- Email: [email protected]
Should aspiring consultant nurses follow a medical training programme?
International Emergency Nursing (2008) 16, 29–34
www.elsevierhealth.com/journals/aaen
Should aspiring consultant nurses follow a medical training programme? Rebecca Hoskins RGN, RN (Child), BSc Hons, MA (Consultant Nurse & Senior Lecturer in Emergency Care, United Bristol Healthcare Trust & University of the West of England) Emergency Department, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom Received 25 July 2007; received in revised form 24 October 2007; accepted 7 November 2007
KEYWORDS
Abstract Aim: To investigate the level of educational preparation current consultant nurses
Consultant nurses; Educational development; Succession planning; Emergency care
felt was required to prepare aspiring consultant nurses for the role. Background: The radical introduction of the consultant nurse role was thought to be groundbreaking. This new role was to provide better outcomes for patients by improving the service and quality of care delivered to patients. With such great expectations of these professionals there was little guidance available as to the appropriate preparation for such a new and innovative role. Method: A national survey was undertaken of the Department of Health Consultant Nurse Emergency Care group (n = 18). Results: Key themes emerged around the development of a medical model of educational preparation for this role, as well as the development of a national programme of preparation. The majority favoured the current medical model and certainly supported the concepts of interprofessional programmes of study in universities. Conclusions: Further work is required in developing a nationally recognised programme of preparation for the role. c 2007 Elsevier Ltd. All rights reserved.
The radical introduction of the consultant nurse role in 1999 was thought to be ‘ground breaking’ as it recognised the full contribution of nurses in the health arena (DH, 2006). This new role was to proE-mail address: [email protected]
vide better outcomes for patients by improving the service and quality of care delivered to patients, as well as strengthening leadership within the profession. With such a massive expectation of these professionals there was little guidance available as to the appropriate preparation for such a new and
1755-599X/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2007.11.003
30 innovative role. The main aim of this study was to investigate the level of educational preparation current consultant nurses felt was required to prepare aspiring consultant nurses for the role. The New NHS - Modern, Dependable (DH, 1997) examined reconfiguring the workforce to reduce the boundaries between professional roles, in order to meet the growing needs of the patient population accessing the services of the NHS. It was recognised that with an increasing and aging population requiring acute and long term care against a background of an aging nursing population, reduction in junior doctors’ working hours as well as an increase in part time working by medical staff meant that new roles in healthcare were required in order to meet the health needs of the community. The NHS Executive (1999) produced clear guidance on establishing consultant nurse posts and identified the key components of the role. These posts have been in existence since 1999 and preliminary targets were put in place in order to develop 1000 consultant nurse posts for nurses and 250 posts for allied health professionals by 2004 (NHS Executive, 1999). Current estimations suggest that there is a deficit of about 200 post-holders (Guest et al., 2004). Various suggestions have been proposed as to why there is currently such a shortfall in recruiting to these posts, such as a lack of a national coherent staff development strategy, professional and interprofessional funding concerns, and health professionals themselves being uncertain about meeting the requirements of these posts (McSherry and Johnson, 2005). The principle aim in developing these posts was to enable advanced clinical practitioners to influence decision-making at a strategic level while maintaining patient contact. This research study aimed to investigate the educational preparation required for the successful development of the consultant nurse role within the NHS, specifically within emergency care.
Literature review The roots of the development of the concept of consultant nurse posts can be traced back to the 1980s when nursing development units were in their infancy and the role of nursing as a therapeutic speciality was recognised in its own right, (Wright, 1991). Throughout the late 1990s extensive consultation took place within the nursing, midwifery, and health visiting professions, looking at a new strategy for the development of the profession, (NHS Executive, 1999). There were over riding concerns that many of the more experienced practitioners were leaving practice–based posts in order to
R. Hoskins advance their careers, because of a fundamental limitation in the career structure. Once practitioners had reached the position of ‘sister’ or ‘charge nurse’ in any speciality then the only options for career progression lay in a few clinical specialist posts, research, management or education, thereby leaving a void in the pool of experienced practitioners in practice (NHS Executive, 1999). A key message from the report was that there was a need to strengthen professional leadership, while promoting awareness of how new and expanded roles could result in improving services and quality care for patients (NHS Executive, 1999). A response to these concerns came in the form of two Department of Health (DH) papers, A First Class Service (DH, 1998) and Making a Difference (DH, 1999). The former identified a clear agenda for action in the NHS to safeguard standards of care and continually strive to improve the quality of care. The latter paper outlined the strategic plans for nursing, midwifery and health visiting and the contribution of nursing to healthcare for the future. For the nursing profession, key to this was the creation of the role of the consultant nurse. It was felt that consultant nurses were in an ideal position to facilitate and support the delivery of government reforms as they had a strategic overview and were able to look at the wider picture. The challenge that was identified was to place this role at an appropriate level, one, which would be able to initiate and direct service developments while obtaining acceptance from all members of the team and professional hierarchy. The Chartered Society of Physiotherapists (2002) suggested that the establishment of consultant nurse and therapist posts were directly related to national initiatives and concurrent government priorities and targets, cutting waiting lists, tackling Ischaemic heart disease, cancer and mental health, handling emergencies more efficiently, strengthening primary care and improving services for older people. This, they argued, would facilitate the success of the post-holders. Crouch et al. (2003) argue that while the creation of such posts was to improve career prospects and strengthen education and training, there was also an important role in boosting the status of nurses. The creation of consultant nurse posts would enable the NHS to implement a new vision for nursing which in turn would facilitate the ‘new modern NHS’ (DH, 1997), by acting as role models and utilising evidence-based practice, clinical effectiveness, increased individual accountability and clinical governance within their role, (DH, 2006). The work of Manley (1997) has informed the development of consultant nurse posts. Through
Should aspiring consultant nurses follow a medical training programme?
