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Transforming nursing roles

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As key figures in government and nursing discuss plans to modernise the profession’s careers, Louise Tweddell finds that frontline staff are already transforming roles

It could be another year before there is a definitive plan for how nursing careers will be shaped in the future.

Yet while key government figures work with nurse directors, unions and universities to draw together the details of the NHS Next Stage Review and Modernising Nursing Careers into a robust framework for the profession’s future, those on the frontline of nursing are already implementing radical change and transforming roles.

Suzie Loader, director of nursing at Berkshire’s Heatherwood and Wexham Park Hospitals NHS Foundation Trust, is such an example. After a comprehensive review of the modern matron and ward manager roles at the trust’s two hospitals, Ms Loader and her team have introduced a new position – that of ward matron.

In 2007, while the government was pledging its commitment to increase modern matron posts across all NHS trusts in England, Ms Loader and Wexham’s corporate nursing team realised that the role was not totally compatible with the aims and needs of their trust.

‘I did not just want to stick with the [modern] matron role, I wanted to give it real gravitas,’ says Ms Loader.

The Wexham review highlighted a need to clarify the qualifications, expertise and skills required for the role of matron. It also called for a reappraisal of the role of ward manager and the nursing structure across all of the hospital’s directorates.

In conclusion, two major changes were proposed, which would see a level of management removed.

First, Wexham’s current matrons – responsible for four wards each and overseeing quality of care in a managerial capacity – would be replaced by lead nurses responsible for actual pathways of care. These nurses would work in a supportive rather than a managerial capacity, promoting practice development on their wards.

Second, the ward manager role on each ward would be replaced by that of a ward matron – a more autonomous, supervisory and managerial post, which would be supernumerary and highly visible, thanks to a new uniform.

The trust accepted the proposals, held a consultation on their implementation and provided £500,000 to put the changes into practice. This funding will enable each ward to employ an extra member of staff to maintain grassroots staffing capacity and allow the ward matron to remain in a supervisory capacity.

By changing roles and management structures Ms Loader hopes the new framework will have a positive impact on the trust’s 33 wards.

‘We have developed our own framework and decided to crack on with it rather than wait for things to get ahead of us nationally – we want to be ahead of the game,’ says Ms Loader.

‘It is important to say, it is not going against the government’s positions, it is just how we have taken things up locally,’ she adds.

Ms Loader emphasises that this has not been a rebadging exercise. She and her team have put huge effort into making sure the new ward matrons have the skills and knowledge the team identified as being essential for the role.

Those wishing to move from ward manager to ward matron have faced a rigorous interview and assessment process. They have also been assigned development supervisors.

‘I wanted to make sure that if we did this, we did it properly and made sure that people could do what we were asking of them. I know that the support we are offering will help them meet those needs,’ Ms Loader says.

She believe that the new framework will benefit both patients and nurses alike.

‘This is about making sure our nurses are used to their full potential, making sure they are trained to the highest standard and helping them get the most from their career,’ she says.

‘But equally this is about ensuring that any patient who comes to one of our wards receives the best possible level of care we can offer them,’ she adds.

Case Study: 'The role is tailored to meet the needs of our patients'

It is not just nurses who are having a direct impact on developing nursing roles and career options, as a new nursing role currently advertised with South Central Ambulance Service NHS Trust proves.

In 2003 paramedics came under the regulation of the Health Professionals Council, which resulted in an extended training and registration process.

Mark Ainsworth, South Central’s head of operations, says: ‘There is now a gap in the system. We have got to the point where we do not have enough qualified paramedics because of the registration and education changes.

‘We have 30 clinical vacancies – we are struggling at the moment and we need to have these people in place.

‘We need paramedics out there on the road now, so we are looking at other ways of recruiting staff into the system,’ he adds.

The answer to this shortfall has been development of a new role – that of ambulance nurse. This will see nurses working alongside paramedics to deliver emergency care to the catchment area’s four million residents.

In response to emergency calls, nurses taking on this role will deliver diagnostic procedures and treatments according to their competencies and will even be authorised to drive ambulances.

The role is advertised as band 5, which according to Mr Ainsworth is the banding of current paramedics. Ambulance nurses will stay on the NMC register and will be required to undertake eight weeks’ in-house training, an eight weeks’ paramedic course, and a four week driving course.

‘This is really a post for band 5 A&E nurses who are used to dealing with rough and ready side of life,’ explains Mr Ainsworth.

‘The other thing we could look at is to train them as emergency nurse practitioners, which are band 6,’ he adds.

The paramedics are looking forward to the introduction of this new nursing role, according to Mr Ainsworth.

‘They will bring new skills and they already have good working relationships,’ he says.

‘We have done this to help our service but because of developments within nursing it means they are more than capable of helping us,’ he adds.

