Specialist Nurse Role Review

Specialist Nurse Role Review Evelyn Fleck Associate Director of Nursing NHS Tayside Cara Taylor MacMillan Nurse Consultant NHS Tayside September 2010

PAGE NUMBER CONTENTS 1. EXECUTIVE SUMMARY 3 2. INTRODUCTION 4 3. BACKGROUND 6 4. REVIEW PLANNING 8 5. METHODOLOGY 9 6. FINDINGS 12 7. CONCLUSION 27 8. SUMMARY OF RECOMMENDATIONS 28 9. REFERENCES 30 10. APPENDICES 32 Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 2

1. EXECUTIVE SUMMARY In January 2010 the Delivery Unit Director of Nursing, within the Nursing and Midwifery Care Governance Framework, made a commitment to undertake a review of the role of specialist nurse 1 posts in NHS Tayside. It is stated that the Delivery Unit Director of Nursing wants the nurses 2 working within NHS Tayside to develop their individual and collective potential, placing them at the forefront of the profession: providing care that is consistently person-centred, clinically effective and safe, for every person, every time. This report presents the key findings and recommendations from the review which was carried out using a mixed methodology of qualitative and quantitative techniques in order to promote opportunities for engagement by specialist nurses and stakeholders. NHS Tayside now has a comprehensive understanding of where specialist nurses practice and the level of advanced practice that it can expect from the specialist nurses in its employment. The greatest challenge facing specialist nurses at the present time is how they can contribute to ensuring that NHS Tayside achieves its strategic objectives of providing services that enhance the health of the population, improve the patient s experience and ensure efficient and effective use of resources (Triple Aim). Changes to the way specialist nurses work must be delivered at a time when the future shape of services in the Delivery Unit is changing towards maximising opportunities for flexible working across the system, providing more choice for patients and the potential for the growth of alternative models of care delivery. The opportunities associated with clinical developments in shifting the balance of care through case management and the evolution of virtual wards provides specialist nurses with unique opportunities to redesign the services they provide. The review has sought to provide NHS Tayside with a clear picture of its specialist nurse capacity and to provide a sound basis for the future of specialist nurses in NHS Tayside. Implementation of the recommendations will require close collaboration between managers, the Nursing Directorate and specialist nurses in order to identify and prioritise areas for improvement. 1 In considering the term specialist nurse the review has included all nurses with the title specialist nurse, clinical nurse specialist, nurse practitioner, advanced nurse practitioner, practice development, clinical educator or clinical development. 2 The term nurse refers to all Registered Nurses, Midwives and Registered Public Health Practitioners. 3

2. INTRODUCTION Nursing is a vibrant profession that is responsive and is adaptable to meet the needs of patients and the public. Nurses have been encouraged to review and develop their scope of practice as a consequence of evolving political, environmental, professional and patient led demands for healthcare. The Scope of Professional Practice (UKCC 1992) provided the professional governance around role extension and supported nurses in developing new roles. Subsequent changes with the introduction of European Working Time Regulations, the resultant reduction in junior doctors hours, Modernising Medical Careers (SEHD 2005) and recruitment and retention issues in some specialties have offered further new opportunities to nurses in developing their roles. As care and treatment has become increasingly complex, a number of specialist nursing roles have been developed with the purpose of improving the quality of care experienced by the patient with nurses taking on new roles, working across professional boundaries, and setting up new services to meet patients' needs. Due to the specialist nature of the posts, and requirements led by subspecialty services, linked with available funding from a variety of sources, these posts have developed in an ad-hoc fashion with little thought to links with organisational objectives, strategic development or career progression. It has been reported in the literature that this results in feelings of isolation for the specialist nurse, fragmented management guidance, a lack of career progression, duplication and a sense of dislocation from the wider organisation (RCN 2005). The literature provides some evidence that supports the effectiveness of the specialist nurse roles in the delivery of high quality of care but they tend to be small, specialty specific studies. There is no doubt that the evolution of role of the specialist nurse has had a major impact on patient care over the past twenty years and the roles have been flexible in responding to changing strategies within healthcare. However, development has been largely opportunistic and the need for a systematic review of the role and how it supports the achievement of the corporate objectives of NHS Tayside is required. The effective deployment of specialist nurse roles places NHS Tayside in a strong position to deliver the current national drivers that have an emphasis on improved patient experience, as detailed in the Scottish Governments Quality Strategy (SGHD 2010). In setting out what the people of Scotland want from their NHS it focuses on: Caring and compassionate staff and services Clear communication and explanation about conditions and treatment Effective collaboration between clinicians, patients and others A clean, safe environment of care Continuity of care and good access to care Clinical excellence Generating an improvement in the experiences of our services users and carers is a central value to this review. Nurses are in a unique position in healthcare as the people that patients and carers meet first and most often in their care journey and must be encouraged to recognise their responsibilities in influencing the quality of the patients and carer s experience. The principles of CEL 4 (2010) guidance on how NHS Board should involve patients, carers, public and staff in developing service 4