Methodology The questionnaire used in this study was used to survey participants in order to gain an insight and understanding into their experiences, knowledge and perspectives of the subject being studied. The aim of the questionnaire was to investigate the issues surrounding the educational backgrounds of consultant nurses currently in post, their perceptions of the characteristics of master’s level education, their perceptions of the ‘ideal’ educational preparation for the role drawing on their experiences as well as their perceptions surrounding current programmes of study offered by universities and the current continuing professional development requirements of the role. Following collection of demographic data in order to gain a profile of the ‘typical’ respondents, the questionnaire was divided into sections and questions were designed to be closed as well as open ended and aimed to investigate the participants’ perceptions and experience of the educational preparation for the role. In constructing the questionnaire the literature was utilised in gaining practical considerations in the design, such as the layout of the questionnaire and the sequencing of questions (Oppenheim, 1992). The Department of Health Consultant Nurse Emergency Care email group provided a purposive sample for the research study. Purposive sampling involves the conscious sampling of certain participants to be included in the study. This sample was deliberately chosen by the researcher on the basis that these were the best available people to provide data on the issues being explored (Parahoo, 1997).
Ethical considerations The questionnaire was piloted with two people who were not involved in the study, as a result of this some minor changes were made. The appropriate NHS multi-centre research ethics committee (MREC) approved the study. Morrison (1993) and Wilson and McLean (1994) comment that piloting the questionnaire has several functions, principally to increase the reliability, validity and practicability of the questionnaire as a tool for data collection.
Results and discussion Questionnaires were sent to 21 participants and 18 were returned by post or email, giving a response rate of 86%. The results were analysed by using the process of coding the answers in order to undertake the process of reducing the data to manageable proportions. A coding grid was constructed for closed questions such as the demographic data collected. From the data, which emerged from the open questions within the questionnaire, the emergent themes were coded. The categories were kept as broad as possible. Using the rule of parsimony enables the data to remain manageable and permitted subcategories to be derived from the larger domain (Morse and Field, 1996). Of the 18 questionnaires analysed the largest proportion were female 83% (n = 15) compared with 17% (n = 3) male respondents. The largest proportion of respondents had been in their current post for between 3 and 4 years. The majority 89% (n = 16) had been in post for 2 or more years. The ages of the respondents ranged from 32 years to 56 years old. The mean age being 42-years old. The range of experience in their specialty ranged from 10 to 22 years. The mean time being 16 1/ 2 years. Educational qualification on entry to post and qualification now 20 No. of participants
action research, Manley (2000) demonstrated how a consultant nurse in an Intensive Care Unit created a positive culture of change in the unit, introduced evidenced based care and multidisciplinary collaboration, empowered colleagues and developed practice. The key findings from this seminal piece of work strongly suggested that providing support, being patient centred, enabling development, active participation, and the development of decision-making was evident. Manley makes the point that strong leadership sustained cultural change, and for this momentum to be fully beneficial, leaders of nursing practice need to provide strong clinical direction. Manley (1997) suggests the work of expert practitioners encompasses both direct and indirect practice, in which direct practice involves caring for patients and their families while indirect practice involves working with staff.
