VOL: 103, ISSUE: 24, PAGE NO: 32-33
Ross Fletcher, BSc, RN
Clinical educator, Bradford Teaching Hospitals Foundation Trust
Abstract: Fletcher, R. (2007) Advancing nursing skills on the medical admissions unit. www.nursingtimes.net.
Aim: To identify the skills that a medical admissions unit (MAU) nurse requires to provide care to patients and ascertain whether advanced nurse practitioners can facilitate the professional development of other nurses.
Method: A systematic review was carried out and the evidence was critically appraised. The literature was reviewed and critiqued. Only four articles were included due to the paucity of information available.
Results: Appropriate advanced skills that are relevant to an MAU were identified. The core principle of professional development was apparent in all studies but the impact of such professional development on patient care was not identified in all studies.
Conclusion: The MAU is an ideal environment for providing professional development, and ANPs could disseminate their knowledge to nursing staff on a variety of issues and aspects of patient care
This review of the literature explores the professional development of nurses working in medical assessment units (MAUs). These can be described as units that rapidly assess patients who are acutely ill and referred by a GP or casualty doctor. The review aimed to identify whether there is evidence that nurses use advanced skills on MAUs and whether advanced nurse practitioners can facilitate the professional development of other nurses.
Professional development is identified by Friedman et al(2000) as ‘the systematic maintenance, improvement and broadening of knowledge and skills, and the development of personal qualities necessary for execution of professional and technical duties throughout the individual’s life’. This is in line with the Department of Health’s (1999) aim for life-long learning - to enable professionals to fulfil their potential.
A nurse practitioner is described as a registered nurse who demonstrates high levels of clinical and cognitive ability that enables her or him to practise as an autonomous practitioner (NMC, 2001). This can be compared to an earlier definition from the UKCC (1994) that identified an advanced nurse practitioner role as concerned with future practice development, pioneering new and developing roles according to changing needs of clinical practice.
Nurses on MAUs should have extended skills in order to cope with the complex needs of patients who are acutely ill; they also require knowledge and skills to copy with a wide variety of medical conditions in order to facilitate the assessment process. There is very little research concerned with how the units function and the competencies nurses working on these units should have (Carroll, 2004; Wood, 2000).
Nurses often carry out roles that were previously undertaken by junior doctors. Greenhalgh et al (1994) identified that the reduction in doctors’ working hours led to an increase in demand for highly skilled nurses. This means nurses need continuing professional development (CPD) to keep their knowledge and skills up to date in order to deliver safe and effective care.
Making A Difference (DH, 1999) highlighted that CPD needs to be purposeful and patient-centred, effective, focused on developmental needs and designed to build on previous knowledge, skills and interpretation. Using the Delphi technique Carroll (2004) identified the need for specific core skills for nurses at different grades on an MAU to enhance the patient journey and quality of care. Pearson (1983) argued that these advanced nursing roles are in line with the growing autonomy of nurses and their role in clinical decision-making. This is reflected in the advice from the NMC (2002) that allows nurses to undertake enhanced roles provided they are appropriately trained and competent in the skills they undertake.
The published literature focusing on MAUs is relatively poor and most studies relating to advanced practice originate from outside the UK (Carroll, 2004; Wood, 2000. This may be explained by the fact that the MAU is a relatively new concept (Carroll, 2004).
The literature on professional development is large, but focuses to a great extent on clinical cases rather than the impact of CPD on clinical practice or the need for it. With the changing face of healthcare and increasing specialisations in nursing, many nurses require a more in-depth knowledge of their speciality. The DH (1999) identified that with nurses taking on a more central role in advanced practice, a highly developed workforce would be needed in the future. It highlighted that nurses would be moving around more frequently and, in some cases, to different areas of clinical practice.
In 2003-2004 £13.5m was spent on CPD in England (DH, 2003) but there is little evidence to support the impact of such expenditure in terms of patient satisfaction and practitioners’ own knowledge and skills (Tennant and Field, 2004).
Database searches of Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library and Medline were conducted and four published studies were examined in detail: Carroll, 2004; Tennant and Field, 2004; Wood, 2000; Mayled, 1998. A manual search of the literature was conducted in the local health studies library.
Inclusion and exclusion criteria were developed to manage the vast amounts of literature related to professional development. These were:
- Literature was published between 2000 and 2006;
- All articles must be written in English;
- Key words should be in the title of the research and/or the abstract;
- Only full texts, not abstracts, were to be used.
Exclusion criteria consisted of:
- Articles relating to psychiatry, paediatrics and non-MAU environments;
- Professional development of disciplines outside nursing;
- Professional development for nurse specialists, for example, diabetes nurse specialists.