changes have been applied. Importantly, it describes major service change which requires ministerial approval. Nationally the work programme for Nurses, Midwives and AHPs is set out in CURAM (2009) and the elements within it are a key driver for the Specialist Nurse Role Review. CURAM has been written in the context of the wider policy direction of the Scottish Government detailed within Better Health, Better Care: Action Plan (2007). The strategic direction for healthcare in Scotland is based on the belief that health and social care systems should be integrated around service users, provide improved support for self care and deliver care as close to the home as possible. In line with the principles of modernising nursing in the community there is an emphasis to shift care from hospital to community based services through the development of a wide range of preventative, diagnostic, treatment and rehabilitation services within the community with patients only accessing specialist secondary and tertiary care services when necessary. It is with this in mind that we have considered how best specialist nurses can work with multi-disciplinary, multi-agency teams to meet the needs of patients, families and communities. In doing this we have acknowledged the aspirations of NHS Tayside in providing services that enhance the health of the population, improve the patient s experience and ensure efficient and effective use of resources (Triple Aim) 3 (IHI 2007). As senior clinicians, specialist nurses are pivotal in supporting the delivery of the aspirations of NHS Tayside. 3 Triple Aim is an approach to improving healthcare that has been developed by the Institute of Health Improvement (2007). It describes three objectives that recognise the interdependency between improving health, the experience of the patient and living within the budget. 5

3. BACKGROUND 3.1 Purpose In January 2010 the Delivery Unit Director of Nursing presented the direction of travel for the nursing profession within NHS Tayside in relation to the provision of healthcare that is safe, effective and person centred. Within the Nursing and Midwifery Care Governance Framework there was a commitment to undertake a review of the role of specialist nurse posts in NHS Tayside (March 2010). As an organisation it is stated we want our nurses to develop their individual and collective potential that places them at the forefront of the profession: providing care that is consistently person-centred, clinically effective and safe, for every person, every time. Historically, specialist nurse roles have developed according to the needs of subspecialty services. For example, colorectal specialist nurses may perform flexible sigmoidoscopy whilst Community Macmillan Nurses have extended their role to include prescribing. Because of such adhoc service specific developments, there needs to be clarity over the contribution of the role of specialist nurses. Therefore, the challenge for specialist nurses is how they quantify the unique contribution that they make to the delivery of safe, effective and person-centred care. Some early work exploring the specialist nurse contribution to the reduction in waiting times suggests that nurse led services have improved access, reduce waiting times and improve the quality of patient care (NHS Tayside, 2009). However, this is only one component of some of their roles and the purpose of this review was to consider their overall contribution to supporting the organisation in its delivery of key policy drivers and targets. 3.2 Scope The aim of the review is to generate and deliver a sustainable vision for specialist nurses which demonstrates the unique contribution that specialist nurses make to the delivery of safe, effective and person-centred care, supporting the organisation in taking forward its work in relation to Triple Aim with its three objectives of improved health of the population over time; reduced total per capita cost and optimised patient/family experience specifically in relation to satisfaction, safety and quality. In order to capture the wide range of specialist nurses in NHS Tayside, the review initially considered nurses in NHS Tayside with the title specialist nurse, clinical nurse specialist, nurse practitioner, advanced nurse practitioner, practice development, clinical educator or clinical development. A Steering Group was established to provide senior clinical leadership and support around the review. Membership is detailed in Appendix 1. Patient and public engagement was secured through the NHS Tayside Public Partnership Group (PPG). Staff side representation was secured following nomination from the Area Partnership Forum. The timing of the review has coincided with the Scottish Executive Nurse Directors (SEND) Group commissioning the development of a national Workforce & Workload Planning Tool for Clinical Nurse Specialists. It was therefore decided that the review would not include workforce and workload planning as the new tool is expected to be available by the end of 2010. It was agreed that the national tool will inform the implementation phase of the review. 6

3.3 Key Aims and Objectives The review is inclusive across the Delivery Unit and has quantified and scoped the current specialist nurse resource in NHS Tayside and made recommendations for future developments in line with national policy. In particular the review has considered: Specialist nurses involvement in all aspects of patient care delivery on both waiting time and quality targets Specialist nurses involvement in the whole patient pathway across the different sectors of healthcare within the Delivery Unit Equity of patient access to specialist nurses Sustainability, models of delivery and appropriate professional development to support succession plan for the future Progress with regard to the recommendations of the 2008 review of Cancer Nurse Specialists The composition of teams and skill mix The impact of CEL (28) on existing and evolving roles 3.4 Definition The review has considered specialist nurse roles which fall into the ISD definition of: A clinical nurse specialist 4 is a registered nursing professional who has acquired additional knowledge, skills and experience, together with a professionally and/or academically accredited post-registration qualification (if available) in a clinical specialty. They practice at a minimum of senior practitioner level (i.e. level 6 or above of the Career Framework) will have a high degree of autonomy and responsibility and may have sole responsibility for a care episode or defined client/group. They may practice at an advanced level (ISD, 2010). 4 There are different types of clinical nurse specialists depending on their area of clinical specialty and there are several clinical nurse specialist titles. These include nurse practitioner, lead nurse, nurse lead, nurse specialist, senior nurse, specialist practitioner and senior practitioner roles e.g. Emergency Nurse Practitioners or Hospital at Night 24/7 Practitioners 7