31
15 10 5 0 BSc
PGDip
MA/MSc
PhD
Educational qualification
On entry to post 11% (n = 2) held a first degree, 28% (n = 5) held a postgraduate diploma and 61%
32
R. Hoskins
(n = 11) held an MSc/MA. The participants who had had a first degree on entry currently have an MSc/ MA, all participants who held a postgraduate diploma now hold an MSc/MA and 2 participants who held an MSc/MA now have a PhD with another 2 working towards a PhD. The lowest qualification for male respondents on entry to post was a postgraduate diploma. One of the men now had a PhD, while 3 of the female respondents either currently possessed a PhD or were working towards this educational qualification. Ninetyfour percent (n = 17) agreed that an MSc/ MA was required for this post, while only 1 respondent disagreed with this statement; interestingly this respondent had a master’s degree on appointment to the post. The most controversial findings were in response to a question where respondents were asked to identify what they felt would be appropriate educational programmes for the role in light of their experience. The majority felt that a medical model of post- graduate education should be adapted to best meet the development needs of this group of health professionals. ‘‘I may be a glutton for punishment, but I feel that something along the lines of the medical membership of fellowship. Some way of nationally accrediting the process of being a consultant, benchmarking the clinical standards and experiences required to fulfil the role’’ (CN 2). Another agreed with this view and commented that ‘‘we need a 3 year medical conversion course especially for consultant nurses.’’ Another respondent observed that ‘‘consultant nurses need to be taught alongside doctors/medical colleagues’’ (CN 11) while another observed that requirements could be met by
educational
‘‘possibly opening medical post grad courses to consultant nurses’’ (CN 15) ‘‘or like medical consultants there should be an entrance exam if you wish to proceed to consultancy i.e. accreditation for required level.’’ (CN 11) ‘‘There is a persistent historic perspective of the division between medical and nursing education understandable since nurse education has only recently become academically focused. This could now be addressed by sharing educational programmes.’’ (CN1).
There were concerns highlighted that adopting a medical model of educational provision would have a less positive impact on the role. ‘‘My main concern is the attempt to mimic Drs, there is no attempt in education to identify the central nursing theme’’ (CN 4). While another consultant nurse commented that while the registrar course developed in Southampton was a positive concept she felt that ‘‘yet again mimics Dr training, developing a pseudo Dr role’’ (CN 4). Another respondent identified that they felt animosity between the professionals and that following a similar medical educational pathway would not be a positive step ‘‘Its them, and us I also have concerns with mimicking Drs, there is a sense of becoming a pseudo Dr’’ (CN 14). Misunderstanding of roles was another barrier identified ‘‘Not understanding the role, there is a perception that our roles are ‘taking away’ power, and providing a substandard medical role’’ (CN10). The participants in this study agreed with the findings from Gerrish et al. (2003), suggesting that in completing a clinical master’s education, the clinical capability of the nurse/practitioner is enhanced enabling nurses to work independently and to stretch the boundaries of the traditional nursing role. In this study master’s level education was seen to entail both a deepening of existing knowledge and a broadening of the participants’ knowledge base. Gerrish et al. (2003) suggested that masters’ level study equipped nurses with an enhanced knowledge base that legitimised their position in relation to established professional groups such as medicine, a view also expressed by Keogh (1997) and Bourgeault (2000). Gerrish et al. (2003) commented that they felt that nursing practice was aligning itself more closely with medical practice, and that in their study many master’s graduates were developing their roles in areas that encroached on areas previously deemed to be in the domain of the medical profession. This, it could be argued, is certainly the case in terms of the development of consultant nurse roles. However, one of the most important distinctions in the advancement of the consultant nurse role is that the role is practice based for 50% of the time (DH, 1999) and that the essence of the role is to develop and advance practice, research, leadership
Should aspiring consultant nurses follow a medical training programme? and education in nursing, not to develop ‘mini doctors’, although several participants expressed their anxieties that their role may be perceived as simply medicalisation of the nursing role. Woodward et al. (2005) discovered in their cross sectional design study that those nurses in post who were finding the demands of the post difficult were often lacking in educational, leadership and/or research experience. They also found that these individuals had not yet obtained a master’s degree. Woodward et al. (2005) also observed that some individuals did not have other professional experience, for example in leadership or educational settings, to equip them for the role, and because of this some seemed to be acting at clinical nurse specialist rather than consultant nurse level. Presently there is a lack of a coordinated career framework and pathway towards becoming a consultant nurse, unlike the career trajectory of a medical consultant where the pathway is clearly set out and nationally agreed programmes are managed by deaneries within strategic health authorities. The Southampton nurse registrar programme is innovative and pulls together the learning needs of aspiring consultant nurses into one coordinated 3-year programme of development (Crouch et al., 2003). There have been concerns voiced not only within this study that the terminology used is medicalising a