Critical care without walls: The role of the nurse consultant in critical care

Intensive and Critical Care Nursing (2005) 21, 334—343

ORIGINAL ARTICLE

Critical care without walls: The role of the nurseconsultant in critical care

Deborah Dawsona,∗, Andy McEwenb

a St. George’s Hospital NHS Trust, General Critical Care, St. Jame’s Wing, Blackshaw Road,London SW17 0QT, UKb Cancer Research UK Health Behaviour Unit, University College London, 2-16 Torrington Place,London WC1E 6BT, UK

Accepted 24 June 2005

KEYWORDSCritical care;Nurse consultant;Role involvement;Survey

SummaryBackground: The nurse consultant role was first described in 1999 and has undergonelittle evaluation since. Critical care nurse consultant roles have developed against abackground of service innovation following a review of adult critical care and haveresulted in a variety of job roles and titles. There is some evidence to suggest thatthese posts are developing differentially and with varied role content.Aims:• To provide a profile of the nurse consultant in critical care.• To identify critical care roles in practice.Method: A national postal survey of all 72 critical care nurse consultants in post inEngland by August 2003; response rate 72% (n = 52).Results: The majority (54%) of critical care nurse consultants were aged between 40and 50 years with a mean of 18.4 years post registration experience. The majorityheld a higher degree (71%) and at least one additional professional qualification(96%); many (44%) continue to study. Most critical care nurse consultants (69%)reported that a nurse does not manage them operationally. Nurse consultants weretaking the lead in developing care outside the traditional boundaries of the Inten-sive Care Unit (ICU) (mean involvement score, M = 4.25) and with outreach roundson the wards (M = 3.78). Despite having an overall high involvement (M = 3.37) withthe practice and service development function, they had a lower involvement withresearch activities (M = 2.87). They also had a low involvement with strategic organ-isations such as the Department of Health (M = 1.63), Strategic Health Authorities(M = 1.54) and Primary Care Trust’s (M = 1.49).Conclusions: The critical care nurse consultants who responded to this survey wereclinically experienced and educated to an advanced level. They were leading the

∗ Corresponding author. Tel.: +44 208 725 3129.E-mail address: [email protected] (D. Dawson).

0964-3397/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2005.06.007

Critical care without walls: The role of the nurse consultant in critical care 335

care of critically ill patients outside the traditional boundaries of the ICU, but havesignificantly less involvement within the ICU. Nurse consultants’ restricted involve-ment with strategic organisations may limit the development of the role.© 2005 Elsevier Ltd. All rights reserved.

Introduction

The emergence of new and innovative nursing rolesin the United Kingdom (UK) appears to have beenin response to a number of factors including: ser-vice pressures (Department of Health (DH) 1993),professional development (United Kingdom CentralCouncil for Nursing, Midwifery and Health Visit-ing (UKCC), 1994), political guidance (DH, 1993,1999a,b), and patient need (Coad and Haines, 1999;Scholes et al., 1999; Manley, 1997). Several authorshave attempted to define these roles (Ball, 1997;Ball and Cox, 2003; UKCC, 1994; Read et al., 1999),but much intra-professional, inter-professional andpublic confusion remains over both role content androle title. There are two major themes in the devel-opment of advanced practice in the UK. First, thatnew posts are emerging as a result of the need todevelop clinical roles at the mface where post holders provvices to patients. The seconwith the advancement of nurers provide services to patients indirectly via subroles as educator, expert clinician, researcher andcTndmssi2

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(Ball, 1997, 2001; Ball and Cox, 2003; Hamric andSpross, 1989; Casledine, 1991; Payne, 1999; Manley,1997, 2000a,b, 2002). Walters (1996) suggests thatclinical expertise is just the starting point and thatthe concept of advanced practice requires a rangeof skills including political and managerial compe-tence.

Due to the relatively recent introduction of thenurse consultant in England there is limited evalua-tion available. The earliest evaluation of the nurseconsultants’ role in critical care (Manley, 1997)found many parallels with the roles of expert clin-ician, consultant, educator and researcher identi-fied by Hamric and Spross (1989). However, a sig-nificant addition to this list was also identified: theneed for the nurse consultant to be a transforma-tional leader influencing both organisational andeducational development (Manley, 1997). This eval-

concludes that it is the elements of transforma-tional leadership, change agent and collaboratorthat have enabled her to influence and develop the
onsultant (Hamric and Spross, 1989; Manley, 1997).
ume and Bullock (2002) suggest that it is vital thatew nursing posts have multi-dimensional roles thatevelop broad nursing services rather than emergeerely to take on discarded medical functions. It is

uggested that the key to advanced practice is thetrategic nature of these posts and the resultantmprovement in patient outcomes (Ball and Cox,004).

