PhD, MNurs, RMN, RGN, is reader in practice development, Bournemouth University, on behalf of South West Consultant Practitioner Forum...
AbstractWarr, J. (2006) Clinical decision-making and the consultant nurse role. www.nursingtimes.net.
This paper reviews the requirement for expert clinical decision-making in the role of consultant nurse. The aim is to gain a better understanding of this role by exploring the experiences and views of consultant practitioners themselves. A summary of this paper was published in Nursing Times; 102: 39, 26 thSeptember 2006.
Since consultant roles for nurses, midwives and health visitors were introduced in 2000, the NHS has grappled to find the best way to utilise this level of skill. The NHS Executive (1999) considered key elements of the role were:
- An expert function;
- A leadership function;
- An education and development function;
- A research and evaluation function.
This can be seen in some ways as an amalgam of the perceived role of medical consultants and the vision of higher-level practice (UKCC, 2002). With lack of adequate preparation for the development of such a role (Redwood et al, 2005), it is not surprising that there is some evidence that it has a greater diversity than previous senior roles. This paper attempts to utilise the experiences of an established group of practitioner consultants to explore their views on the nature of clinical decision-making, the attribute they identified as the primary difference in their role from other senior roles and the means by which the key elements of the role can be demonstrated.
Literature exists on the introduction of the role of consultant practitioners (Department of Health, 2000; 1999; 1989; NHSE, 1999) and the development of the concept and title (for example, Manley, 1997; Wright et al, 1991). Some audit of the characteristics of the appointees has also been published (for example, Da Costa, 2002; Robinson, 2003).
While these are useful in terms of understanding the professional and policy developments, they do not give a clear outline of the key skills and knowledge required for the role. The UKCC (2002) has described it in terms of higher levels of practice and there has been some discussion of educational requirements (Adkins and Forester, 2000; Payne, 1999), particularly in terms of the benefits of a postgraduate qualification.
There is very little empirical research on the consultant practitioner role to date, which reflects the stage of its development - although there is some evidence that it benefits co-ordination of services and interprofessional working (Packham, 2003; Bryan, 2002). A recent study of practitioners in one setting explored individual consultants' perspectives on their role, emphasising the aspect of expert practice but recognising limitations in terms of leadership and research skills (Redwood et al, 2005). No work to date has focused on the specific component of clinical decision-making in relation to the role.
Aim of the study
The aim of the study was to explore the nature and implications of clinical decision-making from the perspective of established consultant practitioners.
In particular, by exploring decision-making it was hoped that the following might be elicited:
- The meaning of decision-making for consultant practitioners;
- The skills required and to what extent these are unique to the role;
- How education/experience contributes to decision-making;
- What aspects help current ability;
- Areas that need development;
- Specific examples of decision-making.
The South West Practitioner Consultant Group Forumwas facilitated by BournemouthUniversity shortly after the first consultant roles were established in the surrounding health authorities. The aim of the initiative was to offer support and shared learning through an action learning group. An evaluation of its early development and the individual perspectives on the role has been reported elsewhere (Redwood et al, 2005).
After discussion with group members about their perspectives and expectations of their roles, it was decided to explore the components of clinical decision-making in order to clarify the nature of 'consultancy'. An anonymised survey, facilitated by an independent representative of the university, was used to gather members' extensive experiences to illuminate the essential qualities of the concept. As well as assisting the group in their individual and collective developments it was decided that the study should form the basis of a group publication to help inform a wider audience.
The study was a collaborative venture in which the focus, method, questions and discussions of findings were determined by group members themselves. It was restricted to the convenient sample of the Consultant Practitioner Group, drew on action research methodology (Lewin, 1946) and, in this study, seeks to achieve an improvement of the understanding of a practice (Carr and Kemmis, 1986). The questions to be addressed by group members were generated from a facilitated group meeting and distributed to all eligible members (n=17) via email by an administrator from the university.
The agreed questions were:
Q1: What does clinical decision-making mean in relation to your role?
Q2: What are the unique skills of clinical decision-making in your role?
Q3: What aspects of your education and experience have assisted your skills of clinical decision-making?
Q4: What aspects of your current role assist your skills of clinical decision-making?
Q5: What areas of your clinical decision-making require further development?
Q6: If possible, please describe an incident or example of your clinical decision-making role.
These questions were designed to be as open as possible to allow free and confidential answers.
Responses were anonymised prior to being sent to the researcher for analysis. The arrangement also allowed respondents to be contacted directly to remind them to respond without contacting the whole group unnecessarily. It also retained the anonymous nature of the data for the researcher.
The response rate was acceptable, with nine of the 17 members responding, although it was hoped that the nature of the group and study design would secure a full response. It should be noted that the group comprised a core of regular members and the remainder receiving updates and information. It is feasible that the respondents were drawn largely from the core members.
The nine questionnaires were thematically analysed within the question categories.
