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Champions of advanced nursing practice

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Claire Anderson.

Senior Clinical Site Practitioner, Great Ormond Street Hospital

HISTORY

HISTORY
The national rise of advanced nursing practitioners (ANPs) coincides with the drive to reduce junior doctors' working hours. Many job titles - including that of clinical site practitioner (CSP) at Great Ormond Street Hospital - encompass the ANP role. The six CSPs at the children's hospital have taken on many junior doctor roles, as well as incorporating their own specialist, patient-focused skills. They provide 24-hour on-site senior nursing clinical support for nurses and junior medical staff across the trust. Claire Anderson describes her week

A new role
In August this year the new European Working Time Directive will become law, and junior doctors will work far fewer hours than at present (Burke, 2002). Great Ormond Street Hospital for Children NHS Trust in London has addressed the shortage of junior doctors, especially at night, by creating the new nursing post of clinical site practitioner.

Six nurses were recruited during April 2001. They provide 24-hour cover across the whole of the trust.

The posts, which are funded by the reduced costs of employing senior house officers, represent a chance for nurses to progress their careers and achieve good-quality care for patients.

In general, advanced nursing practitioners across the country - whose jobs have many titles (Duffin, 2003) - are taking on more and more of the responsibilities of junior doctors.

At Great Ormond Street, the CSP role is evolving all the time. Original definitions for what it would involve came from a Delphi survey of many members of the multidisciplinary team at the hospital (Anderson, 2003).

Though the job title is unique to Great Ormond Street, staff from other hospitals across the country, including Glasgow, Leeds and Liverpool, generally in adult services, have shadowed us on several occasions, with a view to adapting aspects of our job to advanced nursing practice roles in their own trusts.

Although the CSPs carry out regular ward rounds, day and night, they are also called on to assess children who are particularly sick, and those who may need alterations in treatment.

Unlike traditional nursing roles, CSPs have the authority to alter treatments and implement protocols. They have a certain amount of autonomy, particularly when working at night. However, they do work very closely with the rest of the night team, including clinicians who are on duty.

Author's contact details
Claire Anderson, Senior Clinical Site Practitioner, Great Ormond Street Hospital NHS Trust, Great Ormond Street, London WC1N 3JH; email: claire.anderson@gosh.nhs.uk

A TYPICAL WEEK FOR A CLINICAL SITE PRACTITIONER
Shifts begin at 7.30am or 7.30pm with a handover, where staff discuss: any child whose clinical condition or diagnosis has worried the team; staffing levels, in the light of how dependent the children are likely to be over the next 24 hours (we should be able to respond to potential major incidents); and site management, which can include security and child protection

SATURDAY: NIGHT SHIFT
Little surgery is scheduled on a Saturday, but this does not guarantee a quiet shift. Following CSP handover, we join the rest of the night team for handover from the medical and surgical day teams. The night team consists of two CSPs, three registrars who cover medical care, and a surgical senior house officer (SHO).

The night team oversees care in all areas outside intensive care. The medical team cross-covers their specialties. The aim is to react and treat the child overnight, guided by a plan from the child's specialist teams. The specialist consultant underpins this and the surgical registrars remain on-call (Cass et al, 2003). If a nurse or doctor is particularly busy we can redistribute their work.

The CSP attends all wards and makes a direct assessment of all children highlighted by the handovers or ward nursing teams. This direct contact has immeasurable value. Our presence seems to encourage ward team members to express their anxieties.

Tonight, several children within the oncology wards had clinical problems during the day so I go to these wards.

I am asked to neurologically assess a child who had seizures earlier today. The child is seizing again. I speak to the registrar and we implement the seizure algorithm, giving intravenous lorazepam, which works almost immediately. After ensuring the child's heart and breathing are stable, I continue on my rounds.

Our trust has a nurse-led pain team during the day. At night the CSP is the first point of call for pain-management issues. Before 11pm the anaesthetic team provides cover, so at this point I go to discuss with them. No acute problems and I continue my regular round.

At 12.30am the night team meets and work is redistributed if necessary. Everyone, however, seems on top of their workload so we use the time to update all the team about any children highlighted in the general handover.

The rest of the shift is fairly quiet. I answer a query on drug administration and revisit the children who had been unstable earlier - all seem fine. My shift is often directed by the calls from the nursing staff. It is important to intervene appropriately but without undermining ward teams' skill and practice.

SUNDAY: NIGHT SHIFT
Sunday has been quieter for my colleagues. Shortly after the CSP and registrars' handovers I am called to do a 12-lead ECG recording as a child has complained of chest pain and we need to exclude ischaemia as a cause. ECG is normal.

A key factor in this procedure is being able to interpret the results, something I learnt during my period as a cardiothoracic intensive care nurse, but not generally done by nurses here.

I begin my assessment of the wards and a concerned nurse approaches me about a decision by the day shift CSP relating to night staffing levels. We discuss why the decision was made and also that we can change it if the clinical dependency of the children changes. We make unpopular decisions at times, but try to be fair. Nurses need to feel able to approach us if they disagree with a decision.

I cannulate and take bloods from a newly admitted patient and then do routine reviews.

WEDNESDAY: DAY SHIFT
Back on day duty. Today is our team day. Our role often means working independently and making decisions autonomously so regular meetings provide necessary support. We use the time for training, communication and reflection on clinical issues. Today we have sessions on resuscitation - the CSPs lead all arrests within the trust - a meeting with the risk-management department and presentations from two team members.

THURSDAY: NIGHT SHIFT
The routine and work vary over 24 hours. While the CSP continues to have trust-wide awareness and responsibility, we have to recognise the resources within the trust. Ward managers should manage their wards. Senior nurses within each speciality should be the first resource available to ward teams. When these options are exhausted, the CSP gets involved. The importance of having a CSP on duty 24 hours a day lies more with the ability to respond to major incidents and manage acute clinical situations such as cardio-respiratory arrests.

Handover at 7.30am reveals continuing concerns about some children on the oncology ward. I begin my routine rounds here and find the children we are worried about are more stable.

Called to recovery where a relative has fainted. Minutes later receive call from outpatients', where another patient's relative has had a partial epileptic seizure. As this is a paediatric hospital any adult who becomes unwell needs to be stabilised and then referred to an adult facility.

General enquiries and revisiting children occupy the rest of my shift.

***

Anderson, C. (2003)(unpublished) A Delphi Survey to Identify the Defining Characteristics of the Clinical Site Practitioner Role (MSc dissertation). London: University of London.

Burke, D. (2002)Making the European Working Time Directive a reality. British Medical Journal 325: 7362, S66.

Cass, H.D., Smith, I., Unthank, C. et al. (2003)Improving compliance with requirements on junior doctors' hours. British Medical Journal 327: 270-273.

Duffin, C. (2003)Crackdown aims to stop misuse of specialist titles. Nursing Standard 17: 26.

Magennis, C., Slevin, E., Cunningham, J. (1999)Nurses' attitudes to the extension and expansion of their clinical roles. Nursing Standard 13: 51.

Mahon, A., Harris, L., Walshe, K., Higgins, J. (2003)European Working Time Directive and Doctors in Training. An early evaluation of 19 NHS pilot projects. Manchester: Manchester University Centre for Healthcare Management.

NHS Management Executive. (1991)Junior Doctors: The new deal. London: NHSME.

Nursing and Midwifery Council (formerly UKCC). (1992)The Scope of Professional Practice. London: NMC.

Working Group on Specialist Medical Training. (1993)Hospital Doctors: Training for the future. The report of the Working Group on Specialist Medical Training (the Calman report) London: Department of Health.

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