The qualities assessed in each of the studies were (Mays and Pope, 2000):
- Was there a clear explanation of the study purpose?
- Was the description detailed enough for the study to be reproduced?
- Were the sample groups and sizes clearly identified?
- What were the study limitations?
- Did the findings help to answer the review question?
The literature search identified a total of 12,897 papers, of which 1,528 met the inclusion criteria. After the qualities of the papers were assessed four were included in the final review.
The critiquing tool used for the studies was from the Critical Appraisal Skills Programme (CASP, 1993), which identifies 10 questions to ask when critiquing an article. Each study identified the importance of professional development and the need for nurses to extend their skills due to increasing demands of patients and the impact of changing legislation for example, the European Working Time Directive, on nurses’ autonomy.
Study 1: Carroll, 2004
Carroll (2004) aimed to identify the skills needed by nurses on an MAU using a qualitative method incorporating surveys and focus groups. She included 38 advanced nurse practitioners working on MAUs and educated to master’s level.
The aims and objectives of this study were clearly identified at the beginning of the report and a detailed description of the methodological approach was provided so the study could be replicated. However, one limitation was that the participants volunteered for the study, Bailey (1995) stated that people who volunteer for a study are likely to be different from participants who are selected, which could affect the results.
Carroll (2004) identified nurses’ skills according to their grade and found that the most senior grades hadmore advanced skills. Due to the Agenda for Change (AfC) pay system the grades are no longer relevant and many nurses at D and E grades are now banded together. If this research was replicated, therefore, Carroll’s D and E grade roles would be combined.
A range of assessment tools including questionnaires and interviews were used to assess how nurses perceived their role on the MAU according to grade and the skills they used. Denzin (1989) identified the term ‘triangulation’ and stated by using multiple methods of inquiry researchers can distinguish truth from error. However, Carroll failed to say what type of questioning was used in the questionnaires. Beck et al(2001) said that closed questions should be used to ensure respondents can be compared and the answers are easier to analyse. The drawback is that researchers may overlook other possible responses.
Interviews were conducted using the Delphi survey technique. This provides an opportunity for interactive communication between the researcher and ‘experts’ in a field. Akins et al (2005) stated there is no clear identification of what constitutes a sufficient number of Delphi survey participants to ensure reliable results. Qualitative and/or quantitative questions can be asked of the experts and the information is then analysed and fed back to each person, via further questions, until the aim of the study is achieved. As the study involves experts it is assumed that information of reasonable quality will be obtained and this helps to strengthen the validity of the results considerably; Martino (1978), however, stated that the results are only as valid as the opinions of the experts in the panel.
Interviews can allow researchers to share their own views if those interviews are not structured; this can be a problem if interviewers share views they had not intended to (Wilde, 1992).
The results of Carroll’s (2004) study suggested there was a difference in roles and responsibilities according to grade and seniority; however some nurses may have had increased knowledge and skills due to experience and professional development but may not have applied for a promotion. The author identified this and said the participants ‘argued that experience was imperative and the roles of prescribing and interpreting results were appropriate only to senior nurses’. However, the term ‘senior nurse’ was not defined in the study.
Study 2: Tennant and Field, 2004
Tennant and Field (2004) discussed whether CPD makes a difference in their study of nurses undertaking a specialist ICU course compared with those learning on the ICU without attending the training course.
The research question was clear and identified the phenomenon to be studied; Cormack (2000) recommended using two or more variables in a research question, which this study did.
A convenience sample was used and this may be a weakness - Hek et al (2003) described this as the weakest sampling technique as it can lead to an increase in bias. In addition the trust was paying for the ICU course and participants may have felt obliged to take part in such a study.
One group of five participants attended the ICU course and another group of five nurses formed a control and did not attend the course. The Goal Attainment Scaling tool was used as a method of evaluation and effectiveness. The nurses assessed their own abilitiesat the beginning of the study and their manager assessed them all independently.
The findings of the study suggest that nurses learn and develop through experience regardless of training courses attended and the authors concluded that the ICU course did have an impact on practice but participants who did not do the study course also developed.
Study 3: Wood, 2000
Wood (2000) researched MAU provision in the West Midlands and nurses’ perspectives of this provision. The study used telephone questionnaires to gain its findings and 12 participants were interviewed. Cormack (2000) stated the interviewing/questioning of people only allows for their perceptions rather than the phenomena to be investigated. Although the questions were structured Robson (1993) highlighted how interviewees might not understand the question and the answer may not be representative.
