Exploring the perceived role and impact of the nurse consultant

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Musculoskelet. Care 4: 167–173 (2006)Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/msc

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MUSCULOSKELETAL CAREMusculoskelet. Care 4(3): 167–173 (2006)Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/msc.87

Short report

Exploring the perceived role and impact of the nurse consultantSarah Ryan RGN PhD MSc BSc FRCN1, Andrew Hassell MD FRCP2, Catharine Thwaites RGN MSc3, Kim Manley BA RN MN DipN (Lon) RCNT PGCEA RNT PhD CBE4, and Diane Home RGN MSc5

1Nurse Consultant Rheumatology, Haywood Hospital, Stoke on Trent, UK; 2Rheumatologist, Haywood Hospital, Stoke on Trent, UK; 3Lecturer in Rheumatology Nursing, Keele University, Keele, UK; 4Royal College of Nursing Institute, London; 5Department of Rheumatology, West Middlesex University Hospital, Isleworth, UK

Abstract

Background: Nurse consultant roles were introduced in 1999 with defined role criteria including expert practice, research, education and leadership. The primary objective of the role is to develop nurses and nursing to provide effective patient outcomes. In 2000 the first nurse consultant in rheumatology was appointed to establish a co-ordinated service for the management of patients with chronic musculoskeletal pain. There are now ten nurse consultants within rheumatology yet little is known of their role or impact.Aim: The aim of the study was to identify the perceived role and impact of one nurse consultant (NC) in rheumatology within the context of being a practitioner-researcher.Method: Seven peers of the NC and five patients cared for by the NC participated in a semi-structured interview to identify their perceptions regarding the role of the NC within the rheumatology service.Results: The following themes were identified from the interviews: (1) development of a new model of care for patients with chronic musculoskeletal pain; (2) holistic person-centred care experienced and valued by the patient; (3) leadership and education; and (4) feeling cared for.Conclusion: The NC role had impacted on service development and culture in the instigation of a chronic musculoskeletal pain service and leadership and education activi-ties. Patients experienced the holistic nature of the role. Copyright © 2006 John Wiley & Sons, Ltd.

Key words: Nurse consultant, practitioner-researcher, role impact, semi-structured interviews

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Introduction

The creation of nurse consultant (NC) posts has expanded the clinical career pathway. Role components include expert practice, leadership, education and research (Department of Health, 1999). The primary purpose of the nurse consul-tant role is to promote and develop nursing from clinical to strategic and policy levels, while simultaneously creating and maintaining a culture in which nurses and nursing strives for more effective patient and healthcare services (Manley, 1997).

Background

In 2000 a nurse consultant in rheumatology was appointed. The vision behind this new role was to address the absence of service provision for patients with chronic musculoskeletal pain. In common with other providers (Clinical Standards Advisory Group, 2000) services for the management of pain tended to be uncoordinated and lacking a cohesive strategy to address symptom management resulting in patients experiencing long waits to access appropriate services. The author was a co-researcher in the Royal College of Nursing Consultant Nurse Project, which sought to assist nurse consultants to evaluate their work and demonstrate their impact through researching their own practice. The overall project methodology inte-grated emancipatory action research with fourth generation evaluation.

The study

Aim

The aim of the study was to identify the perceptions of peers and patients regarding the role and impact of one nurse consultant in rheumatology.

Method

A qualitative approach was adopted to enable participants to describe their experi-ences of working with or being cared for by an NC. Ethical approval for the study was obtained from the North Staffordshire Local Ethics Research Committee.

Participants

Seven peers of the NC consisting of two consultant rheumatologists, one manager, two outpatient nurses, one inpatient ward sister and one consultant physiotherapist

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of the NC were recruited to the study. In addition, five patients cared for by the NC were interviewed by an independent nurse researcher (INR). The patients’ demographic details are shown in Table 1. The peers chosen by the INR from a role set of 12 were selected on the basis that they had direct involvement with the NC and were available for interview within a two-month period. Patients with a diagnosis of rheumatoid arthritis attending an NC review clinic over one month were selected by the INR on the basis that they had seen the NC on two separate occasions. Patients were sent information regarding the study and contacted by telephone to ascertain their willingness to participate. All peers and patients asked agreed to participate with consent obtained by the INR.

