VOL: 102, ISSUE: 15, PAGE NO: 40
Lynne Hopwood, RN, BSc, OncCert, is assistant chief nurse, The Royal Marsden NHS Foundation Trust, LondonThe range of nursing roles involving an advanced level of practice has grown over the past two decades - and with i...
The range of nursing roles involving an advanced level of practice has grown over the past two decades - and with it the job titles used to describe them. Advanced practice extends the scope of the nurse's role. It involves highly autonomous practice, maximises the use of nursing knowledge and contributes to the profession's development (Bryant-Lukosins et al, 2004). It relates to skills, knowledge, expertise and attitude - all grounded in clinical practice - and encompasses aspects of education, research, leadership and practice development (Thompson, 2003).
The term 'advanced nursing practice' (ANP) refers to the practice of registered nurses who have met advanced educational and practice requirements, usually at master's level, and can demonstrate this in their practice. It is essential to note the importance of clinical and academic expertise working together.
Advanced nursing practice at The Royal Marsden
Advanced nursing practice has long been associated with cancer care. The Royal Marsden employs a number of ANP roles including:
- Nurse consultant;
- Clinical nurse specialist;
- Nurse practitioner;
- Lecturer practitioner.
These roles have different functions and the nurses in these posts require different skills to fulfil them, as seen in The Royal Marsden Hospital's Consensus Document (2002).
Nurse consultants lead nursing across an organisation, nationally and internationally, from a firm and dynamic clinical base. They must develop a clinical role with a tangible effect on outcomes for patients and act as a role model for nurses and other professionals.
The role is structured around core functions defined by the Department of Health (1999). They must offer:
- Expert practice;
- Professional leadership and consultancy;
- Education, training and development;
- Practice and service development;
- A research and evaluation function.
One challenge associated with the development of this role concerns the academic requirements required of nurse consultants - whether they should be required to have master's- or doctorate-level qualifications. At The Royal Marsden they are expected to have a master's-level qualification on appointment and to have enrolled on a suitable doctoral programme within 12 months.
It has often been relatively easy to identify the final four core functions of the role but less easy to define the area of clinical practice for which a consultant will have sole responsibility. At The Royal Marsden, nurse consultant roles have developed in areas of cancer care that facilitate a broader focus, such as rehabilitation, transitional care, critical care and IV therapy.
Clinical nurse specialist
The clinical nurse specialist (CNS) was the first advanced practice role to be described, implemented and fully evaluated. It was introduced to improve patient care and encompassed advanced knowledge, clinical decision-making and specialist skills, and is often associated with cancer and palliative care. Although the specialty of CNS roles has often been determined by client need, their growth has often been disparate and haphazard, reflecting local need and funding opportunities (Folland, 2000).
In cancer care, CNSs are in a unique position to build up therapeutic relationships with patients and carers along the entire treatment pathway. The role encompasses four main components:
While the role is clearly defined, there remains confusion over the educational requirements of CNSs. In the US, entry to CNS practice is at master's or doctorate level, with expertise in a selected area of clinical practice (Sparacino and Cooper, 1990), but in the UK there is currently no established educational entry level.
Nurse practitioners utilise the therapeutic benefit of nursing while providing a service that overlaps with medicine. As the roles are firmly embedded in nursing, nurse practitioners do not merely take on clinical tasks discarded by medical colleagues.
Post-holders must have undertaken a nurse practitioner course - offered at master's level - and have skills in decision-making, physical assessment, diagnosis and management in a defined area of practice. They have a range of responsibilities (RCN, 2002):
- Making autonomous decisions for which they are accountable;
- Receiving patients with undiagnosed problems and assessing their needs using highly developed knowledge and skills - including skills not often used by nurses, such as physical examination;
- Screening for disease risk factors and early signs of illness;
- Making differential diagnoses;
- Developing - in partnership with patients - individual nursing care plans for health, with an emphasis on preventive measures;
- Ordering investigations, and providing treatment and care individually, as part of a team, and through referral to others;
- Helping people to manage and live with illness;
- Providing counselling and health education;
- Admitting or discharging patients from their caseload, and referring patients to other healthcare providers as appropriate;
- Working collaboratively with other healthcare professionals;
- Providing leadership and consultancy as required.
Although nurse practitioners have traditionally worked in primary care and specific areas of secondary care such as A&E, there is a huge opportunity to develop roles in cancer care. At The Royal Marsden, the role is being developed to work in the transitional care unit (TCU). To facilitate efficient and high-quality care for patients, nurse practitioners will be responsible for ensuring:
- Surgical and medical patients receive pre-admission assessment;
- Elective patients receive an assessment - and potentially begin treatment - on the day they are admitted, either in their designated ward or through an outreach service if they are admitted elsewhere;
- All emergency patients receive an assessment, have the appropriate tests ordered and start protocol-driven treatment;
- Active involvement in discharge planning for patients who attend the TCU.
The TCU will also provide the base for a 24-hour nurse practitioner service caring for patients attending the TCU and acting as site nurse practitioners out of hours. This builds on the work of The Royal Marsden's 'hospital at night' team.
Site nurse practitioners will have the following responsibilities:
- Leading and coordinating the hospital's out-of-hours team;
- Managing the hospital site operationally.
Combining the roles of TCU and site nurse practitioner ensures nurse practitioners' skills are fully utilised and maintained as they have the opportunity to practise both routinely and in emergencies. Site nurse practitioners will also support junior medical staff.
This role involves a senior nurse utilising skills in education, research, practice and management in clinical practice and aids the development of less experienced nurses. Lecturer practitioners are usually affiliated to an educational establishment as well as a practice area. At The Royal Marsden they work between the School of Cancer Nursing and Rehabilitation and a practice area.
Specialist sister/charge nurse
The specialist sister/charge nurse role was created to give nurses the opportunity to develop into ANP roles. Through a mentorship and educational programme at master's level, the following facets of the role can be nurtured and further developed:
- Clinical expert;
- Researcher and auditor;
While ANP has led to a range of practice developments, concern has been expressed within nursing and by the public that no standards for this level of practice are enforced. In response to this concern the NMC has consulted on proposals to establish a framework whereby ANP will be registered and those working at this level will be known as advanced nurse practitioners. The earliest any legislation will be in place to achieve this will be August 2006. The NMC (2006) defines advanced nurse practitioners as highly skilled nurses who can:
- Take a comprehensive patient history;
- Carry out physical examinations;
- Use their expert knowledge and clinical judgement to identify the potential diagnosis;
- Refer patients for investigations where appropriate;
- Make a final diagnosis;
- Decide on and carry out treatment, including the prescribing of medicines, or refer patients to an appropriate specialist;
- Use their extensive practice experience to plan and provide skilled and competent care to meet patients' heath and social care needs, involving other members of the healthcare team as appropriate;
- Ensure the provision of continuity of care, including follow-up visits;
- Assess and evaluate, with patients, the effectiveness of the treatment and care provided and make changes as needed;
- Work independently, although often as part of a healthcare team;
- Provide leadership;
- Ensure each patient's treatment and care is based on best practice.
Those working within ANP must review their roles in the light of the NMC's recommendations to ensure they can meet the above criteria and establish how they will collaborate to benefit patient care.