The NHS plan envisages at least 1,000 nurse consultant posts by 2004. But how do individual trusts define and develop the role?
Our experience in establishing three posts in a large acute trust may have valuable lessons for others.
In 1999 when the government launched guidance for establishing and appointing the new role of consultant nurse, developing nursing practice was already high on the trust's agenda.
1Research showed that a huge diversification in roles, and a lack of consistency and appropriate training, had developed over the past decade within the NHS.
2Many postholders felt that they required further training in core skills such as research, audit, IT and specialist clinical skills.
The lack of consistency in the skills required seemed to have left some specialist practitioners without the necessary competencies in terms of audit, professional leadership and clinical decision-making.
So the efficacy and influence that the higher-level role should have produced within nursing has not necessarily materialised. Instead, a plethora of job titles has emerged, without a set of generic core skills.
The resulting confusion and inconsistency has potentially undermined the credibility of nursing as a profession capable of developing and delivering evidence-based healthcare.
No-one in our trust could identify the number, location and remit of all the nurses working in higher-level roles. Indeed, such posts seemed to be created on an ad hoc basis with none of the rigour and trust-wide view that appointments in medicine require. This enabled services to develop rapidly in response to perceived need, but the people appointed were not necessarily in a position to get corporate support to develop and evaluate the post.
There was some confusion in the trust about how the new role of nurse consultant would differ from that of a nurse practitioner/specialist. So work was undertaken to define the new role. This involved developing a set of core competencies based on the following principles:
The practice expertise of consultant nurses is not necessarily linked to a medical specialty.
The role is about advancing nursing practice and service delivery, not merely medical substitution.
3 The practice of the consultant nurse must improve service delivery and the competency of others.
Consultancy, research and education are integral parts of the role and not add-ons.
As senior nurses within an organisation, postholders have a responsibility to uphold and develop the standards of care that patients receive in all areas.
With the aim of embedding the consultant nurse posts within the trust culture, a working group was established to define the role. The group comprised the head of nursing (surgery), a nursing research fellow, the senior nurse for practice and professional development and a specialist nurse (palliative care).
The group agreed that any nurse with the title 'consultant nurse' should be competent in a core set of generic skills.
It was felt important to emphasise postholders' ability to influence and guide all healthcare professionals (including medical staff and managers) to improve the quality of services.
Competency in its broadest sense refers to the capability of an individual to carry out a particular role or function, and is used to denote the level of skill attained or required.
Many trusts have produced competency frameworks for nurses working at different levels within their organisation so that the expectation of their role is apparent to all nurse colleagues and other healthcare professionals. Indeed, work is already in progress nationally to standardise competency levels in relation to the new career framework.
4The working group analysed guidance and research on the consultant nurse role, and reviewed competency frameworks from acute and community trusts.
This enabled competencies for the consultant nurse role to be developed in the areas of expert practice, professional leadership and consultancy, practice and service development and education. In expert practice, for example, the requirement is defined as: 'collaborates with colleagues to work as a practitioner whose expertise demonstrably improves patients' outcomes and experience of healthcare intervention. Demonstrates the ability to analyse their own practice and those of colleagues in terms of its important skills and the synthesis of these skills that make it 'expert' practice in terms of being accountable, empowering patients and developing these skills in others.'
Throughout, the competencies emphasise:
expert core skills of working with patients so that 'hands-on' patient care influences the domains of leadership, consultancy, education and development of practice; operating beyond boxes and across boundaries; ability to function within higher education; ability to communicate with all levels of staff within the NHS.
The working group distributed the competencies to allow feedback, although the timeframe meant that consultation was more limited than desired.
Following feedback and refinement, which occurred as the Department of Health's guidance (HSC 1992/217, NHSE 1999) was published, expressions of interest in establishing consultant nurse roles were invited.
The 'expressions of interest'were required to have links to a clearly defined, previously unmet service need.
The working group analysed their potential and then offered central support. The process resulted in proposals for nurse consultants in pre-operative assessment, palliative care and midwifery, all of which were accepted through the regional and national assessment process.With one exception, these posts have now been filled.
We do not claim that the consultant nurse competencies developed are evaluated or definitive.
But the process used enabled the organisation to own and steer a crucial development, building foundations for the future development and support of such roles.
Research has suggested that this is important if competence is to be sustained.
5,6 Team and organisational competence and values influence individual competence.
If we set up these consultant nurse posts to be stand-alone innovators, we will only compound the mistakes of the past. The success of consultant nurses in really changing nursing practice and service delivery will depend on key factors in all organisations.
These include the organisation's awareness and support for the role, clinical supervision and practical support for postholders, and realistic timescales.
The work of the UK Council for Nursing, Midwifery and Health Visiting in defining higherlevel practice, and strategies to assess it, will assist the process of understanding and appropriately using consultant nurse roles. But the success of such posts will also rely on other factors, particularly the process adopted by individual organisations.
Such attention to process will be the only way that the ambitious NHS plan target of 1,000 consultant nurses by 2004 has any hope of being achieved effectively.
Key points The role of nurse consultant needs to be embedded in trust culture if it is to achieve its potential.
The process of defining key competencies can enhance the organisation's ownership.
The post needs to be evaluated at local level.
1NHSE. Nurse, Midwife and Health Visitor Consultants; Establishing Posts and Making Appointments. Health Service Circular 1992/217. Department of Health, 1999.
2 Read S et al. Exploring New Roles in Practice: Implications of developments within the clinical team (ENRiP). Sheffield University, 1998.
3 Manley K.A conceptual framework for advanced practice: an action research project operationalising an advanced practitioner/ consultant nurse role. J of Clinical Nursing 1997; 6: 17990.
4 Peach L. Fitness for practice. UKCC Commission for Nursing and Midwifery Education, 1999.
5 Edmunds A, Lethbridge Z. Appointing a continence consultant nurse. Nursing Standard 2000; 3 (15): 40-1.
6 Manley K, Garbett R.
Paying Peter and Paul: reconciling concepts of expertise with competency for a clinical career structure. J of Clinical Nursing 2000; 9: 347- 59.
Brigid Reid, nurse consultant (general surgery) Blackburn, Hyndburn and Ribble Valley Health Care trust, was formerly head of nursing (surgery) at Birmingham Heartlands and Solihull trust.
Alison Metcalfe is nursing and midwifery research fellow, Birmingham Heartlands and Solihull trust and Birmingham University.