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New Nursing Nursing Roles: Deciding the future for Scotland

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New Nursing Nursing Roles: Deciding the future for Scotland

Exploring role development and role expansion - is there a difference and does it matter?

Professor Susan Read MBE, Chair in Nursing Research and Postgraduate Tutor University of Sheffield

Abstract

After explaining the author's credentials for undertaking this review, the presentation begins and ends with some dictionary definitions, the most relevant of which are
Development:
Making or becoming bigger, fuller, more elaborate or systematic
Bringing to maturity
Elaborating a theme by modification of melody/harmony/rhythm (music)
Expansion:
An enlargement of scale or scope or area of control
Extension:
Stretching or laying out at full length
Taxing the powers of (an athlete) to the utmost

The term "extension" is included although not mentioned in the title, because it appears frequently as a contrast to "expansion". Definitions of the role of the nurse are also discussed, stressing the need for the registered nurse to exercise clinical judgement based on knowledge, maintain oversight, and be accountable, all in a context of professional and ethical regulation. Distinctions are drawn between professional nursing and nursing undertaken by other people.

The paper continues with a review of the history of role extension, expansion, and development, and related policies. Extension is viewed as mechanistic and task-based, with little use of clinical judgement, characteristics often associated with doctor substitute roles. In the light of the European Working Time Directive, which has recently stimulated a proliferation of such roles to cover acute care when junior doctors are scarce, these considerations are important. Based on the latest thinking on the nursing profession, with its emphasis on judgement, knowledge and responsibility, it is clear that mechanistic role extension is not the way forward for nurses.

The terms role expansion and role development are deemed to be more organic and therefore acceptable, and appear to be used in parallel and interchangeably, often in the context of a movement towards 'nurse-led care', examples of which are discussed.

The author's view is that it is hard to separate and differentiate between role development and role expansion. Warning is given however, that if nurses continue to accept extended roles that are designed to enable NHS management to meet targets rather than to enhance the care of patients, then that extension may result in damage to individual nurses through "burnout", and ultimately damage the profession and the patients for whom we care.

The audience is encouraged to think whether these differing definitions of role extension, expansion and development are recognisable in nursing in Scotland today, and whether the profession needs to be more discriminating and draw some more effective lines between what is acceptable and what is not.

Introduction

First of all may I outline the personal history allowing me to take a reasonably long view of changing roles in nursing. Having qualified as a nurse in 1962, I believe that many of the arguments about nursing role development (at least in the UK) have occurred during my working life. I expect, however, that nurse historians could find instances of such arguments dating back to Florence Nightingale, but we will concentrate on those occurring within living memory! Frost (1998, page 34) says

"Nurses, midwives and health visitors have always sought to redefine and develop the roles that they undertake. If this was not the case, then nurses would not be taking patients' blood pressure readings and health visitors would still be functioning as lady sanitary inspectors."

I suppose the first role expansion in which I was personally involved was in health visiting (my first career) when in the 1970s we needed to learn about the signs indicating a possibility of child abuse and our role in dealing with it. I became really aware of arguments about nursing roles and their development, however, when I began my second career as a researcher in 1989, and began to explore new nursing roles in Accident and Emergency (triage and nurse practitioners, George et al 1992, Read et al 1992, Read 1994) and later (1993 onwards) nursing roles designed and developed to help in the reduction of junior doctor hours. (Read 1995 and 1998 a) (Of course this subject is once again topical in the light of the European Working Time Directive). During the period 1989 to 1998, with colleagues first in SCHARR (University of Sheffield School of Health and Related Research) and then the University of Sheffield School of Nursing and Midwifery I undertook literature reviews which covered the topics of nursing role development, role expansion and role extension as part of several major projects; we published a number of reports and papers from which I shall quote, with the exception of "Exploring New Roles in Practice" (ENRiP) (Read et al 1999, Read, Lloyd Jones et al 2001) because my colleague, Myfanwy Lloyd Jones will speak about that later.

