VOL: 97, ISSUE: 15, PAGE NO: 42
Karen Easton, MSc, RGN, RMN, is now nurse consultant (gynaecology), the women's health unit, Gloucestershire Royal NHS Trust
Nicky Burns, MSc, RN, is advanced nurse practitioner (gynaecology), the women's health unit, Gloucestershire Royal NHS TrustAfter a recruitment crisis early last year at the women's health unit, Gloucestershire Royal NHS Trust, we were asked to take on the duties of an obstetric and gynaecology senior house officer (SHO) for six months in addition to our own jobs. We opted to share this role, rather than one of us taking it over completely, so that we could maintain our special interests as advanced nurse practitioners (ANPs).
After a recruitment crisis early last year at the women's health unit, Gloucestershire Royal NHS Trust, we were asked to take on the duties of an obstetric and gynaecology senior house officer (SHO) for six months in addition to our own jobs. We opted to share this role, rather than one of us taking it over completely, so that we could maintain our special interests as advanced nurse practitioners (ANPs).
The working environment
The unit delivers about 3,000 babies a year and has 42 maternity beds. The gynaecology ward has 16 beds and five day-case trolleys. The ward treats 1,600 inpatients and 1,300 day cases every year. Six consultants and six registrars work in three teams, each of which has a junior SHO. It was decided that we would work for one of the consultant teams in place of its SHO. The other two teams consisted of two consultants, two registrars and one SHO each.
Before taking on the SHO role, the nurse practitioners covered holidays, study-leave and one weekend in four to support the registrar, so it was anticipated that we would be able to cope with the day-to-day management of patients in the unit.
The SHOs' responsibilities include the preoperative clerking of patients for elective major surgery, Caesarean sections, minor surgery, organising investigations for elective and emergency admissions and a diagnostic role in early pregnancy assessment. The early pregnancy service is attached to the gynaecology ward and is totally nurse-led. SHOs also provide on-call cover for the unit to support the registrar until 10pm on weekdays and during the day at weekends.
Advanced nurse practitioners
The gynaecology service at the trust has employed ANPs for the past three years. As ANPs, we already worked on the ward and in the outpatient department, carrying out a variety of tasks which included the provision of an early pregnancy assessment clinic, ward cover, clerking patients before surgery and the assessment of emergency admissions. Apart from sharing some aspects of our jobs, we both had an area of special interest: one of us was working towards accreditation as a colposcopist while the other specialised in continence care and urodynamics.
The decision to expand the ANP role
The clinical director of the unit, a consultant obstetrician and gynaecologist, had to consider the options when one SHO post was not filled at short notice. After discussions with his colleagues and ourselves, it was decided that we would cover the rota for a six-month period.
ANP posts were initially developed partly as a result of the reduction in junior doctor's hours. The expansion of our roles also formed part of a pilot to establish whether this might be a good way to cope with change in the future.
The first ANP post was created three years ago and the second followed a year later, by which time we had already developed assessment and diagnostic skills. We have been well supported throughout by the unit medical team: an important factor in the success of these roles (Woods, 1999).
Professional and legal considerations
The Scope of Professional Practice (UKCC, 1992) states that nurses are accountable for their own competency. Before taking up the SHO post, we attended sessions on several areas of practice, such as preoperative clerking for Caesarean sections, so that we could demonstrate competence in them.
The post was insured by the trust's vicarious liability clause, but we still had to consider the legal implications of this role expansion. Reveley (1999) states that when nurses practise in an expanded role, including tasks that were once considered medical territory, they have to be as competent as doctors. This meant that we did what any junior doctor would do and sought senior medical advice when necessary.
Combining the roles of ANP and SHO necessitated longer working hours than the 37.5 hours a week we were contracted to do (doctors currently work a 48-hour week). For this reason arrangements were made to remunerate us for the extra time we worked, which was a welcome bonus.
The main challenge was to provide quality, holistic care to patients without the authority to prescribe drug therapy - a fact that resulted in great frustration when out-of-hours medical cover consisted of an on-call consultant and a registrar who was often tied up in the delivery suite. Many drugs had to be prescribed over the telephone, being written up and signed for later.
The outcome was that protocols that had been in the pipeline for many months were ratified, allowing us to enable the supply of medicines.
Patient group directives now allow us to supply medicines that are appropriate to our diagnoses, meaning that we can prescribe them via a protocol, which has been sanctioned by the clinical director, the executive nurse director and the director of pharmacy.
This removed one of the role's greatest frustrations as it allowed a nurse-led clinic to offer truly holistic care, with both nursing and medical interventions offered together.
The experience has honed our diagnostic and assessment skills and we demonstrated these successfully in both the women's health unit, the surgical unit and the A&E department, even though the service provided focused predominantly on gynaecology. Midwives delivered all maternity care but we were called to see wounds, site intravenous lines and supply take-home drugs for patients, which were dispensed by the pharmacist and prescribed as per protocol in the same way as the SHOs do.
The role also became visible to GPs, who telephoned for advice and referred patients to the unit. It was a challenge and a pleasure to offer advice to professionals who would normally take note only of medical colleagues. It also prompted other health professionals to examine the ways in which they worked and the services they provided.
The physiotherapist attached to the ward no longer sees every preoperative patient to explain pelvic-floor and deep-breathing exercises. She does, however, accept nurse referrals and sees patients whom the multidisciplinary team feels have specialist respiratory or mobility needs.
The physical impact
During the pilot, we averaged an extra 40 hours a month over and above our contracted hours. That part of our timetable usually earmarked for role development and research was also cut.
Funds which became available because the third SHO post had not been filled were used to ensure that we were recompensed for our effort, which was some comfort while on call and during periods of extreme fatigue. SHOs do not spend whole nights on call, but the work is intense while they are on duty.
Communicating this new role and its responsibility to others was often difficult and took up a great deal of time, but it was important to us that the physical impact of the change in role should not negatively effect the quality of the care provided. Consequently, we covered for one another and curtailed our social activities to get a few early nights.
Communication with others
Health care workers and the public often think that doctors can make decisions and provide patient therapies that are not in accordance with their actual status (Walsh, 2000), so we often found ourselves justifying the work we did in our new role.
For example, in most hospitals a ward round to order care or a discharge is the role of a doctor. But in the unit we could do the same as an SHO, which meant patients would not see a doctor. As a result, lengthy explanations were necessary to reassure patients that they were not missing out.
Record-keeping became an obsession during this period as we wanted to ensure that all parties were clear about why we had made certain decisions or recommended a particular course of treatment.
When called to other departments, we often had to rely on doctors to prescribe what was necessary for our suggested therapy, which required a great effort of communication. We also found that patients asked us much more about their health care, which took up a lot of time.
Since the start of the pilot we have benefited by being professionally recognised and valued in other areas of the hospital and the community. We socialised more with the medical staff, who in turn now socialise more with the nurses, and communication between the two groups has improved.
The pilot has had a significant impact on the service, allowing managers to look at new ways of providing safe and effective care for patients as well as challenging views about the boundaries between professional roles. It has also decreased the perception of threat between professional groups. For example, we now receive care referrals from groups that previously resisted this.
We have begun work to validate anecdotal evidence that we can provide quality care to patients in a specialised unit. This has changed us as people and changed others' perception of us and our roles. The result is a much better, more collaborative working relationship with staff, especially midwives and SHOs.
We now want to build on this experience. The advanced nurse practitioner attached to the unit now carries out this role in support of the medical staff and takes part in the on-call rota while the consultant nurse is involved in the orientation of SHOs. Both also play a major role in the support and education of junior medical staff.