4. REVIEW PLANNING Phase 1 The first phase of the review is the planning phase. The review will be undertaken across the Delivery Unit. The following are to be delivered during this phase: 1. Agreement of Scope of Review and Terms of Reference 2. Agree communications strategy 3. Agree engagement strategy 4. Undertake a review of the literature to ascertain similar evaluations that have been undertaken in other areas. 5. Network nationally and internationally with other health systems to share learning 6. Identify healthcare staff roles to be included in review. 7. Produce a detailed Project Initiation Report to the Delivery Unit Director of Nursing and then to Delivery Unit Executive Management Team to gain approval ahead of review going live Phase 2 The second phase of the review is the assessment phase. The following are to be delivered during this phase: 1. Develop and agree methodology to be used for review 2. Complete assessment of current position 3. Understand the future vision for specialist nurses to identify what services are provided, by who, how and when 4. Develop proposals/options for implementation Phase 3 The third phase of the review is the reporting phase. The following are to be delivered during this phase: 1. Produce a detailed report with recommendations to the Delivery Unit Director of Nursing and then to Delivery Unit Executive Management Team 2. Develop outcome measures for improvement Phase 4 The fourth phase will be the implementation phase. Following acceptance of the recommendations by the Delivery Unit Executive Management Team an implementation plan will be developed. 8

5. METHODOLOGY As this is the first work of its kind in NHS Tayside the opportunity was taken to identify a wide range of specialist nurses in the organisation thus the review has not confined itself to purely patient facing roles but has included staff with an array of titles including specialist nurse, clinical nurse specialist, nurse practitioner, advanced nurse practitioner, practice development, clinical educator or clinical development. The review did not include research nurses or advanced practitioners who currently participate in a duty rota within clinical areas for example, Emergency Nurse Practitioner (ENP) and Advanced Neonatal Nurse Practitioner (ANNP) posts. Identifying the cohort of specialist nurses to be included in the review was complex. Early on in the review it was recognised that workforce and payroll IT systems could not supply the information unless details of all job titles were known. Initially, the six Delivery Unit General Managers were asked to identify the specialist nurses working in their Directorate/Community Health Partnership (CHP) who would be included. In addition, Focus Group meetings and World Café events were advertised on the NHS Tayside Intranet Home Page. However, during the Focus Group meetings it was evident that not all specialist nurses were aware of the review therefore participants were asked to share information and ask specialist nurse colleagues to contact the reviewers directly. In addition reviewers publicised the review at a variety of meetings/forums. During the review further contacts were made with Service Managers, Senior Nurses and Heads of Patient Care and Nursing to finally identify the number of specialist nurses in NHS Tayside. This was a lengthy process and all specialist nurses were not confirmed until August 2010. 5.1 Clinical Engagement Specialist nurses are a major clinical influence in relation to decisions taken with patients in their care, from making the diagnosis to determining the pathway of care and the decisions and actions they take have a direct bearing on the use of resources. They are the public face of the Delivery Unit, often remain in the same post for many years and have considerable experience of the NHS. This gives them a wealth of knowledge about the strengths and weaknesses of the system. They have a professional responsibility to their patients, have a responsibility to their employer and are answerable to their regulatory body the Nursing and Midwifery Council. Ensuring that specialist nurses had the opportunity to be fully engaged, as they would be an integral part of achieving successful and lasting change, was important when planning the review. 9

5.2 Focus Groups In order to ensure that the review listened to a wide range of experiences and issues facing specialist nurses three Focus Group meetings were held, one each in Angus, Dundee and Perth. All specialist nurses who had been identified by their managers were invited to attend one of the sessions. They were contacted by email and provided with a briefing document (Appendix 2) and agenda (Appendix 3) in advance. Discussions were focussed around the three improvement questions: 1. What are the challenges? 2. What change can we make that will result in an improvement? 3. How will we know change is an improvement? 5.3 World Café Events The outputs from the discussions held in the Focus Groups were analysed and informed the development of a set of draft recommendations. These recommendations were presented to participants at two World Café events held in Perth. Invitations were issued by email. The programme can be found in Appendix 5. The events were chaired by the Delivery Unit Director of Nursing. A multiprofessional stakeholder group (Appendix 4) were invited to test the findings of the Focus Group discussions. The aims of the events were to: Highlight the emerging themes from the review Generate discussion and gain agreement about initial recommendations emerging from the Focus Groups Identify structures required to support implementation of the initial recommendations Identify how we can best keep stakeholders engaged in the implementation Debate measures that could be set to demonstrate that changes have been an improvement. 5.4 Data Collection Questionnaire A questionnaire was developed based on existing review tools: Information Services Division Clinical Nurse Specialist questionnaire Ulster Hospitals Review of Clinical Nurse Specialists Royal College of Nursing (2005) Review of Clinical Nurse Specialists North Glasgow University Hospitals (2004) Clinical Nurse Specialist Review NHS Tayside (2008) Cancer Specialist Nurse Review. The questionnaire was extensive and collected details about demographics, role, remit, preparation, managerial and professional support, and development. It was distributed to all identified specialist nurses by email using Survey Monkey 5. The data collection questionnaire can be found in Appendix 6. 5 Survey Monkey is a web-based tool that enables you to create online surveys and view results graphically and in real time. The advantage of using Survey Monkey was the flexibility it gave us to create an extensive quantitative and qualitative survey. It was very quick to create and once the survey was up and running we could analyse the quantitative questions online, download it to an excel 10

