Over the past 10 years a plethora of advanced practitioner roles – clinical nurse specialist, nurse practitioner, nurse consultant – have emerged, along with nurse-led long-term illness clinics. But, notwithstanding the clear benefits to patients and individual practitioners, have these positions had a positive impact on the wider nursing profession?
I would argue not necessarily. On the whole, the development of these roles has been driven by individual practitioners (the so-called tall poppies) or the requirements of specific organisations. Therefore, they have been developed in isolation, outside the wider nursing context.
Many nurse practitioner posts, for example those in endoscopy or theatre, were created as a result of the reduction in junior doctors’ hours. Don’t these posts seem to be rather task-orientated?
In addition, most clinical specialist nurses, with the exception of those in tissue viability, are attached to a medical team – so how exactly does this advance the nursing profession as a whole?
As a result of this haphazard approach to development, nurses in advisory or ‘advanced’ roles often have to prove themselves to the consultants they ‘work’ for, as well as to clinical staff and to patients. This applies on a clinical and professional level. In the case of nursing staff this may take months, whereas if a new medical consultant walked on to the ward, their clinical skills would be taken as read.
If you look further back in history, the inability of nursing to really advance during the past decade should come as little surprise. Even at times when nursing innovations and projects have been well supported and funded – such as between the mid-1980s and mid-1990s – there has been a limit to the amount of progress the profession has been able to make.
During this time, Nursing Development Units (NDUs) – under which nurses came up with comprehensive strategies to develop themselves and their practice – were in full swing. The underlying theory behind NDUs was that if staff and nursing practice developed and improved, so naturally would patient care.
And this proved to be the case. Outcomes included improved communication between nursing and medical staff, better care and cost benefits to services. To capture and share these innovations, the King’s Fund established the now defunct Practice Development Network. The network made these innovations readily available to other nurses, so they could learn from them to improve practice.
At about the same time, the first practice development nurse (PDN) roles emerged. These were created to develop areas such as primary nursing, whereby senior nurses were given responsibility for the assessment, care planning and discharge of a set number of patients, and to set standards in clinical procedures. However, as with today’s advanced roles, variation in job content, accountability and responsibility between organisations meant the concept was hard to define and developments were pertinent only to individual organisations.
As we know, many NDUs ceased to function. A combination of the withdrawal of organisational support and the rigidity of nursing and medical cultures in terms of attitude to change meant that the philosophy was largely unsustainable.
Clearly, while whole unit or whole organisation nursing developments have had an impact on the profession, the developments have been far from perfect. And perhaps the reasons for this are apposite today.
With a lack of uniformity in advanced roles, the lack of guidance from regulatory bodies regarding the minimum educational standards and skills required for such posts, the professional barriers that still exist and the sheer enormity of trying to deliver patient care in the current climate, it is little wonder nursing may have lost its direction.
When you consider that the profession has so much to contribute to patient care, if it didn’t happen in the ‘good old days’ of funding and support, how on earth can it happen today?
Deborah Glover, RGN, is an independent nurse adviser, London