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Rheumatology 2001; 40: 1325-1327
© 2001 British Society for Rheumatology
Editorials |
Consultant nurses in rheumatology: releasing the potential!
Staffordshire Rheumatology Centre, The Haywood, High Lane, Burslem, Stoke on Trent, Staffordshire ST6 7AG, UK
Nursing has entered a new dawn with the creation of nurse consultant posts across the UK [1]. The introduction of these pioneering posts, supported in principle by the Department of Health, reflects the considerable role developments that have occurred in nursing over the last decade, such as the increasing number of nurse specialists, the introduction of nurse prescribers, and the various nursing initiatives throughout the country, for example the nurse-led rheumatology unit at St Helens, which was awarded the NT/3 M National Nursing Award in 1998.
Traditionally, nursing has lacked a progressive clinical career structure. The creation of nurse consultant posts has provided the opportunity to define and expand the career pathway whilst maintaining experienced practitioners in clinical care. Prior to the introduction of this new role, the pinnacle of clinical progression was obtained at specialist/practitioner level. Nurses who had achieved this position then had to consider entering education or management if they sought career advancement, as further clinical opportunities did not exist. Consequently, an essential resource in terms of clinical knowledge and skills was lost to junior nurses and ultimately the patient. This was the experience of a colleague of mine, now a nurse consultant in continence care, who found herself at a crossroads in her nursing career after being a clinical nurse specialist for 15 yr but whose options for clinical progression were limited. She believes that the nurse consultant post has provided her with the opportunity to utilize her clinical skills effectively whilst addressing the educational and research requirements of people with continence needs. This links with the Department's objective of providing new career opportunities whilst retaining experienced nurses across a variety of settings [2].
Four hundred and fifty-one consultant nurse posts have been approved, with a government target of 1000 by 2004 [3]. A notable feature of these new posts is the diverse areas that they cover. There are posts centred on service developments, including intermediate care; posts addressing the needs of specific patient groups, for example mental health; and posts that have a specific focus, for example continence needs. Unlike the existing clinical nurse specialist posts (a previous role development), nurse consultant posts have defined criteria regarding role function. These include:
- expert practice;
- professional leadership and consultancy;
- education, training and development;
- practice and service, research and evaluation.
- professional leadership and consultancy;
These criteria provide a clear framework with which to structure role development. The only component that has a specific proportion of time allocated to it is that of expert practice, where it is specified that 50% of the role must involve direct clinical care. The distribution of time spent on the other components will be determined by the needs of the local population. Having a clear vision will serve to limit the role confusion that has arisen from the development of clinical nurse specialist posts, for which there are still no defined criteria regarding role components.
A key objective inherent in the creation of nurse consultant posts is to strengthen nursing leadership. Leadership is essential in any profession to provide a cohesive, motivated and supported workforce. Nursing has traditionally lacked effective clinical leadership, partly because of the lack of educational opportunities for nurses to develop leadership skills and an organizational structure that has not encouraged autonomous practice. Nursing needs visible, effective leaders in the clinical arena. The requirement that all nurse consultants must spend 50% of their time in direct clinical care will be a distinct advantage, as colleagues will be able to work alongside the nurse consultant and learn from their knowledge and skills. This leadership function will address local needs as well as embracing other disciplines and the wider organization, in order to help deliver better services and ultimately to improve patient outcomes.
Current health policy [1, 3] is committed to providing effective clinical leadership, and ward sisters and charge nurses have access to leadership development programmes. Once these individuals return from such programmes, they will require ongoing supervision and support. The nurse consultant is ideally positioned to contribute to this process and to ensure the ongoing development of leadership skills among the workforce. Leadership is required not only for ward leaders but for all strata of nursing. The nurse consultant can be influential in contributing to this process by ensuring that there are opportunities for professional advancement at all levels within the profession.
The clear emphasis on clinical care in the consultant nurse role is important, as it conveys to the rest of the profession and the wider community that providing effective care for patients is at the heart of all nursing practice.
So what will these posts add to nursing and rheumatology? The answer to this will be dependent on the requirements of the local population. One area where the nurse consultant can make a difference in many localities is in the development of a coordinated care pathway for the management of chronic musculoskeletal pain. The Clinical Standards Advisory Group report for 2000 [4] concludes that the management of chronic pain is uncoordinated, lacking a cohesive strategy to addresses symptom management; health professionals are working in isolation, which results in patients experiencing long waits to have their situation reviewed. The nurse consultant can play a major role in collaborating with all key stakeholders, including primary care trusts, the secondary care sector, the voluntary sector and patient groups, to develop a coordinated strategy for the management of chronic pain. By creating a rapid access system, the nurse consultant can minimize the patient's psychological distress and maintain physical function. Interprofessional and multiprofessional partnerships would be required to provide appropriate care packages, the nurse consultant being responsible for the coordination and evaluation of care initiatives. Such a strategy would require education of all key personnel and the establishment of rheumatology link nurses in all care settings, so that difficulties with symptom management can be identified early, thus preventing illness behaviour affecting function.
