The sphere of professional nursing
The sphere of professional nursing has been characterised by a process of rapid development, professionalisation and augmentation of nursing practice, driven by international policy drivers, national policy drivers, changes in medical and nursing paradigms (including shifts towards evidence-based practice) and the effects of a more consumer-driven NHS culture within the UK. Nursing practice has responded to a variety of rapid advancements in healthcare practice and medical technology by extending and advancing the scope of nursing roles. Advanced nursing practice, with its associated roles of clinical, managerial, academic and combined natures, has afforded nurses the scope to augment their roles within specialist or other spheres, often stepping into areas which were traditionally the province of doctors. The NMC (2005) has supported the development of such roles, but only if they remain true to nursing paradigms and philosophies and enhance rather than detract from the provision of the highest possible standards of nursing care.
According to UK policy drivers, the development of nursing practice into more advanced spheres has been and continues to be a governmental priority, with support for this kind of advanced practice being derived from the claim that it will not only support the NHS in meeting the needs and preferences of consumers, a high priority in the current context of the UK healthcare system, but also because it is one of the characteristics of the ongoing changes of the NHS (Department of Health, 1997, 2000). Wilson and Bunnell (2007) describe advanced nursing practice as a term which covers a wide variety of what are termed ‘extended roles' within nursing, which have appeared because of these changes and drivers. One of these drivers, and one which has been a considerable motivator for changes in the delineation of practice roles which cross over from nursing into medicine, is the introduction of the European Working Time Directive, which has limited not only the numbers of hours which people can work (including doctors), but also set out stringent guidelines on the rest periods between working shifts (Jones et al, 2004).
This essay will critically examine the effects of this particular international policy driver in the redefinition of areas of nursing through expansion into more medical arenas, and how such an advancement of practice can effect the provision of holistic patient assessment for patients attending a surgical pre-admission clinic. It will examine the nature of the advanced nursing role, the potentials inherent within it within this sphere, and some of the evidence which supports such a role in clinical practice.
Discussion
Achieving compliance with the European Working Time Directive has posed a number of challenges for NHS services, (Sheldon, 2004) mainly because the service has been run on a model of doctors and medical students working extended (often apparently unlimited) hours (Jones et al, 2004). Having limitations placed on the length of time Doctors work, and the minimum time for rest periods between work periods, has led to major changes in how doctors practice, but also how care and practice is planned, designed, managed and delivered whilst maintaining high standards of care (Jones et al, 2004). Jones et al (2004) describe one hospital where such changes included a shift in focus of care which included the introduction of a multi-skilled team for night cover, which included advanced nursing roles. Jones et al (2004) found that compliance with the EWTD was possible, whilst still maintaining good standards of clinical care, and also continuing to ensure training opportunities for medical students and doctors in ongoing training, and reducing the workload for both junior doctors and consultants. This is just one example of how nurses across all areas of the service have been moved into advanced roles in order to take over some of the spheres of practice that were historically carried out by doctors, and by medical students (Harris and Redshaw, 1999). This seems to be a timely and serendipitous coincidence of professionalisation of nursing practice and necessary legislative changes which have given some nurses the extended responsibility and (arguable) autonomy that they feel they deserve. The advances in nursing roles and capabilities may also be related to other aspects of professional development in nursing, which include increased opportunities for specialist postgraduate study and education, and other issues such as advanced technologies which have expanded the scope of practice (Gardner and Gardner, 2005). However, such roles are usually equated with the concomitant professionalisation of nursing coinciding with the assumption of advanced roles within traditional medical spheres (Tachakra and Deboo, 2001).
Nursing practice has advanced in a number of ways, including extended responsibilities, and the emergence of new roles that include titles such as Nurse Practitioner and Clinical Nuse Specialist. These have their roots in the 1990s when a range of new advanced roles were emerging in the nursing sphere, not all of which stood the test of time (Walsgrove and Fulbrook, 2005). However, with the approval of the Royal College of nursing, certain of these roles have gained in status and have developed into integral parts of clinical practice in certain areas (Walsgrove and Fulbrook, 2005). There is, however, no separate registration for nurse practitioners or clinical nurse specialists with the Nursing and Midwifery Council, and no central qualification which relates to all advanced practice roles (Walsgrove and Fulbrook, 2005).
According to the NMC, advanced nursing practice can be defined as follows: “A registered nurse who has command of an expert knowledge base and clinical competence, is able to make complex clinical decisions using expert clinical judgement, is an essential member of an interdependent health care team and whose role is determined by the context in which s/he practices.” (NMC, 2005).
