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Examining the effectiveness of the nurse consultant role

VOL: 102, ISSUE: 04, PAGE NO: 23

Sally Redfern, Phd, BSc is professor emeritus of nursing, Nursing Research Unit, King's College London

The role of nurse consultant, introduced by the Department of Health in 2000 amid some scepticism from the nursing as well as the medical profession, aims to improve the quality of nursing services, strengthen leadership and help retain experienced and expert nurses in clinical practice.

The role of nurse consultant, introduced by the Department of Health in 2000 amid some scepticism from the nursing as well as the medical profession, aims to improve the quality of nursing services, strengthen leadership and help retain experienced and expert nurses in clinical practice.

Posts were set up in nursing, midwifery and health visiting across the country and in all fields of acute care, community care and primary care. Expectations were that the job would be senior to and more strategic than clinical nurse specialist and nurse practitioner posts and would provide a top clinical role to which experienced nurses could aspire in much the same way as medical consultants do in their profession. Nurse consultants were not expected to be service managers. Rather, the role would include a substantial expert practice component - 50 per cent was recommended - as well as incorporating leadership, education and evaluation of service developments.

In 2002 the research group at King's College London was commissioned by the Department of Health to explore the impact of nurse and midwife consultants on performance and practice (Guest et al, 2004). This article draws from that study in describing what we have learnt about the influence nurse consultants are making on the quality of services for patients.

During the study we spoke to trust managers who sponsored the role. We held focus groups with experienced nurse and midwife consultants and conducted monthly telephone interviews over six months with a group of 32 consultants. We also asked all the consultants who were working in England to complete a questionnaire on their experiences in the role (79 per cent, 419 out of 528, returned the questionnaire).

The consultants worked in different areas including mental health, learning disabilities, community and primary care, midwifery, specialties based within a clinical area (such as critical care, A&E and intermediate care) and specialties specific to a health condition (such as diabetes and cancer). Consultants had been in the job for two years on average, ranging from a couple of months to about three years.

Findings
Over half (55 per cent) of the consultants said that they were making some positive impact overall on service provision for patients and another 44 per cent reported making a major impact. Not surprisingly, consultants who had been in the job for longest were making the most impact: 71 per cent of those who had been in post for two years or more considered their impact to be major.

Most of the consultants (between 86 per cent and 95 per cent in the areas stated) said that they were making a positive impact on improving services (Table 1, p24).

One consultant, for example, explained how she supported nurses who wanted to challenge decisions of doctors: 'It's fairly hard sometimes for nurses to say 'We're not doing that' so I say 'I'll be responsible for what nurses do'.'

The team was given examples of cost savings that had been made without compromising quality of care. For example, a nurse consultant who had introduced a nurse-led bed service in a care unit for older people reported a saving of some £134,000 when 24 per cent of patients destined for a care home could be discharged home because their level of independence had been improved beyond original expectations.

Many consultants reported making a major impact on the number of guidelines and protocols within their service. For example, one said: 'We set up the non-invasive ventilation (NIV) service. I pulled together a protocol for the trust for the use of NIV and then we provided the training.'

Consultants told us how information and support provided patients with a greater ability to decide how they were treated. Consultant midwives, for example, spoke of being able to give women more options about place of birth and interventions during and after delivery. One explained: 'One of the women who chose to breastfeed did so against all the odds - against all the family's wishes.'

The consultants were less confident about having achieved a direct impact on patient care and health outcomes - improving services was a necessary first step, they said. Even so, between 62 per cent and 92 per cent of the consultants said that they had improved patient care in the following areas:

- Standards of care received by patients have improved;

- Patients receive better follow-up care;

- Patients now have better access to the services they require;

- Procedures for discharging patients are more streamlined.

Further analysis revealed that the nurse consultants most likely to make a strong impact on services and patient care are:

- Those engaged in many activities;

- Those who regard themselves as competent;

- Those who feel well supported by medical staff;

- Those who have been in the job the longest.

Interestingly, fewer nurse consultants in mental health were confident about having made a major impact compared with other groups. Perhaps mental health consultant nurses are more cautious about claiming an impact without more evidence or their roles may be more complex and so more difficult to evaluate than those of others.

Our findings, not surprisingly, show that nurse consultants who are established in their role consider that they are improving patient care and that those newer in post may see their impact increase over time. NHS trust managers who sponsored the consultant role were more outspoken about the positive impact consultants were making than the consultants themselves, although both groups acknowledged the difficulty of evaluating a complex role before consultants have had time to settle into it and implement change.

Sponsors gave the following examples of achievements made since consultants had been appointed:

- Shorter waiting times for patients with minor injuries in A&E departments;

- Decreased morbidity and mortality from outpatient emergencies;

- Reduction in admission and readmission rates to acute wards;

- Improved crisis intervention, outreach and intermediate care services;

- Reduction in medical obstetric interventions.

Even though the role of consultant nurse or midwife is still new, it seems reasonable to conclude that many consultants are already making a difference to the quality of services and patient care or, if they have not yet done so, they soon will.

Good support from medical consultants and managers is important in making a difference. Lack of support was reported as a major hindrance to service innovation.

Conclusion
This study was carried out relatively early on in the life of the nurse consultant. These new consultants and their sponsors are, by and large, confident that they are making a difference but further evaluation is needed when more have been in the job for longer than two years. Views of other stakeholders need to be taken into account.

Now that the role is more established, it is important also to evaluate its impact on direct outcomes for patients in ways that include more than the judgements of consultants themselves and their role sponsors.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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