Nurse-led clinics: 10 essential steps to setting up a service

There has been a huge growth in nurse-led clinics

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This article outlines 10 key steps for practitioners to consider when setting up and running a nurse-led clinic. It lays emphasis on careful planning, professional development and the need to audit and evaluate the service to ensure the clinic is measurably effective.

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Author
Richard Hatchett, PhD, MSc, BA, Cert Health Promotion, RNT, RN, is principal lecturer, adult nursing, faculty of health and social care, London South Bank University, and author and co-editor of Nurse-led Clinics: Practice Issues.

Abstract
Hatchett, R. (2008) Nurse-led clinics: 10 essential steps to setting up a service. Nursing Times; 104: 4, 62–64.

There has been a huge growth in nurse-led clinics, improving the patient experience and offering opportunities for role development to nurses. The clinics vary greatly in the way they are set up, both within and between specialties but there are common characteristics. In most cases, nurses have their own caseload and patients consult them in specified time slots. The nurses have a high level of autonomy, with the ability to make often detailed care decisions, admit and discharge from the clinic and refer to other colleagues.

Many clinics demonstrate elements of advanced practice with detailed physiological assessment, subsequent care planning, delivery of treatments, monitoring of the patient's condition and management of medicines (Hatchett, 2003). A variety
of methods are available for medicines management, such as the use of patient group directions (PGDs) and independent
or supplementary nurse prescribing.

The literature supporting the role of the nurse-led clinic is growing and demonstrates the variety of issues that nurses encounter in setting up and maintaining a service through this method of delivery. This experience forms the development of 10 key steps outlined here, which aim to enhance the nurse's ability to run a measurably effective service.

The ten steps

Step 1: the business case
In the planning stage, you need to make a business case to present to your employing or funding organisation explaining why the service is needed.

The business case does not refer just to the financial aspect of the service, such as the rationale for using resources but also focuses on what the service can provide. This explains what the service can offer to the organisation and the people needed
to run it, and offers a clear overview to all those who may be affected by the project.

For those who have little experience of preparing a business case, the process can be daunting. Using a mentor for support
can help to guide you through the process. To find a suitable person, approach staff experienced in this area within your employing trust or healthcare environment or approach your local university. A number of publications detail ideas and principles for building a business case (Cannon, 2005).

Step 2: aims and objectives
You need to be clear about the aims of the clinic and its associated objectives. This will help clarify what is being offered to patients and other healthcare professionals who may refer into the service. This process is valuable for subsequent publicity.
A clear approach at this stage will also help to demonstrate what needs to be audited and evaluated in the future. It also helps
to clarify which patients are appropriate to access the service and which are not. This helps to avoid wasting the time of referrers, patients and those running the clinic.

Step 3: patient criteria
Establish the criteria patients need to meet in order to access the nurse-led clinic.

The criteria may be quite broad. For example, a walk-in or drop-in service may offer a variety of services. They may also
be quite narrow – for example some clinics investigate a specific symptom and others monitor and treat a particular condition.

Some nurse-led clinics provide leaflets to explain to patients what services they provide. Explicit criteria may come under
the objectives of the service and need to be relayed to all those using the service, both patients and other healthcare staff.

Step 4: publicity
The clinic will not succeed if patients and referrers do not know of its existence and what service it offers.

Publicity should begin during the planning stage as it may prompt discussion that leads to adjustment of the proposed service. These changes may improve the service for patients and those who refer in. Posters, leaflets, web information, group discussions and visits to those who may use it can all highlight what the service is about and when it starts, as well as explaining when and how it can be accessed.

Patient information about the clinic should be posted on the trust or healthcare provider's website, and information about what to expect can be sent out with appointment letters.

Step 5: location
Decide where the clinic will be run.Questions to consider include: Will it be near to your usual work location or some distance away in the community? Does this raise travel issues for you? Do you have computer access and the necessary facilities to carry out your work effectively in the chosen location? Is there likely to be opposition or problems with using the facilities that you need?

One of the most important issues to consider here is that of administrative support. This should be regarded as a make-or-break issue to running the service as it often causes significant difficulty for nurses setting up a service. Find out whether there is support for typing letters and booking appointments. Nurses need to focus on their specific skills and not be in the office late at night typing letters to patients and to GPs.