Wood identified that nurses had an important role to play in emergency admissions in ensuring assessment, prioritisation and treatment are effective.
Wood also identified that nurses on the MAU acted as a source of information for junior doctors and accepted referrals. He suggested that nurses need to come from different nursing backgrounds and have different levels of clinical expertise. This contrasts with the view that advanced nurse practitioners need to be educated to master’s level (Mayled, 1998).
The study was small and may not be generalised to all MAUs. Wood identified that nurses on MAUs need to develop as a new branch of emergency nursing.
Study 4: Mayled, 1998
Mayled (1998) identified the role of the advanced nurse practitioner in improving the quality of patient care and described how the role developed on an MAU. The author used patient satisfaction questionnaires to analyse the role of advanced nurse practitioners. The sample size of 18 was relatively small compared with the 3,716 admissions to the unit that had occurred in three months. Low response rates or a small sample size can lead to a bias in information (Beck et al,2001).
The author identified few previous studies in the literature search to support his findings and there is no evidence of any interaction with advanced nurse practitioners outside of the unit where the study took place.
The researcher in this study assessed how satisfied the patients were with their care, however, as the researcher worked on the unit, a potential limitation could exist as nurses may perform in an exemplary manner if they know research is taking place - researchers may not be aware that it is happening.
The results of Mayled’s (1998) study suggest that patients are relatively happy with the assessment and treatment provided by advanced nurse practitioners. Although it does not report findings about professional development in the MAU the study does provide an opportunity to learn about the role of the advanced nurse practitioner on the unit and the skills/competencies they need.
It is evident from the reviewed literature that healthcare workers require the extended skills to carry out assessments and interventions for patients on an MAU but there is little evidence to suggest what these skills should be. Although previous studies have been conducted, they mainly highlighted the roles of nurses in A&E, (Lee et al, 1996; Parris et al, 1997).
Although patients on MAUs can differ from those in the A&E department, advanced skills and roles for nurses may improve patient care and reduce complaints and waiting times (Hind et al, 1999).
Tennant and Field’s (2004) study identified that professional development had an impact on practice but there was little evidence to suggest improved patient satisfaction and services
Carroll’s (2004) study highlighted that skills required by nurses working in MAU could be identified for different grades of staff, but AfC banding now affects how her results could be applied. However it is evident that protocols and policies need to be in place for nurses who are using extended skills (Carroll, 2004; Scrivens et al,1998
The European Working Time Directive, AfC and the Knowledge and Skills Framework (KSF) have all provided nurses with an opportunity to achieve new skills and knowledge. Nurses are now learning to cannulate, perform venepuncture and administer IV drugs in the absence of a doctor and it is imperative that these skills are appropriate for the patients and they have beneficial outcomes (Carroll, 2004). Without training nurses cannot function in such an acute environment and operate safely and competently.
AfC and the KSF require nurses to increase their knowledge and work to a set standard in order to pass through set gateways to higher clinical bands. Nurses must recognise their own professional accountability and their responsibilities to themselves and others.
The RCN and DH jointly funded a study in 2005 entitled Maxi Nurses. This highlighted how nurses carrying out advanced roles have the potential to contribute positively to the delivery and quality of patient care. However, it also revealed that time and funding constraints are holding some nurses back.
With the development of advanced nurse practitioner roles in MAUs the funding of courses for other staff may decrease due to the access to advanced practitioners who are able to facilitate learning on the unit. Cranston (2002) highlighted how a key element to clinical governance is the right to education, training competencies and skills to deliver the relevant care to patients. The nurses in the Maxi Nurses study were very positive about their roles and described how their advanced roles were having an impact on patient care. They described themselves as maxi nurses and not mini doctors and enjoyed maintaining the patient contact they had.
Three of the studies included in this review were undertaken on MAUs and indicated the need for advanced skills. One study took place on an ICU and acknowledged the need for professional development in a specialist area. However, whether the results from the ICU are transferable to a MAU is questionable.
The MAU is an ideal environment for providing professional development. Nurses encounter a diverse range of medical conditions and the experience is invaluable for health professionals to increase their knowledge and skills.
CPD and life-long learning are essential to providing good quality care to patients. Due to the development of new nursing roles, NHS trusts are increasingly looking for cost-effective, flexible training to educate the workforce quickly and efficiently (Ayers and Smith, 1998). Dissemination of knowledge is important in all areas of nursing and ANPs could disseminate their knowledge to nursing staff on a variety of issues and aspects of patient care.