Definitions

We begin with some dictionary definitions taken from the Concise Oxford Dictionary, 9 th Edition, 1995. The words extend and extension are included because they are frequently mentioned in nursing literature alongside the other terms in the title of this conference session. We will return to some of these ideas later in the paper.

Develop:

  • To make or become bigger, fuller, more elaborate or systematic

  • To bring to maturity

  • (in musical terms) - To elaborate a theme by modification of melody/harmony/rhythm)

Expand:

  • To increase in size, bulk or importance

Expansion:

  • An enlargement of scale or scope

  • An increase in area of control

Extend:

  • To lengthen or make larger in space or time

  • To stretch or lay out at full length

  • To have a certain scope

  • To tax the powers of (an athlete) to the utmost

Extension:

  • A prolongation or enlargement

  • An additional part of anything

The Role of the Nurse

As well as defining words in the paper's title, it is also important to give some definitions of the role of the nurse. Probably the best known is:

"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. This aspect of her work she initiates and controls; of this she is master. In addition she helps the patient to carry out the therapeutic plan as initiated by the physician."

Henderson 1960

A specifically British definition comes next:

"The central role of the nurse is to ensure the care and comfort of the person being nursed, to maintain oversight and co-ordination of that care and to integrate the whole - both preventative and curative - into an appropriate social context."

Briggs 1972

Although this statement was made more than 30 years ago, it seems particularly appropriate now when we have to face the fact that much nursing care has to be delivered by unregistered staff, although they may have vocational qualifications. But the registered nurse has to maintain oversight and take responsibility.

The International Council of Nurses (ICN), as well as adopting Henderson's (1960) statement, established their own definition of nursing in 1987, and published a shortened version in 2002.

"Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management and education are also key nursing roles."

ICN 2002

Finally, the Royal College of Nursing (RCN) published its long awaited paper "Defining Nursing" in 2003. The introduction states

"This document is written for nurses and others to help them describe what nursing is. It incorporates a definition of nursing that can be used in developing policy and legislation, determining skill-mix, and resource management."

RCN 2003, page 1

The RCN give this definition: "Nursing is….The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death."

RCN 2003, page 3

There is not space here to elaborate further but the whole document is freely available to RCN members on the RCN website. http://www.rcn.org.uk

The RCN paper distinguishes (page 4) between professional nursing and nursing undertaken by other people.

"The distinction does not lie in the type of task performed nor in the level of skill that is required to perform a particular task. As for all professional practice, the difference lies in:

  • the clinical judgement inherent in the processes of assessment, diagnosis, prescription, and evaluation

  • the knowledge that is the basis of the assessment of need and the determination of action to meet the need

  • the personal accountability for all decisions and actions, including the decision to delegate to others

  • the structured relationship between the nurse and the patient which incorporates professional regulation and a code of ethics within a statutory framework".

This emphasis on the professional judgement, knowledge and responsibility is key when considering role development. One of the reasons given for accentuating the distinctive characteristics of professional practice is that nursing is vulnerable to being used inappropriately, as will emerge later in the paper. The RCN authors quote from a Scottish policy paper:

"Everyone has special skills to offer but at the margins of the field of competence of each professional group there are areas where there is some overlap of function. Despite these small areas of overlap, the major responsibilities of each professional group are quite clear - with the exception of nursing, where there is a considerable variation in perception." Scottish Home and Health Department 1991

Referring to the effects of skill-mix reviews on caring professions, another Scottish paper reinforces this view:

"The burden of change falls on everyone but is most evident among nurses, perhaps because of their greater numbers and their approach to embracing new skills within a holistic care model."

Scottish Royal Colleges Skill-mix Report 1998

The context for role expansion, extension and development

To set further discussion about roles in context I shall quote from some of my earlier work, "Reduction of Junior Doctors' Hours in Trent Region: the Nursing Contribution", (Read and Graves, 1994). (Abridged quotation in italics)

"The concept of the "extended role" of the nurse originated at a time when a disease oriented, task based, medical model of practice was accepted by a majority of nurses working in hospital. Work study of nurses in the 1950s labelled tasks as either basic or technical (Goddard 1953); successive statements issued jointly by the Royal College of Nursing (RCN) and the British Medical Association (BMA) outlined "the duties and position of the nurse", and also referred to "duties allocated to nurses which appear to be outside the generally accepted and current scope of nursing practice" (RCN 1961, 1970, 1978). These were to be agreed between the professions and adequate safeguards regarding training and competence put in place. The Briggs Report (Briggs 1972) stated that nurses should be required to undertake only those duties for which they had been educated and trained.

