VOL: 98, ISSUE: 01, PAGE NO: 36
Jonathan Casey, MSc, RGN, DipN, is an advanced nurse practitioner (renal) at Arrowe Park Hospital, Wirral Hospital NHS Trust, Merseyside
Opportunities for nurses to work at higher levels of practice have increased in recent years, not least in the area of renal care. In the USA, the value of advanced practice nurses is widely recognised (Headley and Wall, 2000; Anderson et al, 1999; Bolton, 1998). The educational route has been clearly mapped and clinical nurse specialists/advanced nurse practitioners (ANPs) are expected to hold at least a master’s degree. In the UK, however, the requisite educational standards are less clearly defined and qualification for the role tends to depend largely on a nurse’s level of experience (Cox, 2000).
Not everyone is in favour of an expanded role for nurses. Kitson (1999) argues that an expansion of roles constitutes a threat to nursing because it ignores the profession’s ‘essential caring role’. Rushforth and Glasper (1999) argue that the development of an expanded role for nurses is fuelled by the recruitment and retention crisis in nursing and the continued pressure to reduce the hours and workload of junior doctors.
This article explores how the role of an ANP in renal care was developed at a time when many traditional boundaries were being redrawn in response to service needs, practice development and national policy objectives.
Renal medicine has long been an area of advanced nursing practice. Renal nurses have been using skills that in other areas would arguably be considered part of an expanded role, such as performing cannulation and venepuncture, since the 1960s.
The demand for renal services continues to grow: Mallick (1996) estimated that in the UK 80 patients per million people aged under 80 would need some form of long-term renal replacement therapy. As renal services expand and develop, so must the role of the renal nurse.
ANP development at Arrowe Park
Headley and Wall (2000) described patients with end-stage renal disease as having unique interrelated considerations, including adequacy of dialysis, management of anaemia, electrolyte disturbances, renal osteodystrophy, access patency, dietary considerations, treatment of co-morbid conditions and rehabilitative initiatives. In order to meet these needs at Arrowe Park Hospital, Wirral NHS Trust decided to appoint an ANP in renal care.
The role was based on the expectations of the consultant nephrologist, the trust and the Department of Health document, The New NHS: Modern, Dependable (1997), which encourages the development of expert nursing practice.
The UKCC’s (1999) proposed framework for recognising a higher level of practice expects candidates seeking advanced nursing recognition to have made full use of the learning opportunities available to them as well as displaying competence in practice. Therefore, the trust wanted the advanced nurse practitioner to have extensive experience in renal medicine, have completed a relevant postgraduate renal course and hold an MSc in clinical nursing.
An appropriate MSc course was being run by the University of Liverpool and two renal nurses were seconded for 12 months to attend it. The course seemed ideal because it combined academic knowledge with clinical skill development to an advanced level, producing graduates who could act as therapists in their own right or function as members of a multidisciplinary team.
ANPs in renal services
Renal nursing is extremely diverse, with acute and non-acute settings and a wide variety of dialysis modalities. It would seem to be the ideal environment for the development of advanced nursing practice as it bridges the gap between medical and nursing care, promoting continuity of care from the first referral until discharge. At our hospital the ANPs have clinical responsibility to the consultant nephrologist as well as professional responsibility to the head nurse. The role centres on the following interrelated functions: research and evaluation; expert practice; clinical leadership; education and training and service development.
The consultant acts as a mentor and the chief nurse also provides support and guidance. The ANPs perform many tasks previously carried out by doctors, such as the removal or insertion of central venous catheters to provide access for haemodialysis.
Pennels (1998) reminds us that the advanced nurse will be judged against a doctor’s skills. This, and the UKCC (1992) requirement that nurses should only undertake tasks for which they have been adequately trained suggests that protocol development, regular appraisal and open communication between all parties is vital. Membership of the Medical Defence Union is also recommended, and all protocols relating to the ANP role should be viewed by the trust’s legal department.
ANPs in practice
The ANPs work from an office within the renal department, interacting with all members of the multidisciplinary team. Patients and their families can contact them at any time for guidance, support or health promotion advice. Advanced nursing support is provided to dialysis satellite units and all wards with renal inpatients.
The ANPs take patients’ full histories, examine all new referrals from primary care, and order tests and follow-ups. Those patients arriving for renal biopsies or routine admissions are checked in by an ANP. When ANPs act as role models, participation in clinical audits, research studies and standard setting can be encouraged. Although some trusts have developed protocols for ANPs to administer and supply medicines, this remains an area to be developed within our trust.
The challenge facing ANPs when working as part of a medical team and within a medical model is to advance nursing knowledge and encourage communication between the two disciplines to ensure a team approach. It has been suggested that the issues surrounding quality of care are one of the main barriers to nephrologists’ acceptance of ANPs.
The issue of ‘caring’ must remain at the heart of nursing practice at all levels. Many commentators have argued that nursing must have a scientific base (Kitson, 1997) while others, such as Peplau (1988), consider nursing to be an art form. Long (1992) suggested that by emphasising a person-centred philosophy and scientific skills professional nurses will blend art and science, leading to more effective communication and greater understanding between nurses and patients.
In the present climate of cost-efficiency in health care, concerns have been expressed that ANPs could be exploited by being expected to perform mundane medical tasks, thus compromising the quality of nursing (Rose et al, 1998).
Viewed more positively, it could be argued that the role of the ANP in renal medicine is helping to expand professional boundaries. It could also be regarded as improving nurses’ professional status because it gives them enhanced autonomy, with medicine and nursing complementing each other.
A robust, although small, single-centre study of nurses (Magennis et al, 1999) demonstrated a generally positive approach to role expansion, although concerns were expressed about litigation, possible exploitation and adequate training. Rose et al (1998) added that further research should take place regarding the legal implications for both medicine and nursing.
In the short term the future for the renal ANPs involves the ongoing process of devising protocols, standards, policies and developing clinical guidelines. At Arrowe Park we will continue to challenge professional and organisational boundaries in the interest of patients and service development. Our practice will be guided by prevention, education and ongoing research, working in partnership with all members of the multidisciplinary team.
In January 2000 health secretary Alan Milburn announced the creation of nurse consultant posts and said: ‘The hard work and dedication of nurses has long been recognised, as has their potential to develop their roles further.’
This statement gives hope to nurses who are working to advanced level but also want further career opportunities which allow direct involvement with patients.
Nurses working at advanced levels in renal medicine clearly have a multifaceted role; they are expected to marry the needs of the nephrologist, managers, nurses and patients with their own personal and professional goals. This demonstrates the importance of partnership and mutual respect. All health care professionals must recognise and respect the roles and responsibilities of their colleagues in the renal team and beyond.
The continued development of the ANPs’ role is an exciting challenge, which is redefining the professional boundaries within the trust. However, ANPs must be wary of undermining and marginalising the value of being a registered nurse. Professional and practice development must be service-led, with the ANP prepared to innovate and adapt to an ever-changing renal and political environment.