nursing innovation and therefore could be perceived as derisive by both nursing and medical groups. An evaluation of this programme is not expected for another 2 years. The consensus within this study was that some form of formal preparation and framework was required for this role, although agreement was not reached whether this should follow a medical model - one that is tried and tested, but may encourage the notion of the development of ‘psuedo doctors’ and lose the essence of nursing or that the development of a new but as yet undeveloped model should be followed. Opinions were sought from the respondents as to how future consultant nurses could be prepared based on their experiences to date. There were mixed ideas, but by far the strongest and most controversial feeling was that aspiring consultant nurses and those already in post should be taught alongside medical colleagues, in order to gain the necessary depth and breadth of knowledge as well as gaining the additional benefits of understanding each others role and knowledge base through shared learning. It could be argued that it was also believed that additional credibility for the post would be gained through this approach. Interestingly two of the participants suggested following the current medical model of accreditation for the role suggesting that a national en-
33
trance examination resulting in a membership or fellowship of a royal college should be undertaken by consultant nurses, which would encompass testing clinical knowledge and competence, as well as undertaking a research project and being examined on technical and clinical skills as well as management issues. It was felt that such an approach would confer national accreditation on the post holder and would indicate that a nationally recognised standard had been realised. Another strong theme to emerge from the study was the proposal that a career pathway for the role should be developed based on the current medical framework of specialist registrar training. Arguments for this radical concept are that this educational and career pathway has been developed over many years and it would appear to be a reasonably robust pathway through evaluation and experience. It could also be claimed that integrating aspects of this type of educational pathway would incorporate some of the key themes learnt from interprofessional education, standardising competencies and encourage both professions to better understand each others’ roles and scope of professional practice (Barr et al., 1999; Kilminster et al., 2004). Conversely an argument against implementing this type of framework centres on the medicalisation of nursing. Would the ‘essence’ of nursing be lost and would the concept of role substitution be reinforced by following a similar programme of preparation? It could also be argued that a major issue, which arises from both the literature and also from the respondents in this study, is the ambiguity surrounding this role and where it lies within organisations and the professional hierarchy in the NHS (Woodward et al., 2005; Charters et al., 2005). Nursing and in particular the role of the consultant nurse requires the development of a stronger professional identity rather than the erosion of this.
Study limitations The study achieved a high response rate of 86%. Parahoo (1997) suggests that a response rate of more than 50% is acceptable in terms of validity. While the response rate was seen as positive in a national multi-centre study, this was in fact a small-scale study representing only just over 2% of all consultant nurses. It is not possible to generalise the results of this study to the whole population of consultant nurses. The results could be used to represent the views of consultant nurses working in emergency care, because the sample represents 55% of this particular population. A key limitation
34
R. Hoskins
of this study was the time required in registering the study with individual research and development units.
Conclusion There was agreement from the majority of respondents in this study that a national programme of preparation should be developed for aspiring consultant nurses. The majority favoured the current medical model and certainly supported the concept of interprofessional programmes of study in higher education institutions. The notion that a national examination should be undertaken in order to gain entry to be eligible to apply for a consultant nurse post was also highlighted. Successful completion of this would allow the individual to gain ‘membership’ to a register of consultant nurses. Interestingly this study found strong support in the group of consultant nurses surveyed for a medical model of educational preparation for this role. This may be construed as disappointing in that nursing could potentially lose its identity and become subsumed in a medical approach to patient care if this approach was adapted. While the respondents were simply seeking a practical solution to the issue of an appropriate level of preparation for this innovative role a different approach may be required. Instead a more interprofessional approach to postgraduate education in specialties may be the way forward in order to preserve the essence of each professional group while seeking common gaols in high quality patient care with improved outcomes. Further investigation into identifying and overcoming the barriers of achieving joint and collaborative working and learning with medical staff is required as well as the development of a national programme of preparation for the role.
References Barr, H., Hammick, M., Koppel, I., Reeves, S., 1999. Evaluating interprofessional education: two systematic reviews for health and social care. British Educational Journal 25 (4), 533–544. Bourgeault, I., 2000. Delivering the new Canadian midwifery: the impact of integration into the Ontario healthcare system. Sociology of Health and Illness 22, 172–196. Chartered Society of Physiotherapists, 2002. Physiotherapy Consultant (NHS): Role Attributes and Guidance for Establishing Posts, PA56, CSP, London.
