some positions are broad, hospital based (e.g. CNC Belmont); Figure 1: Model of Consultant role engagement When roles have large amounts of direct patient care and requirements for service and staff support they are more likely to be stable positions located within units or clinics. When roles have a broader consultancy focus requiring interdisciplinary practice and decision-making and/or service development and management activities, they are more likely to be complex roles that require input across the District; they are more likely to be strategic in focus 9

5 and involve complex co-ordination and change management. The shaded area indicates how Consultants are currently engaged across Hunter New England Local Health District (HNELHD). The largest amount of Consultant activity occurs in direct association with clients and other staff (through education and other support activities). Activity at the strategic end of the continuum is most often reported by grade 3 Consultants. Networks and Relationships Consultants were asked to identify the level of interaction they had with various groups using a likert scale ranging from 1-daily to 7-never. High level interaction was two to three times per week or more; moderate was once per week or fortnight; and low level was monthly or less. Consultants reported their highest amount of interaction with patients/clients, administrative staff and Nurse/ Midwife colleagues (Figure 2). Seventy per cent of respondents reported high interaction with medical officers, line managers and allied health staff. Low interaction was reported between Consultants and academics, professional bodies and state and national committees. Overall, Consultants report receiving moderate support and appreciation, with colleagues and line managers providing the highest amount of support (mean 3.4 and 3.2 respectively). Interdisciplinary practice was found to be a strong feature of the role (identified in focus groups), strengthened through participation in the Clinical Streams and Networks. Survey analysis demonstrated that interdisciplinary practice is strongly correlated with clinical leadership related activities (e. g. advising and supporting colleagues within and outside their own profession; developing and promoting best practice). Accordance with Award Domains Consultant activity (as reported by Consultants) correlates with the domains described in the NSW Clinical Nurse Consultant - Higher Grades - Public Hospital Nurses (State) award. However there is marked variation in the activity reported by individuals that does not necessarily match with the grading levels of 1, 2 and 3 described in the award. A small number of positions have single and dual components only, which means that they are able to meet just one or two award domains. Appointed grade level is not related to the self-reported level of involvement in any of the domains, except research (higher for grade 3 Consultants) and direct patient care (higher for grade 1 Consultants). Grade 3 Consultants reported having involvement across all domain categories. Figure 3 outlines the level of involvement in domain related activity. Discussion Diversity in the Consultant role is necessary to meet the needs of the Local Health District. Complexity as a feature of the role involves the integration of the various components of the role which currently are often seen and experienced as competing demands. This multi-dimensional nature of the role requires support through shared expectations, capacity building and integration into current and future models of care and service delivery. Networking and engagement across an increasing range of disciplines, sectors, groups and agencies are key features of the role. This reflects the changing structure of the LHD, contemporary health reform agenda, and the connected way in which Consultants need to operate to achieve integrated, coordinated and comprehensive service delivery and development. The flexible nature of the role, particularly at grade 3 level, enables Consultants to be deployed for strategic purposes and in accordance with funding opportunities. This strategic capability may well be unique to the Consultant role and will probably become increasingly important as health reforms and services become linked more effectively to changing populations and health care needs. The findings point clearly to the need for education in the areas of research, project management, teaching and coordination of interdisciplinary care. There is also an urgent need for further research that clarifies the role, differentiates from other advance practice roles and the means by which the role can be better integrated into future workforce reform. Conclusion Diversity in the role is necessary to match the diversity of health care contexts and differing models of care across and within the Local Health District. Competing demands as well as the need for engagement across a range of disciplines, sectors and groups add to the challenges experienced by the Consultants and to the growing complexity of the role. Acknowledgements The authors would like to acknowledge the contribution of the Figure 2: Consultant interaction with health service staff 10

6 Figure 3: Level of involvement in Domain Activity. group of people on the project team who provided advice in regard to health-related policy as well as support for this project: Chris Kewley, Isabel Higgins, Catherine Turner, Kane Wyborn and Peter Reay. The authors would also like to acknowledge Jane Conway and Margaret McMillan for their contribution in facilitating the focus groups during the data collection phase of this project; and Rebecca Mitchell for her advice on quantitative data analysis. References Chiarella, M., Harford, E., & Lau, C. (2007). Report on the evaluation of Nurse/Midwife Practitioner and Clinical Nurse/ Midwife Consultant Roles. North Ryde: Better Health Centre Publications Warehouse Retrieved from midwifereport.pdf. Daly, W., & Carnwell, R. (2003). Nursing roles and levels of practice: A framework For differentiating between elementary, specialist and advanced practice. Journal of Clinical Nursing, 12, Dawson, D., & Coombs, M. (2008). The current role of the nurse consultant in Critical care: Consolidation and consternation. Intensive and Critical Care Nursing, 24(3), Dawson, J. (2001). The Neonatal Clinical Nurse Consultant role: A profile based On measurement of components of practice. [Research Paper]. Journal of Neonatal Nursing, 7(5), DiCenso, A., & Bryant-Lukosius, D. (2010). Clinical Nurse Specialists and Nurse Practitioners in Canada:A Decision Support Synthesis: Canadian Health Services Research Foundation (CHSRF),. Guest, D., Peccei, R., Rosenthal, P., Redfern, S., Wilson-Barnett, J., Dewe, P., Sudbury, A. (2004). An Evaluation of the Impact of Nurse, Midwife and Health Visitor Consultants: University of London. Guest, D., Redfern, S., Wilson-Barnett, J., Dewe, P., Peccei, R., Rosenthal, P., Oakley, P. (2001). A Preliminary Evaluation of the Establishment of Nurse, Midwife and Health Visitor Consultants: A Report to the Department of Health. McSherry, R., Mudd, D., & Campbell, S. (2007). Evaluating the percieved role of The nurse consultant through the lived experience of healthcare professionals. Journal of Clinical Nursing, 16, O Baugh, J., Wilkes, L., Vaughan, K., & O Donohue, R. (2007). The role and scope of the clinical nurse consultant in Wentworth area health service, New South Wales, Australia. Journal of Nursing Management, 15, O Connor, M., & Chapman, Y. (2008a). The palliative care clinical nurse consultant: An essential link. Collegian. doi: /j. colegn Por, J. (2008). A critical engagement with the concept of advancing nursing practice. Journal of Nursing Management, 16, Woodward, V., Webb, C., & Prowse, M. (2006). Nurse Consultants: Organisational influences on role achievement. Journal of Clinical Nursing, 15,

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