Clinical decision-making in relation to your role
Respondents indicated that this form of decision-making was highly complex. Some respondents elaborated on specific aspects, while others made reference to some of the factors that were part of their specialism. The aspects commonly cited as requiring careful consideration as part of decision-making were:
- Patients' history/current situation;
- Nature and ability of family or personal support networks to assist patient;
- Identification of all potential treatment options;
- Previous decisions and outcomes made in respect of the patient;
- Views of patient and significant others in respect of treatment/care.
These case-specific aspects needed to be set against current research findings and evidence of best practice. Additionally, there was a need to place all this information within the context of the locality in which the patient was to be treated. This included consideration of what was actually available as well as what could be resourced during the period of care, both financially and in terms of expertise.
The respondents noted that, in many cases, more complex patients were referred to them. They believed this occurred because they were recognised as having both a specific area of expert knowledge in terms of treatment options and outcomes and the ability to integrate their wider knowledge and expertise when involved in the decision-making process.
The range of factors cited by respondents seems to indicate that the decision-making process they described went beyond the level of clinical experience. This notion is also reflected in responses to later questions regarding education and skills required that cited research skills and forms of management training.
Several respondents focused on the personal autonomy that was associated with the role. This autonomy was seen by some as an enabling factor in the decision-making process as it allowed them to think in a more holistic way about patients' needs and potential treatment options.
In addressing this question, some stated they did not think there were any skills unique to clinical decision-making. The type of skills involved in clinical decision-making that were outlined were:
- Acquired expert knowledge;
- Analytical skills;
- Interpersonal skills.
The greatest emphasis was placed upon knowledge and experience gained over an extended period of time through clinical practice. In addition, knowledge of the practice of other professionals was thought to be particularly important and valuable.
It was common for respondents to add that knowledge alone was not sufficient. It was equally important to have the ability to apply what they knew in a logical and considered manner in accordance with the needs of the situation and/or patient. Several specifically referred to the ability to integrate knowledge and experience to form practical solutions. It was implicit within the responses that strong analytical skills were required, and the term 'problem-solving' was cited by several respondents.
The last group of skills could be broadly termed as 'interpersonal' and included negotiation, communication and the ability to perceive a situation from multiple viewpoints that demonstrate understanding of other people's/ professionals' positions. These skills also implied a need to be a good listener.
One respondent referred to observational skills, which suggests the ability to interpret non-verbal forms of communication may also be necessary.
Four respondents referred to the need to be effective at networking within and across organisations. Having a good understanding of the organisation and a range of points of contact within it were helpful when considering the full range of potential options for a patient. This could result in improved cooperation and better utilisation of a patient's previous experience.
Education and experience
The respondents had broadly similar views on what they saw as necessary education and experience. The most commonly cited factor was some form of advanced educational course. Several respondents mentioned courses at master's level which offered the opportunity to explore theoretical concepts and apply these through research. Others referred to specific types of education and training that were not specifically clinical based, and several cited management-based courses as useful.
Three other aspects were frequently cited. These were:
- Interprofessional/multiprofessional training opportunities
- Skill-based courses to develop/increase expert knowledge
- Opportunities that facilitate personal reflection on practice including the opportunity to share experiences/reflections in a group setting.
Aspects of their current role which assists clinical decision-making
The most common factor to emerge in this section concerned the support of other colleagues. This was described in a range of ways. Several mentioned networks that supported them in terms of reflection/supervision within their clinical area and others cited their relationships with other professionals. These relationships allowed respondents to understand more fully areas of practice outside their personal experience.
Related to the notion of support from others was the perception of the role itself. Several respondents spoke about issues that concerned the way in which the role was enabled to operate within the wider organisation. One respondent cited continued support even if they 'failed' while another felt confident they had the support of their colleagues when they needed to 'move practice boundaries'. A further respondent related how they believed their role had increased 'credibility' with others and this was seen as a positive factor in terms of undertaking their role.
Another aspect raised by nearly half of the respondents was their ability to access information either through having protected time for keeping themselves up to date with research or through their educational commitments to others. Teaching helped with updating and also allowed time to reflect and analyse the evidence and its application in the practice setting.
In addition, supervision was cited as being helpful in undertaking their role, for largely similar reasons as those stated above regarding education commitments.
Further development of clinical decision-making
Fewer comments were made under this section and those that were made covered a range of issues. The points raised could be described as training issues and organisational changes.
In terms of training, many of the respondents felt there was a need for continued training within their role. The types of training cited varied and included more clinical training as well as courses on theoretical models of decision-making, risk assessment and negotiation skills.
In terms of organisational changes, the areas cited were the opportunity for feedback from both colleagues and patients on the decisions the respondents had made. Another aspect was time to collate information about decisions made and retain them for future reference.