In 1977 the Chief Medical Officer and Chief Nursing Officer at the Department of Health and Social Security (DHSS) sent out a circular, (DHSS 1977) which included a working party report, setting out the parameters within which extended role tasks might be assumed by nurses. Such extension of the nursing role might develop from within the traditional role, might occur in emergencies, or might result from delegation by doctors.

In essence, the concept of the extended role of the nurse pictured a registered nurse, after 3 years' training, as a standardised "package" recognised as competent to perform a specified list of tasks for which education and certification had been given. Any new duties of a technical nature, which had been previously, or were also currently performed by doctors, were viewed as "extended roles" and needed training, examining and certifying in the local area. If the nurse moved to another District Health Authority, many tasks would have to be reappraised and re-certified or sometimes proscribed. Examples of the tasks viewed as extensions included: suturing, applying plaster of Paris, infiltration of local anaesthetic, electrocardiogram (E.C.G.), defibrillation, venepuncture, immunisation, ear-syringing, and acting as first-assistant to a surgeon in the operating theatre.

Because of developments in both the knowledge base of nursing, and the profession's growing sense of autonomy during the 1980s, (for example MacGuire's (1980) paper about role expansion in Britain) the Royal College of Nursing (RCN) suggested a new approach to professional accountability for "extended roles" in 1988 (RCN 1988). The DHSS was not yet ready for such a revolution, and reaffirmed the old guidance in 1989 (DHSS 1989). The pressure for change was now increasing, however; the Welsh National Board (Welsh National Board for Nursing, Midwifery & Health Visiting 1990) issued an influential discussion paper on the topic in 1990, which fuelled a debate in the profession. So it was not surprising that in June 1992 the Chief Nurses of the UK Health Departments (DoH 1992) withdrew earlier guidance on the extended role and asked all nurses and managers to act in accordance with the simultaneously issued UKCC documents "The Scope of Professional Practice" (UKCC 1992a) and the new "Code of Professional Conduct" (UKCC 1992b).

"The Scope of Professional Practice" (UKCC 1992a) emphasised the attributes of knowledge, judgement and skill required by nurses, and said that in the context of changing developments in health care, nursing practice must be sensitive, relevant and responsive to patient need and have the capacity to adjust, where and when appropriate, to changing circumstances. Education must keep pace with such change, both in pre-registration and post-registration areas.

The "Scope" document continued:

"The Council considers that the terms 'extended' or 'extending' roles are no longer suitable since they limit, rather than extend, the parameters of practice. As a result, many practitioners have been prevented from fulfilling their potential for the benefit of patients. The Council also believes that a concentration on 'activities' can detract from the importance of holistic nursing care..…. It is the Council's principles for practice rather than certificates for tasks which should form the basis for adjustments to the scope of practice."

UKCC 1992a

The UKCC made it clear, in the letter accompanying the new document to each individual nurse on the Register, that there should be no reduction in professional education preparatory to the assumption of new responsibilities, but that the requirement for certification would no longer remain."

Role expansion, extension and development since 1992

There is no doubt that the 1992 guidance to nurses on their scope of practice encouraged many to consider new developments in their roles, and within a few years the introduction of "Scope" had paved the way for a new set of definitions differentiating between role extension, expansion and development. These definitions were also influenced by discussion flowing from the UKCC's deliberations about specialist and advanced nursing practice which I imagine will be on the agenda for other speakers at this conference. Linked with these discussions were also attempts to define and differentiate between the roles of Clinical Nurse Specialists (CNS) and Nurse Practitioners (NPs). (Read 1995 and 1998a & b, Watson et al 1996, Roberts-Davies et al 1998, Read et al 1999, and Roberts-Davies and Read 2001 amongst others.) Some statements typical of the mid 1990s are quoted below.