Click here for a case study of an angina nurse led clinic

Step 6: multidisciplinary support
Although the term 'nurse-led' implies a strong degree of independence, the clinic is of course part of the patient's broader healthcare pathway.

A clinic that other healthcare professionals oppose or to which they will not refer patients is doomed to failure. In addition, the sharing of knowledge and experience is a part of all nurses' professional development.

Prior to starting the clinic you will need to talk to key healthcare professionals who may refer into the service, who may take your referrals and who may suggest who can offer education, advice and support. Consider what they may suggest in terms of adjustments or adaptation or if they do not feel the service is warranted at this stage. The business case is invaluable here in making a clear argument regarding the need and viability of the service.

Step 7: professional development
This is one of the most important elements of a nurse-led clinic as it underpins a competent service. It is important to put structures in place that enhance your ability to see deficits in your knowledge base and the ability to rectify these.

One of the main problems with an emphasis on personal reflection on education deficits, within documents such as the Scope of Professional Practice (UKCC, 1992), is that we don't always know what we don't know, which may be termed 'unconscious incompetence'.

Professional development places the emphasis on a continual process, and maintaining a personal education portfolio or file can help focus nurses and managers on where training and education is needed, based on job description and service needs (Hatchett, 2003).

Reviewing cases through clinical supervision offers a formal process through which deficits can be noted and education implemented, much more so if it is tied closely to the education portfolio.

Development does not need to be only through classroom teaching, although this has clear advantages, but considering how competence can be assessed and measured is an important point in closing the gap in personal practice deficits. Building strong links with the local university's faculty of health care can be helpful in enabling you to discuss education needs and gain advice.

Step 8: managing medicines
While this is not an element of all clinics, where medicines are a part of the nurse-led service, it can lead to a hiatus in the smooth delivery of care if it is not managed effectively.

There are various methods of managing medicines, from supplying them through patient group directions (PGDs) to supplementary and independent prescribing. It is an area that nurses need to reflect upon, as undertaking a consultation then handing a pre-printed prescription for signing to a professional who has not seen the patient is not an ideal situation.

Nurses have been successfully educated in prescribing skills and offer an invaluable service as part of their holistic care.
Consider what aspect of managing medicines would best suit the service, and indeed the nurses themselves, and
how significant advances can be made in this area.

Importantly, if nurse prescribing is the route taken, consider how you will maintain professional development in this area (Bramley, 2006).

Click here for a case study of community pain nurse led clinic

Step 9: audit and evaluation
Ongoing audit and evaluation is key to meeting patient needs and ensuring that what is offered does make a difference to service users.

There may be areas you are obliged to audit and evaluate but this needs to be considered as part of the planning stage. It will help focus the aims and objectives of the service and allow a consideration of how measurement will be undertaken.

It is important to understand the difference between the two terms – evaluation focuses more on the merit and worth of what is provided, which the audit will make explicit. Are you making a measurably effective difference?

Authors such as Pennery (2003) offer useful advice on the various elements which capture the measured effectiveness of a nurse-led clinic.

Step 10: closing the loop
This final step refers to the need to remember that the clinic is an evolving service. Take care to ensure paperwork, such as job descriptions and publicity, have kept pace with any changes in what is being offered.

Keep audit, evaluation and personal development as a clear part of planning, reflecting on where the service will be, perhaps in a year's time. Audit and evaluation is only useful if it is reflected upon within the healthcare team and adjustments made over time as needed.

Case studies provided by NT.

References

Bramley, I., (2006) Continuing professional development: what is it and how do I get it? Nurse Prescribing 4: 3, 117–120.

Cannon, J., (2005) Making the Business Case. London: Chartered Institute of Personnel and Development.

Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. London: DH.

Hatchett, R., (ed) (2003) Nurse-led Clinics: Practice Issues. London: Routledge.

Pennery, E., (2003) Effectiveness and evaluation of the nurse-led clinic. In: Hatchett R (ed) Nurse-led Clinics: Practice Issues. London: Routledge.

UKCC (1992) The Scope of Professional Practice. London: UKCC.