Of all the questions we have faced as consultant nurses, the most frequent has been about the practice element of our role. The perspective we have outlined in this article has been developed on the basis of our own values and beliefs about practice development, our understanding of the consultant nurse role, our experiences, the expectations of others of the role and our own development work within the role.
VOL: 99, ISSUE: 09, PAGE NO: 30
Jan Dewing, MN, BSc, DipNurseEd, DipN, RNT, RGN, is consultant nurse, Milton Keynes PCT and General NHS Trust, and associate fellow practice development RCN
Brigid Reid, MPhil, BN, CertEd, RGN, is consultant nurse, Blackburn, Hyndburn and Ribble Valley Health Care NHS Trust
Consultant nurse role and expert practice
Effective consultant nurses are able to draw on a set of attributes. To enable them to fulfil their responsibilities to an expert level they require expertise and the ability to apply three key processes. These fall within the six core qualities and skills identified by Manley (2001) as being crucial to the role (Box 1) and they are as follows:
- Transformational leadership processes: the development of everyone’s leadership potential within a shared and common vision;
- Emancipatory processes: helping others to overcome barriers in themselves, their work and workplace. This includes addressing the difficulties that traditional research dissemination and education encounter, which arise because they focus primarily on increasing awareness. Methods consistent with emancipatory processes include action learning, one-to-one and group clinical supervision, and skilled facilitation in the workplace;
- Practising expertly as a practitioner, researcher, educator, consultant and practice developer; acting as a role model and facilitator of individual, collective and organisational learning; and being a facilitator of change, practice and service development.
Manley (2002) cautions that no consultant nurse can afford to work on her or his own. Further to this, we would add that the consultant nurse can never afford to simply ‘do’ practice. The doing should always be accompanied by facilitation with other practitioners to enable the practitioners to see and experience alternative ways of doing things. Everything consultant nurses do must not only enable others to develop their practice but must also help embed any cultural changes in the workplace. It is important that this is applied to the clinical practice element of the role. Thus, a consultant nurse working solo with patients to deliver a regular service (whether in a ward, clinic or community setting) will not be demonstrating the full potential and effectiveness of the practice element of the consultant nurse role.
The dangers of isolated action
The original guidance from the Department of Health (1999) - and many subsequent specifications of the nurse consultant role - stress that practice must form at least 50% of the role. Proposals for consultant nurse posts often contain sample job plans identifying ‘sessions’ for clinical practice. However, while practice must be central to the role, there are dangers in assuming that specific time allocation will produce the desired outcomes.
Guest et al (2001) reported that practice was the area of least engagement by consultant nurses in their first six months in post. Given that the target outcomes for consultant nursing are to transform culture, develop evidence-based and patient-centred practice, it is crucial to examine the way consultant nurses choose to carry out this part of their role.
Without such an analysis there is the danger of repeating the practice of others or replicating the role adopted by many nurse practitioners/clinical nurse specialists. In some instances, such practitioners can influence the practice of others, but they often work alone (Reed et al, 1998) and focus on seeing patients either in a clinic, on a round or on a visit. This does not, of course, mean that the care provided is not of high quality, but it does not generally achieve sustainable changes in the practice of other nurses unless it is underpinned by strategic practice development approaches (Manley, 1997).
Where the clinical practice of consultant nurses acts to compensate for the care delivered by nurses who may have either more limited or more specific expertise, it is inevitable that ethical and organisational issues will be raised. The practice expertise of a consultant nurse lies in being able to facilitate and enable others to change practice culture (Haines, 2002). A consultant nurse will also have expertise and knowledge in a specific field, but this should not be the sole focus of his or her practice.
Thus, it is important that the practice model for the consultant nurse does not focus on the consultant nurse working directly with patients to enhance care. It should encompass work with at least one other person to enable this person to develop the way they deliver care, understand and develop their practice.
Such consultancy at clinical level cannot occur without sustained and meaningful involvement in clinical practice, access to strategic and academic influence of what informs practice (research and education), how practice is organised and conceived (leadership), and how practice is strategically transformed (practice development)
While being a practitioner can bring security and satisfaction, as occurs in similar roles, practice for the consultant nurse must be more than this (Reid and Metcalf, 2001). To persist in a formulaic way with working shifts or sessions a week is an ineffective approach in the long term.
If the consultant nurse role is about shifting practice related to a strategic plan, then the practice element is likely to occur in phases that will depend both on the current stage that practice has reached (in terms of the degree of evidence-based and patient-focused practice) and on the practice development strategy adopted. This means that what you see a consultant nurse ‘doing’ as part of the practice element one week is likely to be different the next month and almost certainly different the following year.