The studies discussed in this review were small but relevant. The field of acute medicine is changing continually (Carroll, 2004) and nurses’ skills and roles should alter as new issues arise. MAUs should have the access to ANPs in order to facilitate professional development in relation to enhanced clinical skills and provide cost-effective training.
It is recognised that nurses undertaking enhanced practice should be monitored and have regular updates, assessments and evaluations.
Akins, R. et al (2005) Stability of response characteristics of a Delphi panel: application of bootstrap data expansion. www.biomedcentral.com/1471-2288/5/37
Ayers, S., Smith, C. (1998) Planning flexible learning to match the needs of consumers: a national survey. Journal of Advanced Nursing; 27: 1034-1047.
Bailey, V. et al (1995) Essential Research Skills. London: Collins Educational.
Beck, C. et al (2001) Essentials of Nursing Research: Methods, Appraisal and Utilisation. Philadelphia: Lippincott
Carroll, L. (2004) Clinical skills for nurses in medical admissions units. Nursing Standard; 18: 42, 33-40.
CASP 1993 Cited at:www.phru.nhs.uk/casp/casp.htm accessed 25/04/2006
CASP 2002 Cited at: www.phru.nhs.uk/casp/critical_appraisal_tools.htm
Cormack, D. (2000) The research process in nursing 4th ed. Oxford: Blackwell Science.
Cranston, M. (2002) Clinical effectiveness and evidence based practice. Nursing Standard; 16: 21, 39-43.
Denzin, N. (1989) Strategies of Multiple Triangulation, Cited in Norman K. Denzin (1989)The Research Act, 3rd ed. (Englewood Cliffs, NJ: Prentice Hall), pp. 235-247.
Department of Health (2003) National CPD allocations provided to work force development confederations in England 2003/2004. Cited in: Tennant S & Field R (2004) Continuing professional development: does it make a difference?Nursing in Critical Care. 9, 4, 167-172.
Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and health Visiting Contribution to Health and Healthcare. London: DH.
Friedman, A. et al (2000) Continuing Professional Development in the UK: Policies and Programmes. Bristol: Professional Associations Research Network.
Greenhalgh, C. et al (1994) The Interface Between Junior Doctors and Nurses. A Research Study for the Department of Health. Macclesfield: Greenhalgh and Co.
Hek, G. et al (2003) Making Sense of Research: An introduction for Health and Social Care Practitioners. London: Sage.
Hind, M. et al (1999) Exploring the expanded role of nurses in critical care. Intensive and Critical Care Nursing; 15: 3, 147-153.
Lee, K. et al (1996) Accuracy and efficiency of X-ray requests by triage nurses in an accident and emergency department. Accident and Emergency Nursing; 4: 179-181.
Martino,J.P. (1978) Technology Forecasting for Decision Making. New York, NY: Elsevier Science.
May, N., Pope, C.(2000) Qualitative research in health care: Assessing quality in qualitative research. British Medical Journal; 320: 50-52
Mayled, A. (1998) Medical admissions units: the role of the nurse practitioner. Nursing Standard; 12: 27, 44-47.
NMC (2002) Code of Professional Conduct. London: NMC.
NMC (2001) Consultation on a Framework for the Standard for Post-registration Nursing. London: NMC.
Parris, W. et al (1997) Do triage nurse initiated X-rays for limb injuries reduce patient transit time? Accident and Emergency Nursing; 5: 1, 4-5.
Pearson, A. (1983) The Clinical Nursing Unit. London: Heinemann.
Robson, C (1993) Real world research: a resource for social scientists and practitioner-researchers. (2nd edn.) Oxford: Blackwell.
Royal College of Nursing, Department of Health (2005) Maxi Nurses: Nurses Working in Advanced and Extended Roles Promoting and Developing Patient-centred Healthcare. London: RCN.
Scrivens, E. et al (1998) Making winter monies work: a review of locally used methods for selecting and evaluating supply side interventions. Centre for Health Planning and Management. Keele: KeeleUniversity.
Tennant, S., Field, R. (2004) Continuing professional development: does it make a difference? Nursing in Critical Care; 9: 4, 167-172.
UKCC (1994) The Future of Professional Practice. The Councils Standards for Education and Practice Following Registration. London: UKCC.
Wilde V (1992) Controversial hypothesis on the relationship between researcher and informant in qualitative research Journal of Advanced Nursing Cited in: Cormack, D., 2000. The research process in nursing 4th ed. Oxford: Blackwell Science.
Wood,I.(2000) Medical assessment units in the West Midlands region: a nursing perspective. Accident and Emergency Nursing; 8: 196-200.