There are key areas here which relate to the move into the sphere of medical practice, including the idea of making complex clinical decisions, which relates to the focus of this essay, the development and implementation of nurse led surgical pre-assessment clinics. This is an area where expert clinical judgement, based on a specialist knowledge base, is required in order to carry out complex and holistic assessments to support optimal patient care. Walsgrove and Fulbrook (2004) describe such advanced roles as Nurse Practitioners as being founded in nursing paradigms which are focused on holistic principles and patient-centred, individualised care, despite such roles comprising medical tasks. Despite this orientation of the advanced role, there are those who continue to see such nurses as merely taking on extra tasks in order to act as substitutes for the Junior Doctors who used to perform such basic medical procedures (Walsgrove and Fulbrook, 2005). This author believes it does not matter how the role is viewed, but only that nurses have espoused these roles and seized the opportunity to not only advance their practice but gain the recognition they deserve for their specialist expertise, whilst simultaneously making use of the opportunity to improve patient care.
In relation to the focus of this essay, Craig (2005) shows that pre-operative assessment (has been advocated for implementation because of its potential to achieve a number of outcomes, including reducing cancelled operations on the day of surgery, and therefore helping to reduce waiting lists. While as Craig (2005) shows, pre-operative assessment has historically been provided by junior doctors, the change in focus of their role, and the limitations introduced by the reduction of their working hours, in addition to the new roles being taken on by nurses, has led to nurse-led preoperative assessment.
Walsgrove and Fulbrook (2005) show that in certain areas of practice, these extended roles can actually improve the standard of holistic patient care, because they incorporate both medical and nursing care, but that there continue to be not enough support for such nurses and not enough understanding of their roles, responsibilities and the scope of their practice (Walsgrove and Fulbrook, 2005). According to Gardner et al (2007), the rapid introduction of such roles has contributed to this confusion about scope of practice, and Wickham, (2003) suggests that to counter this, there needs to be more clarity about role and career progression. Trust support is vital for successful implementation of such roles (Walsgrove and Fulbrook, 2005).
According to Wortans et al (2006), advanced nursing roles such as nurse practitioner roles allow for a focus on quality of care and on consumer satisfaction, despite a lack of clarity about the scope and boundaries of such roles. This means that there is great potential to develop role expression in whatever ways are required by the service. Casey and Ormrod (2003) show that this has emerge from recent health initiatives . which have put the focus on patient-centred care within the health service, with the outcome of nurses performing advanced of roles in surgical pre-assessment. At the same time as the role has evolved, so has the theory and practice of surgical preassessment within the NHS (Casey and Ormrod, 2003). So the evolution of NHS services has perhaps been a driver for the development of such roles, alongside increasing professionalisation and the external drivers such as the European Working Time Directive. But it has been suggested by some authors that advanced nursing practitioners see their role as enhancing their professional status and position, and giving a title and recognition to the kinds of advanced, medical roles that some nurses have been performing for many years without proper reward or appreciation (Wilson and Bunnell, 2007).
The kinds of roles of the advanced practice nurse within the nurse led surgical preassessment clinic will involve utilising assessment skills which include physical examination, evaluation of health care and health promotion/education needs, implementation of interventions or procedures to meet these needs, and interprofessional/inter-agency collaborative working (Walsgrove and Fulbrook, 2005). Research by Gardner et al (2007) show that some of the dimensions of advanced nursing practice include direct, holistic patient care, assessment, interpretation of test data, patient counselling, managerial aspects of the role, education, research and the development and maintenance of clinical care standards. Higgins et al (2006) found similar role parameters, which including teaching for students and developing professional practice. There may be differences across roles in different trusts, but direct patient care is a fundamental aspect (Griffiths, 2006; Gardner and Gardner, 2005). Glover et al (2006) also say that such roles may include case management, mentoring and preceptorship, acting as a patient advocate and as a liaison between different areas of practice and different professionals and the patient.
This finding reflects what Siccardi (1999) describes as a change in philosophical background or paradigm for nurses providing advanced roles, whereby nurses retain a grounding in nursing but expand their functions and actions to include higher levels of critical and diagnostic thinking which contribues to holistic, humanistic care and support of patients. Siccardi's (1999) research suggests that medical roles are being undertaken, particularly in relation to diagnostic reasoning, although the only professionals within the UK who can officially diagnose remain doctors and, with limitations, midwives. This is also underlined by research by Balkon (2000), who underlines the difference between advanced nursing practice roles and traditional functions of nurses, wherein advanced practice nurses must incorporate and combine the knowledge and skills of their nursing background and experience with acquired knowledge and functions associated with medical practice, which then serves to confuse the delineation between the two different professional spheres.