One respondent indicated that, in terms of the organisational structure, their role did not place them within a particular team. This made them feel more detached and also meant less support/opportunity for discussion than team membership might have offered. Therefore they thought it may be helpful to find a way of overcoming this detachment.
The results were considered by the group and the discussion drew on elements of the role as people had developed it, as much as on the process of decision-making.
There was an emphasis on the individual organisational context within which the role operates. There was a perspective that, as these were new roles, selection had focused on the individual as a pioneer, especially an innovator.
There appeared to be little clarity regarding expectations and a definite lack of preparation. While respondents were generally left to define their own role and direction, there was a belief that there was a 'subtext' which resulted in diverse expectations. This resulted in different orientations of role and lack of supervision. Essentially the clinical decision-making derived from this issue and the individual experience and speciality of the consultant.
On reflection, it was not just clinicalbut a wider interpretation of decision-making that was the issue.
Clinical leadership was strongly emphasised. The more general managerial aspects of the role and the position within a hierarchy were not the most important considerations due to the autonomy of the role but this meant that clinical supervision and peer support relied on the individual seeking it. Several aspects of the process of job definition and selection appeared unclear but had a major impact on the role and decision-making:
- cover when away
- what benchmarks were used?
- other's lack of clarity and perceptions of a 'consultant'
- lack of planning and clear strategy for the role
- evaluation of the role and what benchmarks are used now.
This resulted in two key considerations: the role and decision-making within the context of the original thinking, strategy and decisions prior to appointment, as well as what the real effects of these are now. Much energy appeared to be devoted to dealing with conflicting demands in a positive way.
In this context and against these uncertain elements, it appears that clinical decision-making is a largely individualised process. This relates quite well to the concept of transformational leadership but always depends on the context. There appeared to be a 'domain map' that guided some of the processes.
The freedom of the role was seen as a positive catalyst. The role sat outside conventional structures and the question of not being employed by organisations fostered a notion of 'liberated professionals' rarely seen in other groups and teams. It could be seen as having professional control in all aspects of the role, which is a hallmark of professional practice (Dingwall and Lewis, 1983) The freedom also helped to understand the navel-gazing believed to be apparent in nursing and other groups. However, it was also a potentially threatening and threatened position to be in. Some feel the attraction of fitting in to a team structure but this rarely happens.
Consultancy is an interesting notion. It suggests expertise and possibly the option to sell that expertise, while also being a resource to consult. It might be a misnomer in many roles, rather being a point of referral for problems. There is a sense that it is a convenient title for roles outside conventions rather than a true clinical 'expert/leader/consultant'.
The challenge appears to be to make the role explicit. It is not unusual for colleagues to say: 'I don't know what your role is but you are above me!' There is a sense that others also see the consultant as 'not one of us'.
Individually determined parameters and boundaries are the general expectation but this can result in asking whether you have any boundaries. Limit-setting is a vital issue, particularly in the absence of someone else determining them. This has a profound effect on the decision-making, its limits and its potential quality. There is a tension between rigidity and freedom. The boundaries should be clearer but not restrictive or solid in order to promote innovation.
An exemplar of an issue is how the organisation would respond if the consultant left. Would the role be replaced as before or would the organisation redefine the post?
The prevailing view at this stage of the development is that it has created another level of professionalism.This poses real challenges for education, training and preparation.
Limitations of the study
The study only reflects the views and experiences of some members of a single group of consultant practitioners and it would be difficult to generalise beyond that setting. The findings, however, give an insight into the issues and demands faced by the people in these new roles. It may also help others to better understand the implications for their own practice.
This study sought to explore the importance of clinical decision-making within the newly developed roles of consultant practitioners. It drew on the experiences of people who can be viewed as pioneers within this initiative.
It is not surprising, therefore, that there is little real consensus and views are primarily influenced by experience and personality.
There is a very real sense of developing the role without clear guidelines and parameters but, at the same time, pushing the boundaries of accepted practice.
This appears to result in a degree of alienation from others within the team and some misapprehensions.
Implications for practice
At a practical level, the study identifies some shared qualities that influence the decisions (not always clinical) expected of the role and may give some direction for preparation and training of future consultants.
The clearest message, however, is that the role relies heavily on the personal integrity and experience of the individual which is hard to foster through education. The need seems to be for support and sharing from and with others in these new roles which can only be gained through better understanding and co-operative working.
These roles are an exciting development for the professions and have the potential to be a potent force in promoting effective, good-quality care for patients and clients.
This paper has been authored on behalf of the following members of the South West Consultant Practitioner Forum:
- Gina Bird
- Su Down
- Matt Flynn
- Dawne Garrett
- Jood Gibbins
- Clare Gordon
- Alan Howard
- Mike Kelly
- Martin Lewis
- Eileen Mann
- Avril MacDonald
- Sharon Mooney
- Ciaran Newell
- Bernadette O'Hare
- Mandy Rumley
- Lesley-Ann Wareing
- Paul Watts
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