The nurse consultant, as first described by therime Minister in 1998, and further defined by theepartment of Health (DH, 1999a,b), combines theore functions of expert practitioner with the suboles of professional leadership, education, prac-ice development and research. A review of adultritical care (DH, 2000) did not explicitly mentionhe role of the nurse consultant, but proposed thatritical care should be seen as a level of illness andatient need. Although the critical care nurse con-ultant role remains in its infancy, it has potentialor meeting the need for a multi-dimensional nurs-ng role practicing at higher or advanced level withhe ability to develop and disseminate knowledge,he credibility to enhance care across the care con-inuum and to improve outcome from critical illness

role of nurse consultant.A survey of the nurse consultants’ role was

undertaken by Guest et al. (2001) and funded bythe Department of Health in England; it remainsthe largest published evaluation to date. Of thefour core functions of nurse consultants (leader-ship, clinical expertise, research and education)research appeared to be the least developed, andmost of the roles identified by nurse consultantswere related to leadership and to expertise func-tions. The survey did not explicitly capture organi-sational culture as influencing the nurse consultantrole, but this is implied by the results of the survey.Generally, nurse consultants were positive aboutthe role, having an expectation of improved out-comes for patients, but reported concerns aboutthe way the role had been implemented. The studywas limited by the brief time in post of many ofthe respondents, which restricted their ability tocomplete all aspects of the survey.

A high proportion of nurse consultant posts,approximately 70 of the 850 approved posts in Eng-land, are in critical care (DH, 2003). It is suggestedthat any evaluation of these posts should include

edical—nursing inter-ide direct clinical ser-d theme is associatedsing, where post hold-

uation has not been replicated and is based uponthe role of one consultant, in one critical care unit.Likewise, Haines (2002) presents a reflection on herrole within a paediatric intensive care setting, and

336 D. Dawson, A. McEwen

policy implementation, organisational factors, roleclarity, preparation and selection (Wilson-Barnett,2001). Therefore evaluation of the role must startat appointment, ensuring successful appointees areproven leaders of clinical practice and that they arecredible leaders within a specialist area of practice(Ball, 2001), that they possess the skills to developthe culture and are provided with the authority todo so (Manley, 2002). In doing this, it is importantto provide an understanding of the organisationalculture. Therefore, evaluation should ascertain fac-tors that constrain (i.e. conflict with medical staff)or promote (i.e. political awareness) the role. Eval-uation should also reflect patient focused values(Coombs, 2000) making explicit the contributionnurses make to patient welfare, recovery and out-come (Ball, 2001). At present there is no evidenceof such an evaluation. This paper reports on someof the findings of a national survey of critical carenurse consultants in England (Dawson, 2004). Theaims of this part of the study were to:

• provide a profile of the nurse consultant in criti-cal care;

• identify critical care roles in practice.

Fifty statements related to a wide range ofcritical care tasks and roles. Respondents indicatedtheir role involvement in these activities on a fivepoint Likert scale: 1 — ‘not at all’, 2 — ‘to a smallextent’, 3 — ‘to a moderate extent’, 4 — ‘to a greatextent’ and 5 — ‘take the lead’. Respondents werealso asked about their work attitudes, behavioursand organisational culture using a series of previ-ously published scales; publications and presenta-tions since taking up post, demographic and bio-graphic data were also collected. To provide con-text and explore more fully participants’ responses,free text sections were provided within the survey.

Ethical considerations

The survey was sent to the participants workaddress. The letter accompanying the survey high-lighted the background to the study, and the con-tent of the survey. Participants were assured thatany information provided would be treated with thestrictest confidentiality.

Data analysis

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Methods

Design and sample

A postal survey of all 72-nurse consultants in criticalcare in England was carried out during August 2003.The questionnaires were sent out with a coveringletter and a stamped addressed return envelope; 2weeks later a further questionnaire was sent to non-respondents. Fifty-five (76%) questionnaires werereturned: 51 (71%) in the first wave and 4 (5%) fol-lowing the reminder. Of those returned two werenot completed, as those hospitals did not have anurse consultant in post, and one questionnaire wasincomplete (thus providing a usable sample of 52and an effective response rate of 72%).