"There were two ways the increasing responsibilities of nurses could have been recognised. One way was growth by mechanical addition of parts (extension) and the other way was organic growth of the whole (expansion). The UKCC has chosen the latter, as is fitting for the development of a profession. In the "Scope" document the UKCC rejects the notion of "role extension".

Hunt and Wainwright (1994, Introduction page xiv-xv)

"Does role expansion represent a real quantum leap in practice? If so, how exactly? The key to this is autonomy. If role expansion is about anything, it is about nurses taking their own initiative, doing their own thinking and making their own decisions based on their own experience and education, to improve practice for the benefit of patients and clients."

Hunt and Wainwright (1994, Introduction page xv)

"The real test of the development of nursing as a profession…….will be the extent to which nurses do not just take on responsibility for additional tasks, but the extent to which they achieve authority over the nature of their practice"

Wainwright P (1994, p19)

These authors describe "extension" as mechanistic, and other terms used in connection with "extension" include "task-based" and "doctor substitute". For instance:

"Extending practice…..is seen to be a task oriented activity undertaken for the convenience of other professionals and at their discretion."

Mitchinson S and Goodlad S (1996)
(see also Cole 1994, Greenhalgh 1994, Dowling et al 1995, Tye 2000)

Over the past year there has been a resurgence of papers about extended roles, probably in the light of the European Working Time Directive, which has stimulated a proliferation of "hybrid" roles to cover acute care at night or other times when junior doctors are scarce. (Bernhaut and Mackay 2002, Munro 2002, Cox and Farmer 2003, Jones 2003, Nielsen 2003, Parish 2003.) Based on the latest thinking on nursing as a profession, with its emphasis on judgement, knowledge and responsibility, it is clear that role extension on its own, in a mechanistic, task-based way is not the way forward for nurses, however much pressure is exerted due to EU regulations.

The terms "role expansion" and "role development" are however acceptable, and we are charged with considering whether they are different and whether any differences are important. I have found that they are often used in parallel and interchangeably, frequently in the context of advanced or advancing practice.

" Roleexpansion tends to refer to skill and knowledge development within the concept of nursing as a separate therapeutic activity, and may be seen as a development that results from professional autonomy and self-determinism. Enhanced roles are thus developed from activities and skills that are conventionally within nursing, midwifery and health visiting……… Extension of role generally refers to development that goes beyond conventional nursing boundaries."

Frost S 1998 Page 35

Frost acknowledges that her definitions owe much to work by Lovett and Norwood (1995) - she quotes from their paper:

  • "Roleexpansion: Core of nursing is primary practice with a range of post-qualifying specialist developments. Expansion takes the boundary of specialist development further to embrace new dimensions within the broadest concept of nursing.

  • Roleextension: Extending a nursing role tends to focus on one area of practice or skill. The boundary of this area is then extended outside of nursing into another professional domain.

  • Nursing role development: Most role development in nursing embraces both expansion and extension of conventional roles. The consequence is that the boundary of nursing is shifted and the fundamental nature of nursing is gradually changed."

Frost S 1998 Page 36

The notable feature of Lovett and Norwood's definitions is the claim that development involves both expansion and extension, and that nursing boundaries are shifted. Frost comments:

"Developing skills in one area to expand roles is not a threat to the core of nursing unless this replaces that core."

Frost S 1998 Page 39

The next quotation emphasises that core of nursing, and has echoes of the definitions of nursing cited earlier.

"Advanced practice, on the other hand, is seen by some to centre on the core therapeutic nursing roles of nurturing and caring and is focused on the delivery of holistic patient care."

MacAllister L, and Chiam M (1995)

Castledine among others expressed concern about the movement of nursing boundaries. "The nursing profession does not exist to take on the delegated tasks of any other profession, particularly medicine. It must develop its own boundaries and be aware of what it is doing when it develops new skills and competencies."

