The challenge of advancing nursing roles Nurse Clinics Conference 2015, London Julie Napolitano Nurse Consultant Independent Prescriber Judith Graham Advanced Nurse Consultant Psychotherapy Consultant Queen s Nurse Twitter: @Jude_Graham_
Objective: A practice development project was undertaken to produce a framework that enables a clear definition between the clinical roles and responsibilities of different levels of nurses within one organisation. This delineation went beyond focusing upon job descriptions, but was particularly targeted upon stratifying advanced nursing skills, for example: independent prescribing, physical health assessment, specialist diagnostic assessment, and the nurse s role concerning the application of the Mental Health Act.
Step 1: Transition from Medical to Medical and Nurse Led Clinics Investment from Board Level. Training: Independent Prescribing and specific assessments. Analysis of patient needs. Transition of all patients from a medical outpatients. Cultural sensitivity and a slow pace of change was required. Maslow s Hierarchy of Needs model. New Ways of Working Consultant Psychiatrists Nurse Consultant AfC Band 6 Clinic Nurses Number
Process Issues Patient Perception versus Patient Experience Nurse/Doctor Relationships Increased Policy expectation with decreased budget Cultural bias: When you get your Doctorate, you will be fine people will forget you are a Nurse
Step 2: Delineation of nursing roles Problems with collective identity. Accountability and levels of responsibility concerning patient complexity rather than task. Diagnostic challenges. Supervision challenges, specifically with higher grade nurses. Promotion of the service and different roles (i.e. to referrers such as GPs) to increase service confidence. Policy and procedure change
Spectrum of Roles: example Band 6 Typical role: clinic nurse, nurse practitioner, ward sister, or senior community nurse. Typical Training: will have completed the Independent Prescribing course. May have completed additional training in medicines management (i.e.: autonomous practitioner qualification, medication management module). Level of prescribing practice: Independent or Supplementary Prescriber for a defined caseload. This caseload will be specific in focus (i.e.: a defined Care Cluster range, or focused intervention). Typical caseload: caseloads may vary in age, level of need, and complexity. Patient diagnosis will already have been decided/defined prior to being seen by this level of prescriber. This means that this prescriber is providing treatment within a specific range for a predefined condition. More complex prescribing should be referred to a senior prescriber (nursing or medical). Other roles: this clinician would typically provide mentorship for student nurses and trainee prescribers.
Why is this important? For Patients For other nurses For supervisors For medical staff For referrers
Step 3: Commitment to enhanced Nurse-Led Clinics In a medically dominated culture, confidence, joint working, and gradual progression is required. Sensitivity is required in terms of powershifts. Awareness of medico-legal issues and the link with local and national policy. Focus upon other areas where clinics may be useful (i.e. for specific diagnosis, specific treatments, and where there are particular waiting list challenges)
Step 4: Specialist Clinics Initial key areas identified and developed: Lithium Clinic Clozapine Clinic Autism Assessment Clinic ADHD Assessment and Treatment Clinic Bipolar Affective Disorder Clinic
Step 5: Evaluation of new NLC Patient Feedback Difficulties being accepted for training Challenging traditional roles Challenging expectations of nurses The challenge of maintaining the core values of what it is to be a NURSE, whilst encompassing roles that were previously the domain of different disciplines (i.e. Psychiatrist, Psychologist)
Results Successful: resulting in almost complete eradication of traditional Consultant Psychiatrist-led out-patient clinics. Replaced by nurse-led clinics, providing holistic assessment, physical health monitoring, Independent Prescribing, and medication management. Patient feedback is predominantly positive, specifically regarding improved service response time and increased appointment duration, resulting in patients stating that they felt more listened to, and able to process to recovery quicker. Culture Shift and competing roles: the Advanced Nurse role is not necessarily to replace traditional medical roles, but rather to enhance team provision. MDT is now led by the most appropriate professional, which may be a Psychiatrist or an Advanced Nurse, often in equal numbers. The role delineation framework has aided nurses and their supervisors. The framework helps clarify roles and responsibilities, and provides clear career development framework.
Conclusions: o Nursing s collective identity provides both support and challenges, when developing nurse-led services in specialist mental health care. o Nursing roles are advancing rapidly, a challenge for senior nurses within NHS organisations is to ensure that roles are:- well-defined, supported by policy /procedure, and that nurses are educated and supervised to maintain their specialist competency level. o Within our organisation, we introduced Advanced Nurses, Nurse Consultants, and Nurse Specialists, and have redefined care provision to enhance patient care and meet targets introduced as a part of NHS austerity measures focussed upon sustainability. This presentation summarises the achievements, challenges, and future direction of this diverse and increasingly specialised nursing workforce.
Twitter: @Jude_Graham_ Email: judith.graham@rdash.nhs.uk LinkedIn: uk.linkedin.com/in/judithgraham1 Thank you for listening, are there any Questions?
References: Department of Health (2013). Payment by Results: 2013-14 Mental Health Guidance. HMSO, London. Department of Health (2010). Advanced Level Nursing: A Position Statement. HMSO, London. Department of Health (2007) Mental health: New Ways of Working for Everyone, HMSO, London. NHS England (2015). Valuing mental health equally with physical health or Parity of Esteem. [Online] Available at: http://www.england.nhs.uk/mentalhealth/parity/ NHS England (2014). Five Year Forward View. London: NHS England. Royal College of Nursing (2014) NHS Agenda for Change pay scales England 2014/2015. RCN, London.