Charters, S., Knight, S., Currie, J., Davies-Gray, M., AnisworthSmith, M., Smith, S., Crouch, R., 2005. Learning from the past to inform the future – a survey of consultant nurses in emergency care. Accident and Emergency Nursing 13, 186– 193. Crouch, R., Buckley, R., Fenton, K., 2003. Consultant nurses: the next generation. Emergency Nurse 11 (7), 15–17. Department of Health, 1997. The New NHS-Modern, Dependable. HMSO, London. Department of Health, 1998. A First Class Service. HMSO, London. Department of Health, 1999. Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. HMSO, London. Department of Health, 2006. Modernising Nursing Careers. HMSO, London. Gerrish, K., McManus, M., Ashworth, P., 2003. Creating what sort of professional? Master’s level nurse education as a professionalising strategy. Nursing Inquiry 10 (2), 103– 112. Guest, D., Redfern, S., Wilson-Barnett, J., Dewe, P., Peccei, R., Rosenthal, P., Evans, A., Sudbury, A., 2004. A Further Evaluation of the Establishment of Nurse, Midwifery and Health Visitor Consultants. Nursing Research Unit. Florence Nightingale School of Nursing. Keogh, J., 1997. Professionalization of nursing: development, difficulties and solutions. Journal of Advanced Nursing 25, 302–308. Kilminster, S., Hale, C., Lascelles, M., Morris, P., Roberts, T., Stark, P., Sowter, J., Thistlewaite, J., 2004. Learning for real life: patient-focused interprofessional workshops offer added value. Medical Education 38, 717–726. Manley, K., 1997. A conceptual framework for advanced practice: an action research project operationalising an advanced practitioner/consultant role. Journal of Clinical Nursing 6 (3), 179–190. Manley, K., 2000. Organisational culture and nurse consultant outcomes. Nursing Standard 14 (37), 34–38. McSherry, R., Johnson, S. (Eds.), 2005. Demystifying the Nurse/ Therapist Consultant, A Foundation text. Nelson Thornes, Cheltenham. Morrison, K.R.B., 1993. Planning and Accomplishing SchoolCentred Evaluation. Peter Francis Publishers, Norfolk. Morse, J., Field, P., 1996. Nursing research, second ed.. The Application of Qualitative Approaches Nelson Thornes, Cheltenham. National Health Service Executive, 1999. Health Service Circular 1999/217 Nurse, Midwifery, and Health Visitor Consultant: Establishing Posts and Making Appointments. NHS Executive, London. Oppenheim, A.N., 1992. Questionnaire Design, Interviewing and Attitude Measurement. Pinter Publishers Ltd., London. Parahoo, K., 1997. Nursing Research, Principles, Process and Issues. Macmillan Press, London. Wilson, N., McLean, S., 1994. Questionnaire Design: A Practical Introduction. University of Ulster Press, Co.Antrim. Woodward, V., Webb, C., Prowse, M., 2005. Nurse consultants: their characteristics and achievements. Journal of Clinical Nursing 14, 845–854. Wright, S., 1991. The nurse as a consultant. Nursing Standard 5 (20), 31–34.
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/aaen
Should aspiring consultant nurses follow a medical training programme? Rebecca Hoskins RGN, RN (Child), BSc Hons, MA (Consultant Nurse & Senior Lecturer in Emergency Care, United Bristol Healthcare Trust & University of the West of England) Emergency Department, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom Received 25 July 2007; received in revised form 24 October 2007; accepted 7 November 2007
KEYWORDS
Abstract Aim: To investigate the level of educational preparation current consultant nurses
Consultant nurses; Educational development; Succession planning; Emergency care
felt was required to prepare aspiring consultant nurses for the role. Background: The radical introduction of the consultant nurse role was thought to be groundbreaking. This new role was to provide better outcomes for patients by improving the service and quality of care delivered to patients. With such great expectations of these professionals there was little guidance available as to the appropriate preparation for such a new and innovative role. Method: A national survey was undertaken of the Department of Health Consultant Nurse Emergency Care group (n = 18). Results: Key themes emerged around the development of a medical model of educational preparation for this role, as well as the development of a national programme of preparation. The majority favoured the current medical model and certainly supported the concepts of interprofessional programmes of study in universities. Conclusions: Further work is required in developing a nationally recognised programme of preparation for the role. c 2007 Elsevier Ltd. All rights reserved.
The radical introduction of the consultant nurse role in 1999 was thought to be ‘ground breaking’ as it recognised the full contribution of nurses in the health arena (DH, 2006). This new role was to proE-mail address: [email protected]
vide better outcomes for patients by improving the service and quality of care delivered to patients, as well as strengthening leadership within the profession. With such a massive expectation of these professionals there was little guidance available as to the appropriate preparation for such a new and
1755-599X/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2007.11.003
30 innovative role. The main aim of this study was to investigate the level of educational preparation current consultant nurses felt was required to prepare aspiring consultant nurses for the role. The New NHS - Modern, Dependable (DH, 1997) examined reconfiguring the workforce to reduce the boundaries between professional roles, in order to meet the growing needs of the patient population accessing the services of the NHS. It was recognised that with an increasing and aging population requiring acute and long term care against a background of an aging nursing population, reduction in junior doctors’ working hours as well as an increase in part time working by medical staff meant that new roles in healthcare were required in order to meet the health needs of the community. The NHS Executive (1999) produced clear guidance on establishing consultant nurse posts and identified the key components of the role. These posts have been in existence since 1999 and preliminary targets were put in place in order to develop 1000 consultant nurse posts for nurses and 250 posts for allied health professionals by 2004 (NHS Executive, 1999). Current estimations suggest that there is a deficit of about 200 post-holders (Guest et al., 2004). Various suggestions have been proposed as to why there is currently such a shortfall in recruiting to these posts, such as a lack of a national coherent staff development strategy, professional and interprofessional funding concerns, and health professionals themselves being uncertain about meeting the requirements of these posts (McSherry and Johnson, 2005). The principle aim in developing these posts was to enable advanced clinical practitioners to influence decision-making at a strategic level while maintaining patient contact. This research study aimed to investigate the educational preparation required for the successful development of the consultant nurse role within the NHS, specifically within emergency care.