5.5 Limitations of the Methodology The population to be involved evolved over the entire period of the review therefore not all eligible specialist nurses have been given the opportunity to participate. The questionnaire was lengthy. There was the facility to save partially completed questionnaires and return to it at a later date to complete. However, 6 participants started the questionnaire, stopped and revisited it from the start thus some of their responses were counted twice. Towards the end of the questionnaire questions were less likely to be answered i.e. 100% participants answered the first question, 66% answered the final question. The use of a web based tool to encourage participant involvement and analysis of results also identified limitations of interrogating the results. For example, there was limited ability to explore the possible similarities and differences of specialist nurses in specialist and advanced practice roles. The questionnaire was based on available clinical nurse specialist reviews and heavily weighted to the direct clinical contact of specialist nurses and patients. For those nurses in practice development, education and training roles the questionnaire was particularly challenging to complete. spreadsheet and analyse the qualitative questions. This significantly reduced the amount of time required to analyse the questionnaire and allowed us to gather more information from the post holders. 11

6. FINDINGS As at September 2010 the number of specialist nurses identified as working in NHS Tayside is 247. The identification of specialist nurses within the organisation was challenging and required several iterations with managers and participants to finalise a comprehensive and accurate list. Now that this work has been completed it is viewed that there is benefit to the organisation of maintaining this list within a single source. In particular it will afford the organisation the ability to articulate where specialist nurses practice and will identify opportunities for flexible working across the system. It will also ensure that we can communicate more effectively with this group of staff. RECOMMENDATION 1 NHS Tayside maintains a Directory of Specialist Nurses. Of the 247 specialist nurses 12 (5%) are identified as Band 5 (Dundee CHP 8; Medicine 2; Angus CHP 1; Surgery 1). Within the NHS Education for Scotland Career Framework for Health (2009) level 5 posts are not considered as specialist nurses and are identified as registered practitioners consolidating pre-registration experience and getting ready for a higher level of functioning. RECOMMENDATION 2 The role and job descriptions of those Band 5 practitioners who were identified as specialist practitioners are reviewed and amended to reflect the responsibilities of a Band 5 practitioner working within a specialty area. 111 (45%) are Band 6, 108 (43.6%) are Band 7, 15 (6%) are Band 8a and 1 (0.4%) is Band 8b. Table 1 provides a breakdown of the number of specialist nurses by CHP/Directorate. 60% of specialist nurses are employed in the acute sector. Table 1 Breakdown by CHP/Directorate CHP/Directorate Number of Specialist Nurses (%) Access Directorate 0 Angus CHP 23 (10%) Dundee CHP 44 (18%) Infection Control & Management (IC&M) 15 (6%) Medicine Directorate 99 (40%) Nursing Directorate 4 (1%) Perth & Kinross CHP 13 (5%) Surgical Directorate 49 (20%) 12

Table 2 identifies a breakdown of the specialist areas in which specialist nurses practice per CHP/Directorate. There are specialist nurses working within different sectors of the Delivery Unit within the same field of practice. In pursuing the strategic vision of Triple Aim and shifting the balance of care this information offers the potential to managers for working in partnership across CHP s/directorates and to redesign services differently in the future. It also affords the opportunity to consider skill mix within multi disciplinary teams, for example, if a Consultant retires can the existing specialist nurse team extend their role within the parameters of advanced practice. Table 2 Breakdown by clinical specialty and CHP/Directorate Specialty No. CHP/Directorate Specialty No. CHP/Directorate Palliative Care 22 Angus CHP (3) Dundee CHP (10) P&K CHP (9) Mental Health 21 Angus CHP (1) Dundee CHP (3) Medicine (17) Cardiac Specialties 20 P&K CHP (1) Dundee CHP (2) Angus CHP (3) Medicine (14) GI Tract 18 Surgery (8) Medicine (9) Pain 6 Angus CHP (1) Surgery (5) Employability/Working Towards Better Health 4 Dundee CHP Healthy Living 4 Dundee CHP Radiotherapy 4 Surgery Hospital @ Night 16 Medicine Gynaecology 3 Medicine Paediatrics 15 Dundee CHP (2) Medicine (13) ENT 2 Angus CHP (1) Surgery (1) Respiratory System 16 Angus CHP (3) Dundee CHP(3) Medicine (10) Haematology 2 Surgery Infection Control 15 IC&M Infectious Disease 2 Medicine Diabetes 10 Medicine OHPAT/Immunology/IV 2 Medicine therapy Anti Coagulation 9 Dundee CHP Orthopaedic 2 Angus CHP (1) Surgery (1) Neurological Specialties 8 P&K CHP (1) Dundee CHP (1) Rheumatology 2 Medicine Surgery (6) Skin 9 Angus CHP (1) Surgery (8) Child Protection 8 Angus CHP (1) P&K CHP (2) Dundee (5) Practice Development 9 Angus CHP (3) Dundee CHP (1) Medicine (1) Nursing (4) Urological System 8 Angus CHP (2) Surgery (8) Breast 5 Surgery Stroke 2 Angus CHP (1) Dundee CHP (1) Intensive Care 1 Surgery Medical Oncology 1 Surgery Vascular 1 Surgery Further analysis undertaken within the review is presented as a combination and comparison of the results of the three methodologies described: The Specialist Nurse Focus Groups (n-3) The World Café Events (n-2) The completed specialist nurse questionnaires (n-140) 13