Data collection

The 112-item questionnaire was piloted with foursenior critical care nurses, not nurse consultants,prior to the survey. The questionnaire was designedto elicit information from respondents on the fourkey functions of the nurse consultant role (DH,1999b):

1. Expert practice.2. Practice and service development.3. Education, training and development.4. Leadership and consultancy.

ll data was entered on to a computer anonymouslynd analysed using SPSS version 11.5. The Likertcale was treated as a continuous rather than cate-orical variable and a mean involvement score wasalculated for each of the role items. The higher theean score the greater the involvement. Correla-

ion coefficients were calculated between each ofhe role functions and biographic items measureds a continuous variable. For items where thereere just two conditions a Mann—Whitney test wassed, and for items with three or more conditionsKruskal—Wallis test was applied. The free text

ections were analysed for emerging themes andoncepts.

esults

iographics

he largest age group was those nurse consultantsho were between 40 and 50 years of age (54%,= 28), with 44% (n = 23) of nurse consultants beingged between 30 and 40 years and 2% (n = 1) beingver 50 years of age. The majority of respondentsere female (87%, n = 45) and only one respondentid not classify himself or herself as white. Most ofhe respondents were living with a spouse or part-er (64%, n = 33), 31% (n = 16) were single and 6%n = 3) classified themselves as divorced or sepa-


rated. Just over half had dependent children (54%,n = 28), of which 51% were 11 years or under.

The nurse consultants had a mean of 18.4 years(range 11—27, S.D. 4.4) post qualification experi-ence; 55% (n = 28) had 18 or less years experiencewith 45% (n = 23) having more than 18 years expe-rience. The majority of the nurse consultants hadtaken up their posts more than 2 years previouslywith a mean tenure of 25.3 months (range 2—43,S.D. 9.2). Only 10% (n = 5) of the nurse consultantshad been in post less than 1 year when they com-pleted the survey.

The nurse consultants held a range of educa-tional and professional qualifications. Seventy-onepercent (n = 36) had a higher degree with only 2%(n = 1) of respondents not holding a first degree.One-third of the respondents (33%, n = 17) had pro-fessional qualifications other than nursing with twonurses (4%) having two further professional quali-fications. The majority of nurse consultants (96%,n = 50) had at least one additional nursing qualifi-cation in addition to their registration, with 75%(n = 39) holding more than one such qualification.The most commonly reported courses were theEnglish National Board (ENB) 100 General IntensiveCAoewa

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before they took up post. The nurse consultantswere line managed operationally and professionallyby a range of individuals as shown in Table 1.

Critical care nurse consultant roles inpractice

All items had some nurse consultant involvement,although a number of items had very few partic-ipants and low mean involvement scores. Theseincluded roles such as ‘evaluating local servicesagainst best practice’ and ‘delivering educationoutside the hospital and University’. By calculatinga mean overall involvement score for each of thefour functions (the sum total of all mean involve-ment scores for a particular function, divided by thenumber of items in that function), it could be seenthat the nurse consultants were using skills acrossthe range of functions as described by the Depart-ment of Health (DH, 1999b): practice and servicedevelopment (mean involvement score [M] = 3.37);expert practice (M = 2.78); education, training anddevelopment (M = 2.76) and leadership and consul-tancy (M = 2.46).

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are Nursing (78%, n = 41) and ENB 998 Teaching andssessing (65%, n = 34). Furthermore, 44% (n = 23)f the group were undertaking further studies inight different areas. Of this group 52% (n = 12)ere studying for Masters degrees, 17% (n = 4) fordoctorate and 9% (n = 2) for an MPhil.Most nurse consultants (67%, n = 35) were work-

ng in District General Hospitals (DGH), 25% (n = 13)ere in teaching hospitals with 8% (n = 4) of respon-ents classifying their hospital as a specialist ter-iary centre. Remuneration varied across the group,5% (n = 13) were paid less than £35,000, 54%n = 28) were paid £35,000—£40,000 and 21% (n = 11)f the group were earning more than £40,000. Anal-sis of the free text responses highlighted a per-eived lack of financial reward for effort.