Data collection

Semi-structured interview guides were utilized. The guide for the peer group con-sisted of the following questions:

1. Could you describe the role of the rheumatology nurse consultant?2. Can you provide some examples of the activities this nurse consultant is

involved in?3. What has changed as a result of having a nurse consultant?

Two specialist rheumatology nurses devised the patient interview guide:

1. Can you describe what happens when you have a clinic appointment with the nurse consultant?

2. What is it like to be cared for by the nurse consultant?3. What kind of problems/issues are discussed?

All patients were interviewed within a week of their clinic appointment to aid recall. Peers were interviewed over a two-month period. All interviews were con-ducted in a quiet room within the hospital and lasted for 45 minutes

TABLE 1. Demographic details of the patient sample

Participant Number M/F Disease duration (years) Age (years)

1 M 16 652 F 14 603 F 5 404 F 8 435 F 17 70

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Data analysis

The interviews were audiotaped and transcribed in their entirety. They were anal-ysed using thematic analysis. From the transcribed data, significant statements relating to the impact of the nurse consultant were identified enabling categories to emerge (aspects that individual participants stated were important) and themes (groups of categories that appear to be linked). A second independent researcher reviewed all of the interview transcripts to verify that the categories identified could be traced back to the significant statements.

Results

Two key themes emerged from the analysis of peer and patient group data:

Peers:1. Development of a new model of care for patients with chronic musculoskeletal

pain.2. Leadership and education.

Patients:1. Holistic person-centred care experienced and valued by the patient.2. Feeling cared for.

Peers: Development of a new model of care

All peers were able to identify the role of the nurse consultant in developing a new model of care for patients with chronic musculoskeletal pain and recognized the implications and impact of such new roles on patients and the healthcare team

‘. . . been excellent in actually developing a new model of how to manage these patients . . . going away from the medical model . . . where patients take ownership of their symptoms.’ (Rheumatologist 1)

‘The chronic pain service; she has got it going, she has defined it, she’s made predominantly the medical team but other professionals think, hang on that’s useful.’ (Manager)

‘What has changed as a result of having a nurse consultant . . . is the culture, so the culture perhaps, um, the hierarchical structure of doctors feeding down to nurses and allied health professionals has gone . . . the role has almost given per-mission for other health professionals to see patients initially rather than being managed solely by the consultant first.’ (Consultant Physiotherapist)

‘She is influencing how the service is delivered and how the department func-tions.’ (Rheumatologist 2)



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Peers: Leadership and education

Peers identified leadership (both clinical and political) in practice and formal and informal education as key activities that the nurse consultant was involved in

‘She demonstrates excellent leadership skills and, by remaining hands on, she remains part of the team.’ (Ward Sister)

‘The difference between the nurse specialist and the nurse consultant role is that she has become more autonomous, she is also very adept at the politics of interpersonal skills.’ (Rheumatologist 2)

‘I think the clinical practice and leadership is now quite overt in a way that possible it wasn’t before . . . that people do look at her for some kind of clinical mentorship.’ (Rheumatologist 2)

‘The Masters, is the only rheumatology nursing Masters in the country, the only nursing Masters at Keele . . . so you could say it is an example of consultant nurse practice.’ (Rheumatologist 1)

‘These latest rheumatology modules are what we have needed for a long time.’ (Ward Sister)

Patients: Holistic person-centred care experienced and valued by the patient

Patients described the consultation with the nurse consultant as holistic with an emphasis on physical and social concerns, something they both experienced and valued

‘I just think the physical examination, her knowledge base and everything is much better . . . than some medics, in fact when I come to outpatients I’d rather be seen by the nurse consultant than a junior doctor.’ (P3)

‘When the nurse consultant sees you in a consultation she’s thinking not just about your physical problems, she thinks of other aspects of your life.’ (P5)

‘I value my appointment with the nurse consultant, I know she will look at my joints, talk about my blood results and ask how my husband is.’ (P4)

Patients: Feeling cared for

All patients expressed positive feelings relating to their consultation with the nurse consultant and her skills at enabling the patient to feel cared for and important.