6.1 Specialist Nurse Focus Groups Specialist nurses were invited to attend the Focus Group meetings via their line managers. 78 specialist nurses participated in the three Focus Group meetings. The third Focus Group meeting did not generate any new data. Therefore the scheduling of the three Focus Group meetings was deemed sufficient. Flip chart contributions by delegates in response to open questions around the issues for, role, function, influence and impact of the specialist nurse role were explored and themed. The analysis considered the role of the specialist nurse in relation to: Patient centredness Communication Education Efficiency Effectiveness Expert resource Influence 6.2 World Café Events 352 multi-professional stakeholders were invited to two World Café events to test the findings of the Focus Group discussions. 95 (27%) delegates participated. In order to test the results of the Focus Group meetings the noted outputs from the tabletop contributions were analysed, themed (using the same categories as the Focus Groups) and compared to the findings of the Focus Groups. The World Café events also attempted to elicit ideas from delegates to support and sustain implementation of the finally agreed recommendations. Suggestions regarding implementation of recommendations were as follows: A request was made for transparency and honesty in the implementation process. The presentation of the recommendations of the Specialist Nurse Role Review to those who have participated in the Focus Groups/World Café events and to the wider Specialist nurse population working within NHS Tayside. Development of an implementation action plan. Identification of and engagement with other main stakeholders including patients/public and Managed Clinical Networks. An identified professional lead for specialist nurses e.g. one of the Associate Directors of Nursing. RECOMMENDATION 3 NHS Tayside establishes a Programme Board to lead implementation. 14

6.3 Specialist Nurse Questionnaire At the point of undertaking the questionnaire survey 188 specialist nurses were identified. All were issued with a questionnaire by email, 140 questionnaires were returned which gives a response rate of 75%. The full summary of questionnaire findings is available in a separate report (192 pages). It is noted that the 140 respondents to the questionnaire is 56% of the total population of 247 specialist nurses and therefore the questionnaire results are statistically valid. The specialist nurse questionnaire highlighted the variety and inconsistency in specialist nurse job titles with over 30 different groupings of titles. 4% did not include nurse in the title at all, for example Pain Specialist. 61% of titles included specialist and only 1 of the respondents had advanced in their job title. This is inconsistent with the banding of the roles, where 63% of respondents were band 7 and above, indicating, for the majority, a level of advanced practice. The implication of having this variation of titles is the potential for a mismatch of expectation and inability for patients, public and colleagues to identify different levels of practice. Cognisance should be taken of the charity funded or supported roles where there tends to be a contractual arrangement to use the charity name in titles as a means of notifying the public of the charity s role in the development of the post and ongoing support. RECOMMENDATION 4 Further work is required to develop standards in relation to the use of agreed specialist nurse job titles. Such work should be linked to the Role Development Framework for new roles (NHS Tayside, 2009). 6.4 Patient Centeredness Through the Focus Groups and World Café events there were numerous examples and considerable emphasis placed on the coordination, Key worker role of the specialist nurses for patients and their families. Continuity, consistency, availability and responsiveness being the qualities that patients report as being most valuable and essential (While et al, 2008). The Focus Group delegates identified that because of this coordination the patient journey is smoother and problems are anticipated and averted and they provide rescue when problems do arise. However, this can lead to specialist nurses getting involved in activities that may not require their level of expertise or skills in order to deliver care to their patients e.g. administrative tasks, pathway coordination that could be carried out more effectively by other members of the team. This can create dependency for the patients and expectation that the best and most effective access to service is via the specialist nurse. During the review one relative shared their story about their experience of our current systems and processes (see Box 1). Their view was that our systems and processes designed to deliver care were not individualised or person-centred. The example they gave was in relation to an annual review which required two hours travel for their mother and a consultation with the specialist nurse which lasted one hour. 15