Literature review The roots of the development of the concept of consultant nurse posts can be traced back to the 1980s when nursing development units were in their infancy and the role of nursing as a therapeutic speciality was recognised in its own right, (Wright, 1991). Throughout the late 1990s extensive consultation took place within the nursing, midwifery, and health visiting professions, looking at a new strategy for the development of the profession, (NHS Executive, 1999). There were over riding concerns that many of the more experienced practitioners were leaving practice–based posts in order to
R. Hoskins advance their careers, because of a fundamental limitation in the career structure. Once practitioners had reached the position of ‘sister’ or ‘charge nurse’ in any speciality then the only options for career progression lay in a few clinical specialist posts, research, management or education, thereby leaving a void in the pool of experienced practitioners in practice (NHS Executive, 1999). A key message from the report was that there was a need to strengthen professional leadership, while promoting awareness of how new and expanded roles could result in improving services and quality care for patients (NHS Executive, 1999). A response to these concerns came in the form of two Department of Health (DH) papers, A First Class Service (DH, 1998) and Making a Difference (DH, 1999). The former identified a clear agenda for action in the NHS to safeguard standards of care and continually strive to improve the quality of care. The latter paper outlined the strategic plans for nursing, midwifery and health visiting and the contribution of nursing to healthcare for the future. For the nursing profession, key to this was the creation of the role of the consultant nurse. It was felt that consultant nurses were in an ideal position to facilitate and support the delivery of government reforms as they had a strategic overview and were able to look at the wider picture. The challenge that was identified was to place this role at an appropriate level, one, which would be able to initiate and direct service developments while obtaining acceptance from all members of the team and professional hierarchy. The Chartered Society of Physiotherapists (2002) suggested that the establishment of consultant nurse and therapist posts were directly related to national initiatives and concurrent government priorities and targets, cutting waiting lists, tackling Ischaemic heart disease, cancer and mental health, handling emergencies more efficiently, strengthening primary care and improving services for older people. This, they argued, would facilitate the success of the post-holders. Crouch et al. (2003) argue that while the creation of such posts was to improve career prospects and strengthen education and training, there was also an important role in boosting the status of nurses. The creation of consultant nurse posts would enable the NHS to implement a new vision for nursing which in turn would facilitate the ‘new modern NHS’ (DH, 1997), by acting as role models and utilising evidence-based practice, clinical effectiveness, increased individual accountability and clinical governance within their role, (DH, 2006). The work of Manley (1997) has informed the development of consultant nurse posts. Through
Should aspiring consultant nurses follow a medical training programme?
Methodology The questionnaire used in this study was used to survey participants in order to gain an insight and understanding into their experiences, knowledge and perspectives of the subject being studied. The aim of the questionnaire was to investigate the issues surrounding the educational backgrounds of consultant nurses currently in post, their perceptions of the characteristics of master’s level education, their perceptions of the ‘ideal’ educational preparation for the role drawing on their experiences as well as their perceptions surrounding current programmes of study offered by universities and the current continuing professional development requirements of the role. Following collection of demographic data in order to gain a profile of the ‘typical’ respondents, the questionnaire was divided into sections and questions were designed to be closed as well as open ended and aimed to investigate the participants’ perceptions and experience of the educational preparation for the role. In constructing the questionnaire the literature was utilised in gaining practical considerations in the design, such as the layout of the questionnaire and the sequencing of questions (Oppenheim, 1992). The Department of Health Consultant Nurse Emergency Care email group provided a purposive sample for the research study. Purposive sampling involves the conscious sampling of certain participants to be included in the study. This sample was deliberately chosen by the researcher on the basis that these were the best available people to provide data on the issues being explored (Parahoo, 1997).
Ethical considerations The questionnaire was piloted with two people who were not involved in the study, as a result of this some minor changes were made. The appropriate NHS multi-centre research ethics committee (MREC) approved the study. Morrison (1993) and Wilson and McLean (1994) comment that piloting the questionnaire has several functions, principally to increase the reliability, validity and practicability of the questionnaire as a tool for data collection.