‘She puts me at ease and she looks after me and I know that when I see her I will come out better.’ (P2)

‘I do come away feeling relieved and satisfied with what has happened.’ (P4)‘She always seems very bothered about me, there’s nothing I wouldn’t talk to

her about.’ (P3)

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‘When I come and I know I am seeing her, I know that she will do her best for me so I feel fine.’ (P5)

Discussion

Peers recognized the NC as establishing a new model of care for chronic musculo-skeletal pain and identified her leadership and education activities. Patients attend-ing an NC clinic experienced a holistic approach to their needs and felt cared for and important.

The physiotherapist from the peer group referred to a change in the culture of care. Prior to the development of the chronic pain service there was a perception of doctors always leading the clinical care in a hierarchical structure. The NC had demonstrated that other models of care, led by other health professionals could also be effective, something acknowledged and endorsed by the NC’s medical colleagues.

While there has clearly been a positive impact on the rheumatology service it is impossible to say how much of that is due to the role and how much to the individual herself. Manley showed in her consultant nurse research that both the role and the person are inter-related, with both being important. Also, she argues that it is not about developing a cause and effect relationship between the person and the outcome, but a system where leadership can achieve a change in culture, as culture is a social system not an individual (Manley, 2001).

This study demonstrates the importance of organizational authority illustrated by one rheumatologist who made direct reference to a different level of autonomy between the clinical nurse specialist and nurse consultant role. This supports Manley’s (1997, 2002) nurse consultant conceptual framework that identifies orga-nizational authority of the role as the single most influential factor in the work context for achieving cultural change.

Participants from the peer group also recognized that the NC had had an impact of leading and developing staff. Manley (2002) regards the role of the NC as developing a transformational culture, which will enable practice development, with its focus on person-centred and clinically effective services, and staff empower-ment to be ongoing. Through remaining visible, working alongside colleagues the NC is aware of the reality of the situation and endorses their credibility to the rheumatology team. Both medical and nursing peers identified the establishment of a Master’s course and specialist rheumatology modules as examples of role activi-ties. Only one peer (Rheumatologist 1) mentioned the nurse consultant’s involve-ment in research. This may be a consequence of the time required to develop a new service and the research aspect of the role may develop at a later stage or that the nature of everyday practititioner-research is not recognized as research. All peer



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group participants were very positive about the impact of the role. This may have been influenced by the type of research methodology used as, although the results are anonymous, it is easy to identify the individuals concerned by virtue of their profession.

Patients described their clinical consultation with the NC in positive terms regarding the knowledge and skills used, their experience of being cared for and the holistic manner in which the consultation was conducted. Donovan and Blake (2000) demonstrated that patients with arthritis sought acknowledgement of the impact of their symptoms to feel reassured from the consultation.

Conclusion

The proposed activities of the NC role (Department of Health, 1999) are shown to be occurring in one rheumatology setting and also to be having an impact. This impact has been on service development, through the instigation of a new model of care for patients with chronic musculoskeletal pain as well as on leadership and educational activities that can change the culture. The expert practice component of the role was identified by patients as incorporating physical, psychological and social needs as well as focusing on the patient as a person. Explicit research activi-ties were not identified as a common aspect of the role, but this may be because the research approach used is different. Future research is required to demonstrate the impact of the role on the culture in which nurse consultants work

References

Clinical Standards Advisory Group (2000). Services for Patients with Pain. London: Department of Health.

Department of Health (1999). Nurse, Midwives and Health Visitor Consultants: Establishing Posts and Making Appointments. Health Service Circular 217. London: Department of Health.

Donovan JL, Blake DR (2000). Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: ‘Just a touch of arthritis, doctor?’ British Medical Journal 320: 541–4.

Manley K (1997). A conceptual framework for advanced practice: An action research project operationalising an advanced practitioner/consultant nurse role. Journal of Clinical Nursing 6: 179–90.

Manley K (2001). Consultant Nurse: Concepts, Process, Outcome. Unpublished PhD Thesis. University of Manchester/RCN Institute London.

Manley K (2002). Refining the consultant nurse framework: Commentary on critique. Nursing in Critical Care 7(2): 84–7.

Address correspondence to Sarah Ryan, Nurse Consultant Rheumatology, Haywood Hospital, High Lane, Burslem, Stoke on Trent ST6 7AG. Tel: 01782 556148. E-mail: [email protected]

Exploring the perceived role and impact of the nurse consultant

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