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Day in the Life of an ENT Clinical Skills Sister

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Name: Debbie Gifford
Role: ENT Clinical Skills Sister
Location: Kent & Sussex Hospital
Wage: £28K-£37K (band 7)

I work in an acute trust as a band 7 ENT Clinical Skills Sister. This role is akin to that of a nurse practitioner. The post was set up in 2004 as a local response to the Hospital at Night initiatives to enable the ENT department to meet its European Working Time Directive for junior doctors.

I work in a team of four senior nurses, whose primary role is to provide first on-call cover for all ENT inpatients, A&E emergencies and GP referrals at night, in place of junior doctors, with the ENT middle grade doctors being on-call from home. We diagnose and treat a wide range of ENT conditions, and either admit or discharge patients as appropriate.

Admitted patients are reviewed by a senior ENT doctor on the post-take ward round in the morning. To our knowledge, we are the only trust in the country where nurses work in this way at night, although we have also had senior nurses from other hospitals visit with a view to setting up similar schemes in their hospitals.

During the day we run nurse-led micro-suction clinics and pre-operative assessment, as well as providing teaching for other departments. I am also the paediatric lead for the team, as I have both paediatric and adult nurse qualifications. At all times we promote evidence-based practice both among junior doctors and ward-based nurses by providing them with the teaching and support needed to care effectively for ENT patients.

This seems to have become increasingly important as not only have the junior doctors’ placements been reduced to four months, but also as the trust reconfigures its services, ENT patients are cared for on a variety of wards rather than on a dedicated ENT ward.

In order to perform this role, a wide range of extended skills are required. These include extended role skills like ALS, cannulation, venepuncture, male catheterisation, ECG recording and interpretation, as well as advanced role skills such as physical examination, clinical decision-making, x-ray interpretation, nasendoscopy, tracheostomy care, microsuction, nasal cautery, and nasal packing to name a few.

Basically anything a junior doctor may need to do, we also need to know how to do. All our ENT extended skills were taught in-house by an ENT consultant or registrar, and we attend regular teaching and clinical supervision with both senior doctors and senior nurses.

As well as physical skills, the role requires excellent communication and liaison skills; I do not have direct line-management authority over any of my colleagues, so the ability to influence practice is solely down to my professional credibility, personability and leading by example. Additionally, the ability to keep calm in an emergency, self-belief in your own abilities and decisions, while being able to acknowledge quickly when you need back-up from someone more senior, are all crucial.

I am incredibly lucky to be able to say I love my job. The beauty of a peripatetic role is that I can go to where the patient is, and I find it enormously satisfying to be able to provide continuity of care and build relationships with patients right from when they first set foot through the hospital door.

I am genuinely able to influence the patient pathway and the quality of their care. I love the autonomy of the role, as it releases the frustrations I felt as an A&E nurse when it seemed obvious what a patient needed to me, yet I still needed to not only request permission from a junior doctor to be able to meet that need, but would also probably have to tell the junior doctor exactly what that need was too.

The job can be very isolating at times, as we work alone at night, and no-one else in the hospital has a similar role; the closest would be the emergency nurse practitioners. It can be very frightening when you have a bleeding patient about to exsanguinate in front of you, and everyone is looking to you to decide what to do. However, the ENT consultants, and middle grade doctors are hugely supportive, as are the other doctors and A&E nurses working in the hospital during the night.

Interestingly, I feel I meet with more hostility from ward-based nurses, who seem to see me as having crossed the invisible ‘us and them’ line that is always there between doctors and nurses, to become ‘one of them’. My view is that I have taken the necessary bits of ‘them’ and combined it with the best bits of ‘us’ to give patients a better quality experience in hospital, by giving them the right treatment in the right place the first time.

My team recently presented about our role at the national RCN ENT/Maxfax conference. We also won a team award within our trust for innovative practice. A recent departmental audit demonstrated that the clinical skills team were just as able as the junior doctors to diagnose ENT conditions and admit/discharge patients appropriately.

Additionally since we also undertake additional duties that junior doctors do not do at night, such as providing senior nursing support to the site practitioners, A&E and wards at night, as well as helping to prevent inappropriate admissions by inexperienced junior doctors in the day, we represent good value for money.

Empirically, patients seem more than happy to be treated by a nurse – we have received no complaints since the project started, although we have yet to conduct a patient satisfaction survey to evidence this.

The future scope for career progression in this role is pretty much sky high, since it is constantly evolving to meet service needs. Projects for the near future include completing the non-medical prescribing course – it has become apparent that PGDs cannot cover every eventuality within ENT, and further developing and refining clinical skills such as suturing.

I also plan to begin an MSc in February to build on my BSc (Hons). In the medium term we are looking at providing an outreach service within the hospital, and establishing nurse-led post-op follow-ups of routine procedures.

Looking ten years into the future it is not inconceivable that we may find ourselves doing sessional work in GP surgeries and polyclinics or even in operating theatres performing routine surgeries ourselves.

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