Results and discussion Questionnaires were sent to 21 participants and 18 were returned by post or email, giving a response rate of 86%. The results were analysed by using the process of coding the answers in order to undertake the process of reducing the data to manageable proportions. A coding grid was constructed for closed questions such as the demographic data collected. From the data, which emerged from the open questions within the questionnaire, the emergent themes were coded. The categories were kept as broad as possible. Using the rule of parsimony enables the data to remain manageable and permitted subcategories to be derived from the larger domain (Morse and Field, 1996). Of the 18 questionnaires analysed the largest proportion were female 83% (n = 15) compared with 17% (n = 3) male respondents. The largest proportion of respondents had been in their current post for between 3 and 4 years. The majority 89% (n = 16) had been in post for 2 or more years. The ages of the respondents ranged from 32 years to 56 years old. The mean age being 42-years old. The range of experience in their specialty ranged from 10 to 22 years. The mean time being 16 1/ 2 years. Educational qualification on entry to post and qualification now 20 No. of participants
action research, Manley (2000) demonstrated how a consultant nurse in an Intensive Care Unit created a positive culture of change in the unit, introduced evidenced based care and multidisciplinary collaboration, empowered colleagues and developed practice. The key findings from this seminal piece of work strongly suggested that providing support, being patient centred, enabling development, active participation, and the development of decision-making was evident. Manley makes the point that strong leadership sustained cultural change, and for this momentum to be fully beneficial, leaders of nursing practice need to provide strong clinical direction. Manley (1997) suggests the work of expert practitioners encompasses both direct and indirect practice, in which direct practice involves caring for patients and their families while indirect practice involves working with staff.
31
15 10 5 0 BSc
PGDip
MA/MSc
PhD
Educational qualification
On entry to post 11% (n = 2) held a first degree, 28% (n = 5) held a postgraduate diploma and 61%
32
R. Hoskins
(n = 11) held an MSc/MA. The participants who had had a first degree on entry currently have an MSc/ MA, all participants who held a postgraduate diploma now hold an MSc/MA and 2 participants who held an MSc/MA now have a PhD with another 2 working towards a PhD. The lowest qualification for male respondents on entry to post was a postgraduate diploma. One of the men now had a PhD, while 3 of the female respondents either currently possessed a PhD or were working towards this educational qualification. Ninetyfour percent (n = 17) agreed that an MSc/ MA was required for this post, while only 1 respondent disagreed with this statement; interestingly this respondent had a master’s degree on appointment to the post. The most controversial findings were in response to a question where respondents were asked to identify what they felt would be appropriate educational programmes for the role in light of their experience. The majority felt that a medical model of post- graduate education should be adapted to best meet the development needs of this group of health professionals. ‘‘I may be a glutton for punishment, but I feel that something along the lines of the medical membership of fellowship. Some way of nationally accrediting the process of being a consultant, benchmarking the clinical standards and experiences required to fulfil the role’’ (CN 2). Another agreed with this view and commented that ‘‘we need a 3 year medical conversion course especially for consultant nurses.’’ Another respondent observed that ‘‘consultant nurses need to be taught alongside doctors/medical colleagues’’ (CN 11) while another observed that requirements could be met by
educational
‘‘possibly opening medical post grad courses to consultant nurses’’ (CN 15) ‘‘or like medical consultants there should be an entrance exam if you wish to proceed to consultancy i.e. accreditation for required level.’’ (CN 11) ‘‘There is a persistent historic perspective of the division between medical and nursing education understandable since nurse education has only recently become academically focused. This could now be addressed by sharing educational programmes.’’ (CN1).
There were concerns highlighted that adopting a medical model of educational provision would have a less positive impact on the role. ‘‘My main concern is the attempt to mimic Drs, there is no attempt in education to identify the central nursing theme’’ (CN 4). While another consultant nurse commented that while the registrar course developed in Southampton was a positive concept she felt that ‘‘yet again mimics Dr training, developing a pseudo Dr role’’ (CN 4). Another respondent identified that they felt animosity between the professionals and that following a similar medical educational pathway would not be a positive step ‘‘Its them, and us I also have concerns with mimicking Drs, there is a sense of becoming a pseudo Dr’’ (CN 14). Misunderstanding of roles was another barrier identified ‘‘Not understanding the role, there is a perception that our roles are ‘taking away’ power, and providing a substandard medical role’’ (CN10). The participants in this study agreed with the findings from Gerrish et al. (2003), suggesting that in completing a clinical master’s education, the clinical capability of the nurse/practitioner is enhanced enabling nurses to work independently and to stretch the boundaries of the traditional nursing role. In this study master’s level education was seen to entail both a deepening of existing knowledge and a broadening of the participants’ knowledge base. Gerrish et al. (2003) suggested that masters’ level study equipped nurses with an enhanced knowledge base that legitimised their position in relation to established professional groups such as medicine, a view also expressed by Keogh (1997) and Bourgeault (2000). Gerrish et al. (2003) commented that they felt that nursing practice was aligning itself more closely with medical practice, and that in their study many master’s graduates were developing their roles in areas that encroached on areas previously deemed to be in the domain of the medical profession. This, it could be argued, is certainly the case in terms of the development of consultant nurse roles. However, one of the most important distinctions in the advancement of the consultant nurse role is that the role is practice based for 50% of the time (DH, 1999) and that the essence of the role is to develop and advance practice, research, leadership