The majority of nurse consultants 65% (n = 34)ere working in the same hospital as they had been

Table 1 Job title of Operational and Professional Man

Title Operation

Director of Nursing/Chief Nurse 21 (11)Assistant Director of Nursing 2 (1)Senior Nurse 8 (4)Directorate Operational Manager 35 (18)General Manager 16 (8)Lead Clinician 18 (9)

Total 100 (51)

NB: total responses varied for these questions with only 51 res

ractice and service development

he greatest involvement for nurse consultants inritical care was with practice and service develop-ent roles. Table 2 shows all the items in the prac-

ice and service development function. The threetems involved with clinical audit score highly in thisunction, with much less involvement in the itemsertaining to research. In the free text responsesurse consultants cited a lack of time as a reasonor not undertaking research.

Nurse consultants with an additional professionalualification (n = 17) were more involved with pre-enting and implementing evidence based practicen their acute hospital (M = 3.2, S.D. 1.34) thanhose nurses without such a qualification (M = 2.3,.D. 1.23) (Z = −2.30, p < 0.03). Table 3 shows thaturse consultants working in specialist hospitals had

of nurse consultants in critical care.

anager (%) (N) Professional Manager (%) (N)

86 (45)6 (3)8 (4)———

100 (52)

es for Operational Manager and 52 for professional.


Table 2 Mean involvement scores for practice and service development roles.

Role Mean involvementscore (S.D.)

Developing clinical audit 4.04 (0.97)Developing clinical guidelines/protocols/procedures for use outside your ICU/HDU 4.00 (0.99)Collecting data for clinical audit 3.96 (1.09)Analysing/writing up clinical audit projects 3.94 (1.00)Presenting/implementing evidence based practice in your acute hospital 3.85 (0.87)Developing clinical guidelines/protocols/procedures for your ICU/HDU 3.38 (1.33)Presenting/implementing evidence based practice in the ICU/HDU 3.19 (1.14)Developing research proposals 2.87 (1.21)Carrying out research 2.87 (1.28)Presenting/implementing evidence based practice outside your acute hospital 2.62 (1.33)Evaluating local services against best practice 2.37 (0.99)

Table 3 Comparison of role involvement of nurse consultants by hospital type.

Role Specialist (n = 4),mean (S.D.)

Teaching (n = 13),mean (S.D.)

DGH (n = 35),mean (S.D.)

�2 p-Value

Developing researchproposals

4.25 (0.96) 3.08 (0.95) 2.63 (1.21) 7.15 <0.03

Carrying out research 4.75 (0.50) 3.15 (1.14) 2.54 (1.20) 10.66 <0.005Evaluating local services

against best practice4.00 (0.82) 2.15 (0.90) 2.26 (0.89) 8.98 <0.02

a higher involvement in a number of practice andservice development items than those working inteaching hospitals or DGHs (only those differencessignificant to p < 0.05 are shown).

Expert practice

Expert practice had the next highest overallinvolvement and Table 4 shows the mean involve-ment scores for the expert practice roles. Itemswhere nurses were receiving referrals or refer-

ring patients showed the highest involvement.There appeared to be a lower involvement inroles to do with follow up clinics, communitycare, direct care for ICU patients and adminis-tering medicines under a Patient Group Direction(PGD).

Education, training and development

The highest mean involvement scores across allnurse consultants were for two items in the edu-

Table 4 Mean involvement scores for expert practice roles.


Receiving nurse led referrals from the ward areas 3.92 (1.13)Making patient referrals to other members of the MDT 3.87 (1.09)Making patient referrals to medical staff 3.71 (1.12)Receiving referrals from another member of the multi-disciplinary team 3.61 (1.30)Receiving medically led referrals from the ward areas 3.51 (1.24)Making patient referrals for diagnostic procedures 2.60 (1.36)Undertaking interventions normally carried out by medical staff 2.54 (1.09)Caring for a patient in the ICU/HDU 2.21 (1.13)Follow up clinics in a hospital setting 2.12 (1.58)

n
Administering medicines under a Patient Group DirectioFollow up in the communityClinical care in a community setting
2.08 (1.25)1.73 (1.27)1.56 (0.98)


Table 5 Mean involvement scores for education, training and development roles.