However, there is still debate about the degree of autonomy that such nurses enjoy, and there are some suggestions that this will also vary depending on the actually sphere of practice of the nurse (Cutts, 1999). This underlines the need to have clear understanding of the role, especially to justify the value and importance of specialist nursing roles within the wider context of holistic service provision (Glover et al, 2006). Research by Zuzelo (2003) shows that, similar to doctors, nurses within advanced nursing practice roles are educated to postgraduate in both general advanced practice and specialist areas of knowledge. The generic advanced knowledge would include similar levels of knowledge about health and physiological/biological, assessment, physiology, pathophysiology and even elements of pharmacology and prescribing, perhaps involving acquisition of nurse prescriber status (Zuzelo, 2003). Footner (1998) also emphasises that advanced nursing roles involve specialisation. It is this specialisation which also mirrors medical practice but also consolidates the role of the nurse within surgical pre-assessment clinics.
However, Ormrod and Casey (2004) also demonstrate the nature of the current methods of education and preparation for these roles, especially within surgical preassessment, and the apparent lack of any consistent approach to education and training for staff adjusting their scope of professional practice. There is a need to redefine what constitutes competence for these practitioners, and to have clear strategies and guidelines to ensure nurses within these roles are provided with the support and guidance required to acquire the knowledge and skills necessary for preassessment. This, obviously, would have an impact on the quality of care and the quality of the patient experience.
The ideal seems to be, within surgical pre-assessment and within advanced nursing practice in general, that nurses will be able to employ the skills, knowledge, and autonomy of medical practice within nursing care, within nursing models that are more holistic and patient-centred rather than within medical models (Wilson and Bunnell, 2007; Gardner and Gardner, 2005). This may be where some of the resistance to the expansion of advanced nursing roles may be found, where doctors and other professionals, and even the public, find that this threatens the status quo (Cutts, 1999).
Within the field of surgical pre-assessment, Clinch (1997) show that not only can nurses provide consistently high standards of care, but that patients found that such pre-assessment clinics helped to reduce stress and providedmuch needed information and counselling about the coming surgery. Research by Hunt (2006) also shows clearly and unequivocally that nurse-led pre-assessment clinics make a real and important difference to patients' hospital experiences and expereinces of surgery, including their recovery rates. While this is a limited study and cannot be generalised, there is some indication within this research that certain dimensions of the patient experience of surgery, related to the subjective experience of the quality of care and recovery, are affected by having nurses lead pre-assessment clinics (Hunt, 2006). However, Haine et al (2003) also argues that such clinics are not always the panacea they are purported to be, and there are limits in their scope and application, and these should be taken into account when designing and planning such services. Craig (2005) shows that nurse-led preopertive assesssment clinics can contribue to reducing the number cancellations of surgical procedures, but Ewens (2003) shows that the lack of clarity in such roles can lead to nurses finding them difficult to carry out. This may be related to the general changes which show the negative effects of the European Working Time Directive, particularly its effects on training and quality of care (Shabbir et al, 2005). Newton (1996) shows that nurse-led pre-admission clinics in orthopaedic surgery can positively affect patient satisfaction, length of in-patient stay and watiing list management. Koay and Marks (1996) also show such clinics can be successful in ENT elective surgery. There is, apparently, plenty of evidence of the success of these kinds of extended nursing roles within surgical pre-assessment, and many have occurred before the introduction of the European Working Time Directive, showing that while this external driver may have been the driving force in consolidating these roles, and making them more prevalent across NHS services, their origin may actually lie in the added value of specialist nursing knowledge and input which also fits in with ongoing developments of healthcare provision and design.
Conclusion
It would seem, from the literature, that advanced nursing roles within surgical preassessment clinics are not only viable, but a fundamental aspect of the provision of the best quality holistic patient care. Within the restrictions imposed by the European Working Time Directive, doctors have had their scope of practice seriously curtailed, which has opened the doors for nurses to fill this gap. While some may argue that this goes against the fundamental model of nursing care, it would seem, from the literature and from debate on this issue, that nurses carrying out advanced roles, taking on some of the functions of their medical colleagues, can actually provide a better service because it is more holistic and comprehensive, based on more patient-focused ideologies which look at all aspects of the individual, and build on the specialist knowledge, experience and training that they have acquired along their journey of professional development and practice within a specialist area.
Castledine (2002) sees this kind of practice as the future of advanced nursing, whereby nursing and specialist medical practice, and holistic care are combined within evolving, quality-led NHS services. This change and development was already taking place, and so the introduction of the European Working Time Directive has only consolidated the changes and encouraged those within medical and health services who were reluctant to accept advanced nursing practice roles to see their value and their inevitability. External drivers of this nature may unwittingly serve the purposes of nurses as a profession and healthcare services in general, but only through processes of change. Serendipitously, in this case, the changes have benefited service quality and nursing professionalisation, but the longer-term effects on the medical profession have yet to be seen.
