One stop outpatient clinics led by nurse practitioners have a positive impact on care. A hospital urology department encouraged nurses to take initiatives forward
Loraine Lane, MSc, BSc, AdvDip, RGN;Sarah Minns, MSc, BSc, AdvDip, RGN; both are urology advanced nurse practitioners at Queens Hospital, Burton upon Trent.
Lane L, Minns S (2010) Empowering advanced practitioners to set up nurse led clinics for improved outpatient care. Nursing Times; 106: 13, early online publication.
Nurse led clinics have been shown to provide more efficient outpatient care and reduce waiting times. A hospital urology department set up two clinics to improve the patient care pathway, one of which is led by advanced nurse practitioners. This article describes the training and development process, audit results and future plans.
Keywords Urology, Nurse led, Advanced nurse practitioner, ANP
- This article has been double blind peer reviewed
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- Nurse leaders and managers need to recognise and use the skills of their nursing team.
- Nurses must be aware of a shift in emphasis towards the use of a “one stop approach” (James and McPhail, 2008).
Nurse practitioner led outpatient care has a positive impact on quality of care (Loftus and Weston, 2001), improves patient experience and offers role development for nurses. Nurses working in nurse led clinics are called upon to demonstrate elements of advanced practice ; carrying out detailed physiological assessment, care planning, delivering treatments, monitoring of patients’ condition and medicines management (Hatchett, 2003). Lipley (2001) found that nurse led clinics provide more efficient outpatient care while cutting waiting times. It is not surprising that this method of organising care is now accepted by medical staff and managers as an alternative to traditional consultant led systems of care.
Queens Hospital opened a designated urology department in 2001. At this time the majority of work in the department was consultant led.
Over the past eight years we have implemented changes to meet the constant challenges of ensuring patients are assessed, diagnosed and treated within specified waiting times. These targets appear to have developed into an evaluation tool for measuring individual hospital performance in the NHS (DH, 2009; 2007a).
It has become essential to empower appropriately qualified nurses to undertake a wider variety of clinical tasks to make the department a predominantly nurse led service. This enables us to optimise advanced nurse practitioners’ (ANP) skills, which then frees up time for the urological consultants to meet clinical demand and provide medical expertise in other areas of complex patient diagnosis/treatment.
New ways of working are discussed at monthly urology team meetings, and senior nurses in the department take initiatives forward with the support of urology consultants, hospital matrons and business managers. Working collectively as a team, changes in practice are introduced.
Within the urology department is a facility for postoperative urology/gynaecology patients who are deemed medically fit for discharge to undergo trial without catheters (TWOC) before going home. This has helped to free up inpatient beds, resulting in a reduction in cancelled operations.
As part of the service redesign, we have redefined the ANP role to include the following diagnostic interventions:
- Performing prostate biopsies;
- Ordering diagnostic and staging radiological investigations;
- Consent for certain diagnostic procedures;
- Independent nurse prescribing.
Implementing the nurse led clinics has been an ongoing process that has met with numerous challenges along the way, such as writing business cases.
Throughout the process we have networked with urology colleagues across the country to find evidence that nurse led services are successful, financially beneficial to the hospital and provide a more streamlined service for patients (James and McPhail, 2008; Lipley, 2001).
The Nursing Midwifery Council (2005) stated that “advanced nurse practitioners are highly experienced and educated members of the care team who are able to diagnose and treat your health care needs or refer you to an appropriate specialist”.
Throughout the process of developing nurse led services, it has been necessary to review the skills and knowledge of all nursing staff and develop these skills according to the department’s needs.
This has involved developing training packages that are competency based and signed off by a designated mentor (for all ANPs’ training needs a urology consultant has acted as mentor). This has enabled us to achieve a high standard of safe practice.
Primary responsibility for the governance of new roles designed to meet the needs of service provision should rest with employers and commissioners, to ensure robust organisational governance arrangements to monitor clinical practice (Council for Healthcare Regulatory Excellence, 2009). This is the process adopted at Queens Hospital, where all advanced nursing practice must be authorised by the nursing professional forum committee, executive management team and trust board.
It became apparent that we were experiencing problems with meeting cancer waiting time targets for patients referred with suspected prostate cancer. Working with the cancer service improvement team, we looked at ways of solving this problem. One of the initiatives we decided to implement was a one stop suspected prostate cancer clinic, which meant the two urology ANPs had to train and deemed competent in transrectal ultrasound sonography and prostate biopsy. Part of the training included visiting other urology departments that had already implemented this service.
We have completed two audits, a patient satisfaction survey and a comparison of the results of prostate biopsies taken by a urology consultant with those taken by the urology ANPs.
The clinical audit manager reviewed the audit/patient satisfaction survey registration details from an ethical perspective and felt it did not require research ethical committee approval. Clinical governance issues were also addressed; the professional forum committee discussed and approved all documentation.