Working with individuals or teams outside the ICU/HDU to develop their practice 4.25 (0.84)Developing education programmes for your acute hospital, but outside the ICU/HDU 4.13 (1.09)Delivering education for your acute hospital 3.96 (0.91)Mentoring/clinical supervision outside the ICU/HDU but within the acute hospital 2.90 (1.21)Working with individuals or teams in the ICU/HDU to develop their practice 2.87 (1.14)Delivering education in the ICU/HDU 2.85 (1.06)Developing education programmes/courses/modules for your University 2.75 (1.28)Delivering education for your University 2.75 (1.06)Developing education programmes for your ICU/HDU 2.60 (1.36)Developing education programmes/courses/modules for disciplines other than nursing 2.44 (1.18)Mentoring/clinical supervision within the ICU/HDU 2.40 (1.09)Delivering education outside your acute hospital and University 1.88 (1.06)Mentoring outside the acute hospital 1.56 (1.11)Developing education programmes/courses/modules for an outside body 1.35 (0.74)

cation, training and development functions. Thesewere for working with individuals or teams todevelop their practice and for developing educa-tion programmes for the acute hospital, in bothcases outside the ICU/HDU. Table 5 shows meaninvolvement scores for the education, training anddevelopment items.

Nurse consultants working in specialist hospitalswere more involved with developing educationprogrammes for their universities (M = 4.25, S.D.0.5) compared with those in DGHs (M = 2.63, S.D.1.33) and teaching hospitals (M = 2.62, S.D. 1.04)(�2 = 6.0, p < 0.05). Nurse consultants who helda professional qualification other than nursing(n = 19), of which 47% (n = 9) were in education;had higher involvement with education, trainingand development functions as can be seen inTable 6.

Leadership and consultancy

The lowest involvement across the group was withthe leadership and consultancy function. Table 7shows mean involvement scores for the leader-ship and consultancy roles. Two items showed highinvolvement, strategic decision making in the acutehospital and working with the critical care network.Many items showed a low involvement includingward rounds in the ICU/HDU and strategic workingwith organisations outside the acute hospital. Nurseconsultants who were not working in the same hos-pital as they had been before they took up postwere more likely to be working with their PrimaryCare Trust (a community based provider and com-missioning organisation) (M = 1.7, S.D. 0.83) thanthose who remained working for the same hospital(M = 1.4, S.D. 0.74) (Z = −2.02, p = <0.05).

Table 6 Relationship between role and professional qualifications other than nursing.

Item Professional qualificationother than nursing(n = 17), mean (S.D.)

No professional qualificationother than nursing (n = 35),mean (S.D.)

Z-value p-Value

Developing education programmesfor your ICU/HDU

3.6 (1.22)

Delivering education outside youracute hospital and University

2.4 (1.12)

Mentoring/clinical supervisionwithin the ICU/HDU

2.9 (1.30)

Mentoring/clinical supervisionoutside the ICU/HDU, butwithin the acute hospital

3.3 (1.0)

Mentoring outside the acutehospital

2.3 (1.53)

2.2 (1.28) −2.76 <0.006

1.6 (0.94) −2.66 <0.008

2.1 (0.88) −2.20 <0.03

2.7 (1.25) −1.96 <0.05

1.2 (0.58) −3.15 <0.002


Table 7 Mean involvement scores for the leadership and consultancy roles.

Roles Mean involvementscore (S.D.)

Contributing to the strategic decision making for the critical care service within the acutehospital

3.98 (0.81)

Working with your critical care Network 3.96 (1.09)Representing critical care on senior management committees within the acute hospital 3.94 (1.04)Outreach rounds in the ward areas 3.78 (1.59)Outreach rounds with the multi-disciplinary team 2.43 (1.46)Multi-disciplinary ward rounds in the ICU/HDU 2.17 (1.06)Medical ward rounds in the ICU/HDU 2.10 (1.03)Nursing ward rounds in the ICU/HDU 1.88 (1.16)Managing a budget for a clinical area 1.70 (1.45)Working with the Department of Health 1.63 (0.74)Working with Strategic Health Authorities 1.54 (0.58)Working with Primary Care Trust’s 1.49 (0.78)Managing operationally the ICU/HDU 1.35 (0.76)

Discussion

Limitations

This study is limited by the fact that it relies on self-reported role involvement and so self-presentationbias cannot be ruled out. Additionally, nurse con-sultants were asked to report level of involvement,rather than report the more quantifiable amount oftime, they invested in the activities. It can also beassumed that despite piloting the questionnaire theterminology may have been interpreted differentlyacross the cohort, which in turn may have affectedresponses. This is not a unique finding, Guest etal. (2001) reported different levels of engagementin various nursing roles but recognised that thereis a lack of conceptual clarity in the terms usedto describe phenomena related to nursing prac-tice, particularly to do with practice development(Unsworth, 2000; Garbett and McCormack, 2001;Manley and McCormack, 2003) and expert practice(Benner, 1984; Benner et al., 1996; Conway, 1996).

