VOL: 99, ISSUE: 37, PAGE NO: 32
Mark Flowers, RGN, DPSN, PGCert, is senior nurse in placement support; Susan Wright, RGN, is sister, orthopaedics outpatients department; both at Harrogate District Hospital
During the past decade, health care provision within the NHS has been subject to a number of radical changes. Many of these changes have been in response to developments in technology and professional knowledge that have brought about new treatment options. Others have occurred as a result of changing government policies and priorities, or of increased expectations of the NHS among patients and their families.
The emergence of nurse-led clinics in a growing number of clinical areas has, in many situations, been initiated in response to a number of factors. These include the need to rationalise services so that each aspect of patient care is provided by the most appropriate professional (Department of Health, 1999). This stance was also supported by the document The New NHS. Modern. Dependable (DoH, 1997), which identified a need to find new ways of working.
An additional influence on the development of nurse-led services has been the need to improve patient access to services. The NHS Plan (DoH, 2000) set targets for reducing waiting lists for outpatient appointments and, once again, reiterated the need for patients to be seen by the most appropriate person at each stage, and to be seen as quickly as possible.
The Harrogate Health Care Trust previously ran a very traditional orthopaedic service that was heavily reliant on patients being seen by the consultant or registrar, both before and after surgery.
The orthopaedic service at Harrogate District Hospital handles, on average, 20,400 appointments each year. The service is provided by four consultants, who are supported by registrars and two associate specialists.
The predominant caseloads are related to elective hip and knee replacements as well as follow-up appointments for patients post-trauma. These services are provided in 16 to 18 clinics per week.
Until one year ago, nursing staff who worked in the orthopaedic outpatient department performed a ‘traditional’ role. This involved escorting patients to see the medical staff, dealing with any documentation relating to the clinics and managing patients’ postoperative dressings as necessary.
Approximately 18 months ago, frustrated by the limited nature of their role, the nurses began to explore new ways of working. At the same time, a newly appointed orthopaedic consultant expressed an interest in supporting this initiative.
The nurses identified that many of the patients who were attending for postoperative follow-up appointments after elective surgery for a joint replacement did not need to see a medical practitioner, as many of the issues raised in these visits appeared to be more ‘social’ than medical in nature.
Development of a nurse-led service
The first stage in the development of a nurse-led service was to establish a project management team to explore fully the implications of the proposals. The team needed to include members of the various professional groups involved in orthopaedics, as well as individuals with the appropriate project management skills.
Once it was established, the project management team consisted of the outpatient department’s project manager, a consultant orthopaedic surgeon, nurses from the orthopaedic clinics and a senior nurse who had previous experience in project management.
Initially it was decided that the outpatient service should be reviewed. The model for service review was adapted from Hammer and Champy’s (1993) model of business process re-engineering.
Outpatient service review
The review was carried out by the senior nurse from the project management team who had previously used Hammer and Champy’s model to review the ophthalmic services in the trust.
The key information highlighted as a result of this service review was:
- Patients who saw the consultant at a post-discharge appointment often did not report any clinical problems but presented with issues that were more social;
- The consultant who was keen to introduce nurse-led follow-up clinics also felt that these visits were mainly social and did not make the best use of his time;
- Initial observations of contact between patients and health care professionals suggested that patients preferred to disclose problems of a social nature to nurses rather than to medical staff.
The main reason for this preference seemed to be that patients often felt that they had much more limited time with medical staff and that their problems were not important enough to discuss with the doctor. This information was obtained through informal discussions with patients as well as non-participant observation in the department by the senior nurse.
After the initial review, financial backing was obtained to establish a pilot of a nurse-led follow-up clinic that would include one consultant’s patients following hip and knee replacement surgery.
This pilot project required that appropriate nursing practice guidelines be developed so that the nurse practitioner running the clinic would be supported by appropriate protocols. No specific guidelines covering this area of extended practice had been previously initiated within Harrogate Health Care Trust, so the senior staff nurse working within the department was appointed to the post of lead nurse for the project and was given appropriate training to undertake this role.
The training involved shadowing the orthopaedic consultant responsible for the patient group. The lead nurse, together with the senior nurse from the project group (who was a qualified and experienced orthopaedic nurse) was also fully involved in developing the nursing protocols. Members of the project group also visited Leeds General Infirmary where similar nurse-led initiatives were in place.
The project group decided that the nurse-led initiative provided an opportunity for patients to deviate from the normal patient journey through the department. The new route resulted in more opportunities for patients to be in contact with health care professionals.