Box 1. Relatives Story My mother said that she could not recall any of the information shared at the consultation. When I asked her if there was any change in her care or treatment plan she said no. I felt that there could have been a more efficient and effective way of reviewing my mother s care needs annually. Managers and specialist nurses need to take more cognisance of the patients ability to work in partnership and use existing and emerging models of care delivery. For example, many areas have implemented a system where the patient initiates an out patient review meeting which reduces reliance on service led out patient review and has created additional capacity in the out patient setting. In particular they need to align their services with the strategic direction of shifting the balance of care and work with community teams on initiatives such as the virtual ward development and self management within the Long Term Conditions agenda. In addition they need to ensure effective use of developments in technology in order to support people at home and reduce the need for hospital attendance. RECOMMENDATION 5 Managers need to consider how patients access services and review the capacity within the multi professional team to provide administrative and support for coordination of patient pathways. RECOMMENDATION 6 Implement models of care that promote patient ownership and partnership in care with improved effectiveness and efficiency. Despite the emphasis placed on the importance of the specialist nurse in the facilitation of effective patient and family communication as well as inter professional and interagency coordination the specialist nurses completing the questionnaire suggest the importance of enhanced communication skills training on commencing the role. Many of them have developed an enhanced level of communication skill through experience in practice without formal education. RECOMMENDATION 7 Through KSF outlines and PDP, ensure specialist nurses complete communication skills training. In trying to examine and quantify the clinical aspects of a specialist nurse role Table 3 illustrates a breakdown of the clinical activities that are undertaken by the specialist nurses responding to the questionnaire. 76% of respondents answered this question. 9 respondents were in Practice Development and/or Educator posts and did not have a direct clinical role. For those nurses in practice development, education and training roles the questionnaire was particularly challenging to complete. RECOMMENDATION 8 Further work specifically focussed on the role of the specialist nurse in Practice Development and Education roles is required. 16

Table 3 Clinical Aspects of Role Number of SPN with no direct clinical role <25% time in direct clinical role 25-50% time in direct clinical role 50-75% time in direct clinical role >75% time in direct clinical role Clinical Activities: Carry out specialist nurse 81 assessment (58%) Medical history taking 69 (49%) Clinical examination of patients 60 (43%) Gaining consent for interventions 74 (53%) Request diagnostic investigation 75 (54%) Interpret diagnostic investigations 44 (31%) Make diagnostic decisions 67 (48%) Devising integrated care plans 59 (42%) Number 9 12 21 43 22 Percentage of respondents 8% 11% 20% 40% 21% Extended roles 78 (56%) Non-medical prescribing 48 (34%) Carry out procedures 59 (42%) Referral to other health care professionals 104 (74%) Ability to admit patients 24 (17%) Ability to discharge patients 20 (14%) Screening for early signs of disease / risk 60 (43%) The results suggest that there is a varied range of the types of clinical activity that the specialist nurses undertake. In line with previous studies (J Corner, 1997, J McPhelim et al, 2009) there is some evidence of advanced practice. This raises questions about variation in practice, the availability of specialist nurses, equity of access to services and the expertise of specialist nurses in the delivery of person centred care. Specialist nursing is difficult to measure and continues to be a hidden aspect of care. In order to progress this debate and connect specialist nurse activity to patient outcome, organisational and national priorities service managers and specialist nurses need to embrace a consistent approach to workforce and workload planning. RECOMMENDATION 9 The organisation considers and implements the recommendations of the Clinical Nurse Specialist National Workforce and Workload Planning Group. 17

Table 4 describes the respondents activity in relation to patient education and also demonstrates the responses in relation to the amount of estimated time spent in the support and education of others, either learners or colleagues. 74% of respondents answered this question. Table 4 Education Patient education either individual /group No. % of respondents Education of students/other staff No. % of respondents Not part of role < 25% of role 25-50% of role 50-75% of role > 75% of role 8 41 34 14 7 8% 39% 33% 13% 7% Not part of role <25% of role 25-50% of role 50-75% of role >75% of role 5 75 17 5 1 5% 73% 16% 5% 1% 53% of specialist nurses spend more than 25% of their time undertaking patient education as part of their role. Additional information provided identified that this is broken down into informal or formal, individual or group sessions. The literature suggests this positively impacts on patient satisfaction, compliance with treatment and contributing to the patients ability for self care/ self management (Jardine & Knill-Jones, 2007). However, in comparison, the amount of time spent in the education of learners and colleagues is less with only 22% of specialist nurses spending more than 25% of their time in this activity. In the Focus Groups specialist nurses identified that they prioritised clinical activity above other aspects of the role. Without question the specialist nurses are an untapped and underutilised resource that could support the Senior Charge Nurse/Team Leaders in ensuring appropriate specialty specific educational opportunities are available within the workplace for more junior staff and students. For example, specialist nurses could co-ordinate a student nurse placement which would allow the student to follow complete patient pathways. The changing context of nursing and healthcare requires the educational preparation and the ongoing development of nurses to take place and to be supported in both clinical practice and in academic settings. NHS Tayside and the University of Dundee are working in partnership to achieve this through a Clinical Academic Collaboration Programme. RECOMMENDATION 10 Education provision for staff needs to follow the patient journey and be provided in all care settings. Novel ways of delivering education in the workplace should be explored. RECOMMENDATION 11 The specialist nurse contribution into the Clinical Academic Collaboration Programme should be formalised. 18