Biographic data

ple, not all nurse consultants held a higher degree,although the majority who did not were studying forone. Previous evidence has suggested that nurseswith more continuing professional education haveimproved communication skills, enhanced individ-ualised care and more research centred practice(Woods, 1998). It has also been argued that individ-uals practicing higher level nursing skills should beeducated to Master’s level (Brown, 1995; Benner,1984; Hamric and Spross, 1989; Castledine, 1996;Ball, 1997, 2001; Manley, 1997; Payne, 1999); thiswas reflected in a national nursing strategy (DH,1999a, p. 37), although guidance accompanying this(DH, 1999b) did not include any specific educa-tional requirements. Interestingly, the survey didnot demonstrate any significant differences in roleinvolvement between those with higher-level studyand those without. This possibly indicates that thelevel of academic achievement is less critical thanpreviously thought.

Professional line management of nurse consul-tants was almost exclusively by the Director of Nurs-ing and this perhaps reflects the strategic natureand senior position of these posts. Operational man-agement varied with about half of nurse consultantsbauuios

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The results show that the subjects for this currentstudy were very experienced with a mean tenure ofover 2 years and that the critical care nurse con-sultants had an impressive number of additionalprofessional qualifications. It is likely that this isbecause additional post registration qualifications,such as the ENB 100, are required for senior postsin critical care. Nurse consultant respondents to aprevious survey (Guest et al., 2001) reported farless professional qualifications, however, they werefrom a variety of different specialties. Despite theimpressive range of qualifications held by this sam-

eing managed by a General or Directorate Man-ger, approximately a third by a nurse and justnder one-fifth by a doctor. Given the present poornderstanding of these posts, even within the nurs-ng profession, it appears remarkable that membersf other professions should operationally manageuch an important group of senior nurses.

Ranges of annual salaries for nurse consultantsn critical care were reported in the questionnaire,owever, the free text sections suggested a lack ofeward for effort. Since the inception of these postshere has been an argument that if these posts were


to have the same status within nursing that medicalconsultants have within their profession (Salvage,1998) then there should be equity in remuneration(Stephen, 1999).

Critical care nurse consultant roles inpractice

The results of this survey demonstrate that nurseconsultants were using skills from across the rangeof functions described in the guidance for nurseconsultants’ posts (DH, 1999b). The survey resultsshow that critical care nurse consultants are highlyinvolved with practice and service developmentroles, but with progressively less involvement inexpert practice, education training and develop-ment and leadership and consultancy functions.Given the nature of critical care and the back-ground of service development it is not surprisingthat individuals have become so highly involved inthis area. However, the four functions are compli-mentary and activity in all four areas is required toenable the potential of the posts to be realised.Guest et al. (2001) reported different levels ofengagement with the four functions. This may beengetdm

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resources, mentoring and organisational support fordeveloping nursing research is attributed to theseposts. McGee (1996) suggests that research activ-ity is dependent on what the advanced practitionercan reasonably achieve given both personal andorganisational attributes, however, it is difficult toforesee who is to develop advanced research activ-ity if these posts are not afforded the opportunity.If nurse consultants are to hold the same statusas their medical colleagues then they must reflectsimilar academic ability. This does not mean allnurse consultants should be actively engaged inmore advanced research activity, not all medicalconsultants are, but it is important that this groupof senior nurses has credibility in developing andutilising the evidence base.

Expert practice

Nurse consultants show low involvement with directpatient care within the ICU/HDU, however, resultsfrom this study suggest that more direct care maybe occurring in areas outside the traditional bound-aries of ICU and HDU. The lack of direct carein the ICU/HDU could be due to the nature ofanfamlatstpcptnpowctpiidhr

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xplained by the diversity of their sample or by theature of the items, which although based on theuidance may have been interpreted quite differ-ntly in the two studies. It is interesting to notehat across all functions, activities outside the tra-itional boundaries of the ICU/HDU had a higherean involvement.