Opportunities for new routes
The patient journey that was agreed upon for the nurse-led initiative was:
- The nurse introduces himself or herself at the preoperative assessment clinic and explains his or her involvement in postoperative care;
- After the operation the nurse sees the patient prior to discharge. A date is arranged for the nurse to telephone the patient within one week of discharge;
- At one week postdischarge, the nurse telephones the patient to ask questions from a proforma that has been devised in conjunction with the consultant. This proforma was developed based on the best evidence available. A date is also arranged for a second telephone call at six weeks postdischarge;
- At six weeks, the patient is telephoned with a second series of questions relating to his or her progress;
- At three months, the patient attends the clinic and has an X-ray, which is reviewed by the consultant. The nurse sees the patient to discuss their progress and any issues that relate to his or her care;
- At this appointment the patient is also given a patient satisfaction questionnaire to complete, which helps the clinic staff to constantly evaluate the quality of service their patients receive.
Postoperative assessment tools
The questionnaires are designed to document patient follow-up in the nurse-led clinics and are based on the Oxford scoring system (Dawson et al, 1996), which is a postoperative orthopaedic assessment tool. This assessment identifies 12 areas (Box 1).
The data from the assessment tool questionnaires forms the basis of a benchmarking tool that will be used as part of a recently formed orthopaedic collaborative established with other NHS trusts. At present, Harrogate is the only member of the collaborative with an established database.
Issues encountered when setting up a pilot
When setting up the nurse-led orthopaedic clinic pilot the project team encountered a number of issues that can be summarised as follows:
- There was concern among the team that since the pilot only included one of the unit’s four orthopaedic consultants, the patients may perceive that they are being offered an inconsistent service;
- Obtaining funding to support the initial project proved difficult, which resulted in a delay in starting the pilot. However, funding was eventually obtained from the primary care group;
- Harrogate Health Care Trust had only limited previous experience of setting up nurse-led clinics and, as a result, a great deal of preparatory work had to be done to establish protocols to support nurse autonomy prior to starting the pilot;
- The nurse-led clinics needed to cross professional boundaries to make direct physiotherapy and occupational therapy referrals. Initially this resulted in some professional territorialism;
- At the beginning of the pilot no clear funding strategy for a permanent change in practice had been agreed. As a result, there was a certain amount of scepticism in the group as to whether a long-term change in practice would be possible.
Evaluating the pilot
After the initial pilot was completed, it was evaluated by the lead nurse and senior nurse from the project management team (Box 2, p33). It was felt that when developing any patient-focused service, the patients who had been on the receiving end of the service should be involved in the review process.
The pilot review process was based on an adapted model for reviewing changes in practice presented by Jennings et al (2001) who identified three dimensions to the process:
- Structure of care indicators;
- Process indicators;
- Outcome indicators.
The structure of care indicators within nurse-led orthopaedic clinics include structural variables such as the environment and location of the clinic and the provision of appropriate resources in terms of both equipment and personnel.
Methodologies of evaluation
The methodologies used to evaluate the pilot included both participant and non-participant observation by clinic staff, as well as a patient satisfaction questionnaire.
The indicators for the processes of care were measured by observing patients attending the clinic and noting any problems with the processes of the clinics that arose during the pilot.
This was achieved by using both participant and non-participant observation by staff and using data obtained from patient satisfaction questionnaires.
The third evaluation methodology was the measurement of outcome indicators. This involved recording the number of patients seen at the nurse-led clinic as well as measuring quality indicators achieved from the patient satisfaction surveys.
The main issues highlighted by the evaluation of the pilot study related to patient satisfaction, cost-effectiveness, reduction in waiting time and clinical responsibility.
Patients were observed to talk more freely to the nurse about social problems. This communication improvement was also helped by the longer, 15-minute slots allocated within the nurse-led clinic.
Patients identified that they had easier access to advice because the nurse at the clinic was able to provide a permanent contact number.
Patient evaluation indicated that in all cases they were happy to be seen by a nurse rather than the consultant for the follow-up appointment.
The provision of a nurse-led service was cost-effective compared with a consultant-led service. On a sessional basis, the cost of a nurse-led clinic was £50 compared with £110 for a consultant session.
Reduction in waiting lists
During the pilot the nurse saw, on average, eight patients per week. This, in turn, translated to freeing up approximately four new referral slots for the consultant. On an ongoing basis this will allow up to 200 extra patients to be seen each year by the consultants (Fig 1).
The new nurse-led clinics provided a team approach to patient care with both the consultant and the nurse taking responsibility for caseloads.
This has led to the more efficient utilisation of resources. Both medical and nursing staff feel that they have benefited from the development. Clinic nurses say that their increased responsibility and autonomy give them greater job satisfaction.
Patients have also benefited from the introduction of rapid referral processes so that they are seen by physiotherapists and other members of the multidisciplinary team as required.
After a six-month pilot it was decided that the nurse-led orthopaedic follow-up clinics should be continued and expanded. It is hoped in the near future to incorporate the caseloads of other consultants as well as patients with other orthopaedic postoperative conditions.