6.5 Providing Safe and Effective Care Focus Groups and World Café events highlighted the challenges faced by specialist nurses in articulating the impact of their role, the evidence of their contribution to providing safe and effective care and their ability to inform service development as a result of undertaking audit and evaluation. The questionnaire respondents provided some evidence of improvements in practice as a result of the audit activity and Table 5 shows that 94% of respondents were spending up to 25% of their time in carrying out audit and service review. Despite this level of activity the views shared at the focus groups and world cafés suggest specialist nurses need to evaluate the audit activity they are undertaking and find a mechanism to share the results. Table 5 Research and Audit Research % of No. respondents Research not part of role 48 46% <25% of role 55 52% 25-50% of role 2 2% 50-75% 0 0 >75% 0 0 Audit No. % of respondents Undertakes audit 103 94% Audit not part of role 7 6% 46% of questionnaire participants suggested that they spend no time undertaking research. However, the questionnaire was unable to gauge the extent to which specialist nurses accessed, critiqued and disseminated available research to inform practice. It would not be the expectation for many staff in these posts to be named primary researchers on funding applications however, it is recognised that many will have undertaken or be leading research as part of academic attainment. It is an expectation that specialist nurses contribute to research within their specialist field for example, by acting as clinical collaborators on grant applications, considering clinical questions which may generate primary studies, and actively supporting research studies in their areas of practice. The research contribution of specialist nurses should be part of a portfolio of research within the team that contributes to improving the patient experience and outcomes and the organisations objectives. Focus Groups / World Café events identified the desire to pursue electronic collection of data to generate reports to be used as evidence of activity and level of practice. There was also a willingness to investigate the potential of developing generic and specific quality indicators. RECOMMENDATION 12 NHS Tayside should influence the national agenda regarding the challenges and importance of consistent, effective specialist nurse data collection. RECOMMENDATION 13 Pursue the development of clinical quality indicators for specialist nurses. RECOMMENDATION 14 Promote a culture where audit and research informs practice and contributes to the organisational objectives. 19

6.6 Capacity and Capability The specialist nurse questionnaires identified the range of experience prior to taking up post. Most specialist nurses had been recruited from within the same speciality. The educational preparation of specialist nurses is varied. Table 6 outlines the educational qualifications of the specialist nurses who responded to the questionnaire. 90% of respondents answered this question. Table 6 Education / qualifications of specialist nurses RN 126 (100%) Diploma 44 (35%) RSCN 12 (10%) Degree 109 (87%) RM 9 (7%) Masters 20 (16%) HV 11 (9%) SPQ 5 (4%) Registered Teacher 2 (2%) 109 (87%) of respondents were qualified to graduate level, 20 (16%) to masters level or higher with a further 11 (8%) either working towards or having completed master level modules. In a recent study of senior charge nurses in NHS Tayside, of those who had responded at the time of writing, 56% were qualified to graduate level and 1% to master s level. This would suggest that within NHS Tayside that specialist nurses are more likely to access graduate or higher qualifications than other senior nurses in the organisation. In addition, the Advanced Practice Toolkit (SGHD, 2009) advocates master level education capability for advanced practice. Specialist nurses at AfC Band 7 and above (n-123, 50%) have yet to demonstrate this capability. Non-medical prescribing was identified by 43% of specialist nurses as part of their role. Specialist nurses with the skill of independent prescribing enhance the patient experience by ensuring that the service is responsive to patient needs (Wix, 2007). Capability frameworks have been developed to help managers quantify the types and level of activity in specialist clinical practice, assessment, diagnostic investigation and interpretation (NES, 2008). Some specialist nurse report statistical information on nurse led clinics to Information Services Division (ISD). However, this information provision is not consistent across all specialist nurses and as a result the reported statistics we receive from ISD are not accurate. RECOMMENDATION 15 Ensure that all nurse led activity is reported. RECOMMENDATION 16 Job descriptions and specifications, knowledge and skills framework professional development plans (PDPs) should identify the expectation of graduate level education capability in line with NES Career Framework and Advance Practice Toolkit. RECOMMENDATION 17 Ensure specialist nurse educational needs are articulated in the annual training plans developed with Directorates/CHPs. 20

The questionnaire asked the specialist nurses to quantify the time they spend in management and leadership activities and their responses are summarised in Table 7. Table 7 Management / leadership as part of role Management and Leadership No % of respondents Leadership Not part of role Leading a service/ corporate 11 10.3% responsibility <25% of role External responsibilities /other 52 49% organisations 25-50% of role 28 26.4% Managing other staff as part of role 27 (25%) 21 (20%) 50-75% of role 4 4% Management of other staff 32 (29%) >75% of role 11 10.3% No Management responsibilities 79 (71%) The majority have identified that management and leadership responsibilities accounts for less than 25% of their role. More than 63% of the respondents were Band 7 and above but only 29% have line management responsibilities. This would suggest that the majority of senior specialist nurses received their banding linked to expectations articulated within the job descriptions of the need for advanced practice. There are opportunities to explore whether this is truly advanced practice and to review whether all practitioners in a team need to be operating at that level or whether skill mix needs to be introduced within teams. RECOMMENDATION 18 Review services in order to determine the level of practice required and clarify the primary function of individual members of the team. Within the questionnaire the definition of leadership was not clear and therefore it is difficult to make conclusions about the leadership contribution of specialist nurses. Within the Focus Groups the specialist nurse highlighted their contribution to getting involved and articulated their contribution to influencing in relation to work with partners however, they where less able to express their leadership within the organisation. It is undoubtedly the case that they are senior clinicians within the organisation and their leadership potential should be explored in contributing to the corporate capacity of senior clinical leaders. 21