ractice and service development

he results suggest that there was high involve-ent in practice and service development. How-

ver, there was far more engagement with theevelopment of clinical guidelines and audit activ-ty than with promoting evidence based practicend participation in research. This study identi-es that over two-fifths of nurse consultants’ statehat they have little or no involvement in researchctivities. Nurse consultants working in specialistnd teaching hospitals had a higher involvement inesearch than those working in DGHs, which pos-ibly reflects the culture and accessibility of aca-emic support. It was envisaged that nurse con-ultants’ would play a principle role in developinghe research culture (Gelling, 2003; Guest et al.,001), however, this appears not to be the caseith respondents to this survey, or more widely

Gelling, 2003; Guest et al., 2001). Although theajority of nurse consultants in this study hold a

igher degree it is important that adequate time,

dvanced nursing practice in critical care whereurses may not be able to achieve independencerom their medical colleagues (Fairley, 2003; Maniasnd Street, 2001). The intensive care unit is a highlyedicalised arena. Conflict, resistance and estab-

ished values are all constraining factors to thective development of the advanced nurse practi-ioner (Ball and Cox, 2004). To ‘survive’, nurse con-ultants will need to constantly adapt and respondo changes in healthcare (Mills, 1996). Outreach isossibly the path of least resistance, where criti-al care nurse consultants can make a difference toatient care. Kohnke (1978) suggests that in ordero be an effective consultant, the nurse shouldot have a direct caseload; however, an explicitre-requisite for these posts is that at least 50%f time should be available to work in practiceith patients in order to provide expert nursingare (DH, 1999b). It is difficult to see how compe-ence and credibility could be maintained withoutracticing directly. The role of a nurse consultantnvolves being a role model for others, includingn clinical practice (Manley, 1997, 2002), and theevelopment of such practitioners is dependent onaving experts to ‘show the way’ through theiresponse-based practice (Benner et al., 1996).

ducation, training and development

uch of the educational activity appeared to be too with developing practice outside the ICU/HDU.


This educational activity may meet the needs ofthose staff that did not receive adequate pre-registration education to care for the critically illpatient in the ward environment. It is surprisingthat nurse consultants are not as involved witheducation and development within the ICU/HDUgiven the shortage of experienced critical carenurses (Audit Commission, 1999; DH, 2001). Thishas required units to provide regular programmesof education to develop nurses without previouscritical care experience (O’Sullivan, 2002). Thesenovice nurses might benefit from role modelling bythe nurses consultant who can proactively manageand influence the outcome of a critically ill patient,using their expert knowledge, experience and expo-sure (Ball and McElligott, 2002).

The survey showed that nurse consultants whowork in specialist and teaching hospitals have agreater involvement with developing programmeswith their universities, probably due to the greateracademic links in these hospitals compared withDGHs. The results also show that nurse consultantswith professional qualifications other than nursing,which are most likely to be in education, are moreinvolved with a range of educational activities.

There is a low reported involvement in research andworking with strategic organisations outside theacute hospital; this may impact on future develop-ment of these posts. Generally, critical care nurseconsultants are not involved in the care of patientswithin the traditional boundaries of ICU and HDUas might be expected given the current changes incritical care nursing staffing. Interestingly, duringthis early stage of formative development, resultsshowed that someone other than a nurse managesmany operationally.

Further investigation is required to assess theimpact of this emergent group of senior and poten-tially influential nurses. This should consider theimpact of their roles in clinical practice but alsoin the development of practice and policy. A majorconcern raised by this study was the lack of timespent in research activities, this suggests that par-ticular investigation is required to assess the impactof nurse consultants have on the critical careresearch agenda and process.

Acknowledgements

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B

Leadership and consultancy

It is encouraging that nurse consultants are involvedwith strategic decision making and representingcritical care within their hospitals. It is possiblethese are the leadership activities that are enablingthe move to greater involvement outside the tradi-tional boundaries of ICU/HDU. In the past, criticalcare areas have developed in an ad hoc mannerresulting in some of the problems being experi-enced presently in acute hospitals (McQuillan etal., 1998). An integrated approach to strategicdecision-making that includes liaison with the Pri-mary Care Trust and Strategic Health Authority mayimprove decision-making, communication and ser-vices for patients.

Conclusions

This study provides an overview of the self-reportedroles of nurse consultants in critical care; anddemonstrates that critical care nurse consultantsare both experienced and well educated. The sur-vey results show that critical care nurse consultantsare highly involved with practice and service devel-opment roles, with progressively less involvementin expert practice, education training and devel-opment and leadership and consultancy functions.

would like to thank all the nurse consultants whoave up their time to complete this survey, withouthom the study would not of been possible.

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Critical care without walls: The role of the nurse consultant in critical care

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