Should aspiring consultant nurses follow a medical training programme? and education in nursing, not to develop ‘mini doctors’, although several participants expressed their anxieties that their role may be perceived as simply medicalisation of the nursing role. Woodward et al. (2005) discovered in their cross sectional design study that those nurses in post who were finding the demands of the post difficult were often lacking in educational, leadership and/or research experience. They also found that these individuals had not yet obtained a master’s degree. Woodward et al. (2005) also observed that some individuals did not have other professional experience, for example in leadership or educational settings, to equip them for the role, and because of this some seemed to be acting at clinical nurse specialist rather than consultant nurse level. Presently there is a lack of a coordinated career framework and pathway towards becoming a consultant nurse, unlike the career trajectory of a medical consultant where the pathway is clearly set out and nationally agreed programmes are managed by deaneries within strategic health authorities. The Southampton nurse registrar programme is innovative and pulls together the learning needs of aspiring consultant nurses into one coordinated 3-year programme of development (Crouch et al., 2003). There have been concerns voiced not only within this study that the terminology used is medicalising a nursing innovation and therefore could be perceived as derisive by both nursing and medical groups. An evaluation of this programme is not expected for another 2 years. The consensus within this study was that some form of formal preparation and framework was required for this role, although agreement was not reached whether this should follow a medical model - one that is tried and tested, but may encourage the notion of the development of ‘psuedo doctors’ and lose the essence of nursing or that the development of a new but as yet undeveloped model should be followed. Opinions were sought from the respondents as to how future consultant nurses could be prepared based on their experiences to date. There were mixed ideas, but by far the strongest and most controversial feeling was that aspiring consultant nurses and those already in post should be taught alongside medical colleagues, in order to gain the necessary depth and breadth of knowledge as well as gaining the additional benefits of understanding each others role and knowledge base through shared learning. It could be argued that it was also believed that additional credibility for the post would be gained through this approach. Interestingly two of the participants suggested following the current medical model of accreditation for the role suggesting that a national en-
33
trance examination resulting in a membership or fellowship of a royal college should be undertaken by consultant nurses, which would encompass testing clinical knowledge and competence, as well as undertaking a research project and being examined on technical and clinical skills as well as management issues. It was felt that such an approach would confer national accreditation on the post holder and would indicate that a nationally recognised standard had been realised. Another strong theme to emerge from the study was the proposal that a career pathway for the role should be developed based on the current medical framework of specialist registrar training. Arguments for this radical concept are that this educational and career pathway has been developed over many years and it would appear to be a reasonably robust pathway through evaluation and experience. It could also be claimed that integrating aspects of this type of educational pathway would incorporate some of the key themes learnt from interprofessional education, standardising competencies and encourage both professions to better understand each others’ roles and scope of professional practice (Barr et al., 1999; Kilminster et al., 2004). Conversely an argument against implementing this type of framework centres on the medicalisation of nursing. Would the ‘essence’ of nursing be lost and would the concept of role substitution be reinforced by following a similar programme of preparation? It could also be argued that a major issue, which arises from both the literature and also from the respondents in this study, is the ambiguity surrounding this role and where it lies within organisations and the professional hierarchy in the NHS (Woodward et al., 2005; Charters et al., 2005). Nursing and in particular the role of the consultant nurse requires the development of a stronger professional identity rather than the erosion of this.
Study limitations The study achieved a high response rate of 86%. Parahoo (1997) suggests that a response rate of more than 50% is acceptable in terms of validity. While the response rate was seen as positive in a national multi-centre study, this was in fact a small-scale study representing only just over 2% of all consultant nurses. It is not possible to generalise the results of this study to the whole population of consultant nurses. The results could be used to represent the views of consultant nurses working in emergency care, because the sample represents 55% of this particular population. A key limitation
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R. Hoskins
of this study was the time required in registering the study with individual research and development units.
Conclusion There was agreement from the majority of respondents in this study that a national programme of preparation should be developed for aspiring consultant nurses. The majority favoured the current medical model and certainly supported the concept of interprofessional programmes of study in higher education institutions. The notion that a national examination should be undertaken in order to gain entry to be eligible to apply for a consultant nurse post was also highlighted. Successful completion of this would allow the individual to gain ‘membership’ to a register of consultant nurses. Interestingly this study found strong support in the group of consultant nurses surveyed for a medical model of educational preparation for this role. This may be construed as disappointing in that nursing could potentially lose its identity and become subsumed in a medical approach to patient care if this approach was adapted. While the respondents were simply seeking a practical solution to the issue of an appropriate level of preparation for this innovative role a different approach may be required. Instead a more interprofessional approach to postgraduate education in specialties may be the way forward in order to preserve the essence of each professional group while seeking common gaols in high quality patient care with improved outcomes. Further investigation into identifying and overcoming the barriers of achieving joint and collaborative working and learning with medical staff is required as well as the development of a national programme of preparation for the role.
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