Matt Griffiths, clinical nurse manager, works as a volunteer nurse for the East Midlands Ambulance Service NHS Trust and says he would be interested in taking up a full-time paid position, similar to the one being advertised at South Central.

‘Nurses a capable of a lot more today than ever before,’ he says. ‘Interprofessional boundaries are being blurred.’

However, Mr Griffiths has reservations about the new post’s banding. ‘They need to look at what they are asking people to do, really they could be using nurse consultants and nurse practitioners but they will have to pay the right money for them – band 8,’ he says.

At Newham University Hospital NHS Trust in east London they are taking advantage of nurses’ extended skills to enhance their A&E department.

The trust has employed three nurses as majors nurse practitioners – a new role that has been created in conjunction with City University London, which has launched a course to train nurses for the position.

The role spans the gap between emergency nurse practitioners and nurse consultants, according to Andrew Fraser, Newham A&E Nurse Consultant, who has helped pioneer the post.

These nurses can carry out assessments and deliver treatment packages to patients who present in A&E with the symptoms of a condition that meets the nurse practitioner criteria of practice such as chest pain, asthma or COPD.

‘I’ve been trying to get it [the role] off the ground for four or five years now and it will allow nurses already treating minors to move up. It is the kind of job I was looking for when I was thinking about becoming a nurse consultant,’ Mr Fraser explains.

‘We have designed a master’s level programme with City University – it is an MSC in professional practice in emergency care and will take two to three years to complete, depending on whether you do it full or part time,’ he adds.

Case Study: 'It was time to break out and do things differently'

So how has the role benefited patients?

‘In the same way that the emergency nurse practitioners have been good for minors patients in that there is a continuum of care and there is a depth of experience you do not always see with a senior house officer any more,’ Mr Fraser says.

‘The SHOs move on after six months and we may end up with a nurse who has been working in A&E for 15 years.

‘There is the element of continuity, from triage through to discharge and explanation of medication and sometimes you do not get that in A&E as there is a dislocation between nurses and doctors.

‘There is potential within the role to develop into a nurse consultant,’ he adds.

Brian Boag, principal lecturer in pre-registration nursing and midwifery at the University of Cumbria, has recently completed a study into how A&E services in the US compare with those in the UK.

The majors practitioner role in Newham is similar to how A&E nurses in the US are already practising.

‘Nurses are more than capable of working autonomously in the UK and more needs to be done to encourage this,’ says Mr Borg.

‘The role at Newham, from my experience, is pretty new from a national perspective, it is a really interesting and impressive
way forward and it shows that nurses are willing to take the lead, it shows nurses continue to develop.

But innovation is certainly not confined to the acute sector.

Rosemary Cook, Queen’s Nursing Institute director, agrees there could be a surge in the number of nurses leaving the NHS to run their own services, and that the government’s promise of extra funding and support is a leap in the right direction.

‘We are going to see a lot more nurses stepping outside the traditional roles and away from the cover of the NHS to set up their own businesses,’ she says.

However, she warns: ‘We are still missing a trick that we do not train people to be managers and entrepreneurs along the way – some are natural and some are not and we would want to prepare nurses to be better at that.’

Ms Cook believes that there should be different opportunities for people.

‘Those who are very entrepreneurial and questioning will look for new things to do within their organisation and some people who will step outside their organisation.

‘But we are in danger here of creating boxes that not everyone can fit into. We have to encourage a way of thinking so
that the support does not just go to those who are setting up their own business,’
she says.

‘It needs to be about changing mindsets and making sure that everyone is thinking about whether there is value for money, whether services could change and how that change could happen.’

What is clear is that nurses and nursing teams are not waiting for specific direction from government but are developing new roles and new structures to help improve service delivery for patients.

The Department of Health wants such innovation to thrive – it does not expect to be driving all change centrally – that would be impossible and counterproductive as it would fail to take into account local requirements and conditions.

Therefore, it is up to those on the frontline who recognise the specific needs of their staff group, their patients and services users and their organisations to come up with specific solutions.

It is a challenge to which nurses are already rising.

Seven key skills you will need to be an ambulance nurse

  • Applicants must be physically fit as they will be required to safely transfer patients, to and from vehicles, using manual handling techniques

  • Successful applicants will receive training in driving ambulances but they must have two years' motoring experience and no more than three points on their licence

  • Nurses taking up the post will be expected to work with minimal supervision as the role will require an ability to work flexibly in double manned ambulances with other ambulance staff or to work alonein a solo responder car

  • An in-depth knowledge of the local geographical area covered by the individual trust’s ambulance service is essential

  • An understanding of the national response time standards that have been set for the ambulance service is also important

  • As paramedics can be vulnerable to physical attack, it is important that ambulance nurses have the ability to recognise the warning signs of potential violent situations and are be able to use de-escalation techniques to minimise risks and harm to both patients and colleagues

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