The results demonstrated that both the ANPs’ outcomes are equal to those of their medical colleagues.
After the audit and patient satisfaction survey were presented, further discussions took place and we decided a multidisciplinary approach would be the most appropriate way to deal with our particular care pathway issues, in terms of reducing waiting times and meeting cancer target treatment times.
We have achieved this by running two clinics on the same day, the one stop prostate specific antigen clinic run by a urology consultant, and the nurse led prostate biopsy clinic (patients attending this clinic have already been seen by a urologist).
The setting up of these two clinics was an operational decision and the patient satisfaction survey focused solely on those who attended the one stop PSA clinic. Our intention was to gain opinions of the new clinic from the men who used this service.
The one stop clinic has been running since April 2009 and over 120 patients have so far attended. A patient satisfaction survey showed extremely positive results. We wanted to gain specific information so the questionnaire used closed questions but gave patients the opportunity to add comments for each question. Some examples of survey results and patient comments are given below:
- Ninety five per cent of patients felt the wait between GP appointment and hospital appointment was about right;
- All said they were pleased to have been offered the biopsy on the same day as the clinic appointment;
- All said they were given adequate information about the biopsy and the possibility of diagnosing prostate cancer;
- The majority (84%) felt they were completely prepared for the biopsy in terms of information provided at the consultation;
- Ninety per cent rated the quality of the one stop PSA clinic as excellent.
Patient comments included the following:
“All staff very friendly – helpful and very courteous and very caring. Couldn’t have been better.”
“The one stop prostate biopsy clinic is an excellent procedure, it saves extra appointments and gives immediate treatment when required.”
We also received some negative comments, which all focused on the environment, for example:
“The downside to my four visits was that I had to spend much time sitting in the passage which has to double as a waiting room.”
The patient satisfaction survey has demonstrated that patients who have attended this clinic feel we are delivering a high quality service.
To continue to achieve high levels of patient satisfaction, the team realises we need to run a successful, viable, cost effective unit that provides high standards of care, responding to the ever changing challenges and new opportunities of the NHS. This can be achieved by reflecting on current practice and looking at where improvements can be made (DH, 2008). However, this requires knowledge of commissioning to ensure we meet patients’ needs and treatment trends.
To achieve all the above it is vital that nurses receive adequate continuing professional development opportunities and support from both senior nursing and medical colleagues.
Looking forward, the urology team plans to introduce a training programme later this year for the two urology ANPs to learn how to perform flexible cystoscopies. At a number of hospitals both locally and nationally this has already proved to be an effective and efficient use of the urology ANP role and will help us to meet the increasing number of patients needing this procedure.
A further project is based on the DH (2007b) initiative on implementing care closer to home, which will help reduce waits and delays and contribute to our meeting the 18 week pathway.
Our urology/gynaecology department has already successfully implemented a care pathway between primary and acute care for female patients with continence problems. We are currently negotiating with business managers and primary care, looking at other clinics that could be taken out into the community. These could include:
- Lower urinary tract assessment clinic;
- Psychosexual counselling clinic;
- Prostate biopsy clinic.
The two urology ANPs have demonstrated that they can deliver an optimal service for patients in terms of better resource use, provide high quality care with shorter waiting lists for diagnosis, treatment and reduced hospital visits, resulting in improved patient experience and health outcomes.
- The NHS next stage review suggested that “we need to…move from an NHS that has rightly focused on increasing the quality of care to one that focuses on improving the quality of care” (Department of Health, 2008).
- The nurse led clinics aim to achieve excellence in outpatient services through an improved focus on the patient pathway and service user experience.
Council for Healthcare Regulatory Excellence (2009) Advanced Practice: Report to the Four UK Health Departments. London: CHRE.
Department of Health (2009) Equality Impact Assessment (EqIA): 18 Weeks Referral to Treatment Standard. London: DH.
Department of Health (2008) High Quality Care For All: NHS Next Stage Review Final Report. London: DH.
Department of Health (2007a) Cancer Reform Strategy. London: DH.
Department of Health (2007b) Implementing Care Closer to Home: Convenient Quality Care for Patients. Part 1: Introduction and Overview. London: DH.
Hatchett R (ed) (2003) Nurse-Led Clinics: Practice Issues. London: Routledge.
James N, McPhail G (2008) The success of a nurse-led, one stop suspected prostate cancer clinic. Cancer Nursing Practice; 7: 3, 28-32.
Lipley N (2001) NAO backs nurse-led clinics to ease outpatient waiting. Nursing Standard; 15: 46, 6.
Loftus LA, Weston V (2001) The development of nurse-led clinics in cancer care. Journal of Clinical Nursing; 10: 2, 215-220.
Nursing and Midwifery Council (2005) Post Registration Nursing Framework. London: NMC.