Professional advancement needs to be supported by an educational framework. The Arthritis and Rheumatism Campaign Allied Health Professional Working Party has revealed limitations in educational opportunities for nurses working in extended roles. At the Staffordshire Rheumatology Centre we run an MSc in clinical rheumatology nursing in collaboration with Keele University. This provides an educational framework for nurses engaged in extended roles. However, it only addresses the tip of the iceberg. A range of educational opportunities is required for nurses practising at all levels to ensure that there are individuals in the future who can lead and develop rheumatology nursing. Already many areas are experiencing difficulties recruiting experienced rheumatology nurses with the necessary knowledge and skills. The nurse consultant can take a leading role here, in collaboration with universities, to provide innovative interprofessional and multidisciplinary educational opportunities utilizing the revolution in information technology.
Despite collaborative care being adopted in clinical practice, it has yet to be endorsed comprehensively in nursing research. One reason for this is that the research agenda in nursing has been stunted by reliance on communication and knowledge that is accessible only to members within the discipline. The nurse consultant needs to foster research communication between other professionals and be immersed in environments where ideas and knowledge generation come from a wider collaboration of interested parties. This should ensure that the research undertaken will have relevance to the speciality. This role will also provide the opportunity to develop confidence, knowledge and research skills among junior nurses. Research should be the vehicle that drives and dictates practice.
It is easy to view the development of nurse consultant posts through rose-tinted glasses, but it is important to address potential obstacles to the success of these posts. One thorny issue is that of funding because, despite the creation of these posts, there is no specific funding for them. This has led to many positions being filled by the existing nurse specialist/practitioner in the respective area with no money for the appointment of a new clinical nurse specialist. Consequently, the nurse consultant is left juggling two roles whilst trying to deliver new initiatives.
The creation of nurse consultant posts should not be at the expense of other senior clinical nursing posts, but unless these posts are funded it is difficult to see how the problem can be addressed. The holders of these new posts must also be given remuneration commensurate with their role. If incumbents are offered the lower range of the designated pay spine the posts will be devalued, which will limit their appeal to potential applicants.
Early evaluation of the first 451 posts highlighted the lack of support many nurse consultants had encountered [5]. David Moore, the assistant chief nursing officer for England, in reviewing the evaluation findings, stated that some nurse consultants were expected to perform their role ‘on a wing and a prayer’. Organizational support and commitment to the implementation of nurse consultant posts is essential if the nurse consultants are to have the necessary authority to make changes and develop the service. Regular meetings with the appropriate individuals in the organization are paramount in discussing how objectives are being met. A local mentor will also be required to provide supervision and support.
I have purposely left one of the most contentious issues to this stage so as to not distract from the more important agenda of the opportunities that the creation of this new role brings to nursing. But I would be naive not to address it now: it is the use of the ward consultant. During the rheumatologist and nursing workshops hosted by the Arthritis Research Campaign Allied Health Professional Working Party on extended roles, it was clear that both groups had reservations about the title of the role, interpreting the use of the term ‘consultant’ as implying that these posts have a medical remit. This is not the case. This is a nursing initiative designed to lead and develop clinical nursing practice. It has been reassuring that any bids focusing on a managerial or medical remit have been rejected by the Department of Health. The use of the word ‘consultant’ is intended to reflect the position of the incumbent in the career pathway. It will require nurse consultants to explain their remit to their colleagues and the public alike to prevent confusion and to ensure that clarity regarding the purpose of these roles is achieved.
There is a need for ongoing evaluation of these new roles, as they are developmental and there are many questions to address regarding the support required for the incumbents to function at this level and the outcome of this new initiative in the four key areas of practice, leadership, education and support
The rheumatology community needs to support this development. This is an initiative that values and develops nursing and provides an extension to the clinical career structure, which must be in the interests of nursing. Already I have encountered situations in which nursing colleagues have been negative in their appraisal rather than recognizing the opportunity this offers not just to a few but to the whole of the profession. Advancing the role of nurses in clinical care, leadership, education and research will lead to benefit for all, but the whole profession needs to unite behind this initiative for it to succeed: apathy and hostility will serve the interests of nobody. Nursing remains an untapped resource in many respects and this is an opportunity to release its potential. Let us take that opportunity!
References
- Department of Health 1999. Making a difference: Strengthening the nursing, midwifery and health visiting contribution to health and health care. London: Department of Health.
- Department of Health 1999. Nurses, midwives and health visitor consultants: establishing posts and making appointments. Health Service Circular1999/217. London: Department of Health.
- Department of Health 2000. The NHS plan: A plan for investment, a plan for reform. London: Department of Health.
- Clinical Standards Advisory Group 2000. Services for patients with pain. London: Department of Health.
- Alderman C, Lipley N 2001. Consultant nurses: set for success. Nurs Stand 15:17–22.
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