Interpreting a visible activity as the sum total of the consultant nurse role, without seeing it in the context of the whole approach, is likely to provide a misleading picture. Moreover, it is crucial for practice to be undertaken as much as possible where and a time when the majority of practitioners operate. The consultant nurse must become involved in the practice of others, rather than set up discrete conditions (such as ward rounds or clinics) to demonstrate what can be achieved within everyday practice in multiprofessional settings. This is getting to the heart of modernisation.
To view practice as a discrete entity is a flawed approach, in that when skilled consultant nurses practice they are using approaches underpinned by education, practice development and research (Manley and Dewing, 2002).
For example, work-based learning principles can be used to address the use of evidence-based practice in practice and to influence the practice of others. In addition, when consultant nurses deliver formal education or provide research input away from practice settings, they will derive their activities from, and build them on, practice, rather than merely take examples from practice to illustrate formal knowledge.
In many ways consultant nurses have a key link role between strategy and practice. By using practice to inform strategy and by discussing relevant strategies/policies with practitioners, they are able to work alongside their colleagues to promote awareness and involvement.
Practice and role competencies
The outcomes expected of the consultant nurse relate as much to modernising and transforming culture as they do to traditional health care outcome measures that might include activity figures (Jones, 2002). For example, enabling nurses to use criteria effectively to refer, admit and discharge patients, and thus achieve reductions in length of stay, depends on a range of factors, such as:
- The existing culture of nursing and medical practice (informed by a baseline assessment of practice) (Field and Reid, 2002);
- Strategies to extend skills and empower nurses;
- Approaches to change that are inclusive and emancipatory, and do not disempower doctors and other health care professionals.
Achieving such a cultural shift is likely to have a major impact on the creativity and commitment of practitioners, which will in turn lead to further developments. In addition, it will help improve or maintain activity and other effectiveness indicators. Ultimately, practice will not change without all nurses modernising and changing their practice. Strategies and protocols can help guide change, but they are merely incentives and do not guarantee improved outcomes.
Consultant nurses need to explain the clinical element of their role and demonstrate that it has strategic intentions and outcomes (Manley and Dewing, 2002). Competing demands can mean that practice time is the first element to be squeezed within the work of a consultant nurse (Adams, 2002). Therefore, although fixed timetables are not appropriate, clear and regularly reviewed diary management is important to enable nurse consultants to retain contact with practice.
Practice often feels infinite and, while frustrating, it is often rewarding. This can lead to either overload and avoidance of practice, or to undertaking practice to feel effective immediately on a personal level. In the short term, this may be a comfortable domain but it is not an appropriate activity in terms of achieving longer term strategic effectiveness.
Without clear a strategy of what the consultant nurse does in practice there is also a danger of compensating for poor or absent management. This can result in the consultant nurse acting as an expensive bank nurse, functioning as a clinical specialist or, in some circumstances, undermining local leadership.
To date, the model underpinning our practice work has been fluid, as it is refined through our experiences. The model includes several components (Box 2). All of these rely on the consultant nurse having expert competence in the core skills of nursing and in at least one specialist area, as well as knowing what is relevant (saliency) and timely.
An appreciation of the culture(s) and expertise in facilitation and coaching, and other practice development skills, are essential attributes or competencies. In addition the consultant nurse must ensure that practice is seen as part of a bigger practice development strategy so there is a clear focus and organisational ownership. The consultant nurse needs access to skilled clinical supervision to reflect on these complex issues.
Finally, the consultant nurse must be part of a bigger team - one that has clear roles and accountability - to ensure that there are others who can reinforce and act on the consultancy that is offered by the consultant nurse.
Evaluation with the inclusion of others as key stakeholders will give valuable information about the effectiveness of the clinical or practice contribution of consultant nurses. Key stakeholders who want consultant nurses to work as a clinical nurse specialist will need support to understand the scope and potential of the consultant nurse role.
We are still testing and developing this model through our work, and with involvement and support from others. However, at this stage it is clear to us that consultant nurses should not work in isolation on a regular basis in providing care or a service that would usually be, or could be, provided by another nurse.
In addition, facilitation of others is a critical element of the practice role. Modernisation through implementation of strategic practice development plans is critical to the practice element of consultant nurses in order to provide better outcomes for patients, strengthening leadership in the team and retaining staff through improved job satisfaction (NHS Executive, 1999).
The consultant nurse, therefore needs to be an expert in facilitating the achievement of cultural change in teams and the organisation as part of the practice element of the role.