An emerging theme from the Focus Groups was the concern expressed by specialist nurses regarding how decisions are and will be made to determine the most appropriate workforce resource to deliver services. The specialist nurses described the challenges of demonstrating not only their activity but also the complexity of their intervention and impact. The use of job / work plans was identified as a methodology for allowing discussion with specialist nurses, teams and managers regarding the focus of activity for specialist nurse. Job plans could allow a greater understanding between the parties of the actual activities undertaken and focus discussions to ensure the needs of the service are met whilst considering patient demand and the capacity required to deliver it. This would inform: Succession planning; Team development; Skill mix opportunities; Development of service objectives; The leadership contribution of the specialist nurse to clinical areas/services; The clinical contribution of the specialist nurse to shifting the balance of care. RECOMMENDATION 19 Development and roll out of annual job planning as a way of articulating activity and focus of specialist nurse roles. RECOMMENDATION 20 Create and implement templates that promote consistency in job descriptions/ job specifications/ KSF post outlines. Parallel to this review the organisation has commissioned as part of its Steps to Better Healthcare Programme an Out Patient Redesign Project. Observations of care in the out patient setting have identified variation in the design and management of clinic profiles. As the programme moves from scoping capacity into its next phase of implementing the redesign the specialist nurse contribution will be considered and this will be reflected in their job plans. 22

6.7 Responsibility and Accountability The majority, 60%, of respondents were able to identify their line management arrangements. This suggests that there is confusion for some of the specialist nurses around who provides the line management responsibilities for their posts. The Nursing Directorate has a professional leadership role in relation to post holders however some respondents believed this to be a line management responsibility. RECOMMENDATION 21 Each specialist nurse should be clear about who they are managerially responsible to, the managerial structure and the frequency and method of managerial input they should expect. There was a sense from the focus groups that specialist nurses felt disengaged from the processes of organisational, service and professional development. A goal, therefore, would be to ensure that specialist nurses would be afforded equitable opportunity to engage with line managers and professional leaders. The Focus Group and World Café delegates suggest that the specialist nurses professional forum would be an effective way to facilitate specialist nurse engagement and increase their knowledge and influence in relation to organisational objectives and priorities. RECOMMENDATION 22 A review of the role and remit of specialist nurse professional forum and the professional support and leadership required from the Nursing Directorate in relation to the forum. When it came to objective setting, 88% of questionnaire respondents suggested that they work to set objectives. The majority of these describe their objectives to be based on their appraisal / PDP but only 32% made any link to strategic or organisational objectives / MCN or clinical service plans. RECOMMENDATION 23 Objectives should be linked to the organisations corporate objectives and local service plans. 23

6.8 Team Working Recently within the NHS there has been a shift from being organised around independent medical practitioners to an NHS that is now organised around systems and teams. The benefits for the organisation, practitioners and patients is improved patient safety, sustainability of services, reduced professional isolation and assurance in relation to standards of care and clinical governance. 75% of the questionnaire respondents reported that they worked as part of a specialist nursing team, and as discussed earlier there remain a number of singlehanded practitioners. In studies within nursing and looking at other professions in relation to generic and specialist roles there is evidence that the most frequent activities are generic in nature (Lloyd et al, 2004). In examining the practice of various specialist nurse groups, it should be possible to define the generic role and ensure what is distinct and special for each specialist nurse group is maintained. As a result single handed practitioners could be aligned to teams within specialist areas. In addition the research suggests opportunities for skill mix, education and training and recruitment of specialist nurses with generic skills. RECOMMENDATION 24 Align single-handed specialist nurses with other teams by identifying generic or shared skills. The majority of specialist nurses (70.5%) described their key working relationships being with both their nursing team and the multi-professional team. This reinforces the need to consider all contributors to patient care when looking at job planning, setting personal and team objectives, and undertaking service reviews and development. A number of questionnaire respondents identified their most significant relationships as being with their extended teams including primary care teams and interagency partners. Specialist nurses often practice autonomously, their roles are complex in nature and they are recognised as senior clinical leaders in the organisation. Clinical supervision was highlighted throughout the focus groups as being essential or helpful in the development and support of practitioners to ensure they maintain standards of safe and effective care. The questionnaire findings suggest that 64% of the specialist nurses participating had access to clinical supervision with fewer (43%) providing clinical supervision for others. The NHS Tayside Clinical Supervision Framework (2010) provides guidance for registered nurses in relation to clinical supervision. This includes participating in supervision themselves as the supervisee and providing the role of supervisor for other staff members. Recommendation 25 Specialist Nurses and Advanced Practitioners engage in, and participate in providing clinical supervision. 6.9 Leading at the Point of Care Specialist nurses are senior members of clinical teams (Band 6 and above). However the role they play in supporting clinical leadership at the point of care, within the nursing profession, is variable. The need for leadership training was identified throughout the focus groups and identified as an educational requirement by 21% of 24