Castledine G (1994 p105)

The key principle enunciated by many writers is that patient needs must be given priority.

"It does not follow that because certain doctors should not do certain tasks, that nurses or midwives should do them. The pertinent consideration here surely is that role expansion should be led by patients' needs rather than by medical delegation or cost saving."

Hunt and Wainwright (1994, Introduction page xii)

My own conclusion after the first "Junior Doctors' Hours" project was as follows:

"When nursing knowledge and experience continuously informs a practitioner's decision making, even though some parts of her or his role may overlap the medical role, then that may be said to be advanced nursing practice. Conversely, when a nurse is expected to perform routine technical tasks with no opportunity to exercise nursing knowledge or take autonomous decisions, then that is when a nurse becomes a doctor's assistant, and in this study, a few nurses have expressed their feelings that this has happened to them. There is a difference between a nurse carrying out a succession of technical tasks on a whole list of patients, and an individual "named nurse" or primary nurse carrying out the specific technical tasks that her own allocated patients need. The former could be described as "an extended role," or becoming a doctor's assistant - the latter may be advanced practice and can be classified as role development which includes expansion."

Read S M and Graves K, (1994), brought up to date for this paper.

This view is supported by a quote from participants at a workshop for nurses in innovative roles in 1995:

"Advanced nursing practice is much more strongly related to a high level of clinical decision making for a discrete caseload of patients than to the carrying out of highly technical procedures" Reported in Read 1998a

Role development and nurse led care

The quotations so far have only touched on role development, but we remember that Lovett and Norwood (1995) claimed that development involves both expansion and extension, and the shifting of nursing boundaries. In a recent paper Daly and Carnwell say:

"Role development tends to imply a new role that not only embraces aspects of extension and expansion, but also involves higher levels of clinical autonomy brought about by new demands and perceived shortcomings in the quality of patient care and health care resources. The outcome of such roles is that the fundamental nature of service provision and scope of nursing practice within that specific role may be changed. Although this may often involve the acquisition of knowledge and skills associated with, for example, the medical domain, these should be used in a manner that enriches the holistic quality of nursing practice, patients' health care experience and health care provision generally."

Daly and Carnwell 2003

Between 1996 and 1998, I was grant holder for an English Department of Health funded collaborative project, "Exploring New Roles in Practice" (ENRiP). My colleague from the University of Sheffield's School of Health and Related Research, Myfanwy Lloyd Jones, will tell you more about ENRiP later today but the research plan included three sets of case studies, each set undertaken by one of the three teams involved in the project. In the Sheffield team's case studies two models of nursing role development were identified,

  • the "hands-on" practitioner

  • the practice developer

(McDonnell et al. 2000, Read et al 1999 and 2001).

In the set of nursing case studies conducted by the King's Fund team, (Scholes et al 1999, Scholes and Vaughan 2002) they identified three types of development:

  • Complementary roles, where specialist nurses provided expert advice to patients in partnership with other professions

  • Niche development, where nurses with a special interest carved out a particular role or a new service, in an innovative way.

  • Substitution roles, where nurses took on new activities, often technical, in place of doctors

The substitution roles were probably extended rather than expanded roles, and often led the nurses into a professional "cul de sac". The Bristol University ENRiP team's case studies covered allied health professionals (or PAMs as they were then called.) In the closing stages of the ENRiP project, advice was distilled for managers about the safe development of new roles (Levenson and Vaughan 1999). This guidance document covered issues identified by project participants to be particularly important in their capacity to function in their new roles: strategic planning, including career pathways and progression ; support from the multidisciplinary team and managers; effective communication; professional regulation and accountability; access to appropriate education and training; adequate resources of time, support staff, equipment, facilities and financial provision; role evaluation and identification of outcomes.

Work in Scotland concurrent with ENRiP was summarised by Laurenson (1997). Laurenson surveyed NHS Trusts in Scotland and reported that nursing role development fitted into two main categories:

  • Expansion of existing roles with additional skills (upskilling)

  • Creation of new posts incorporating new skills and wider decision making powers, such as those for Medical Support Nurses (created to reduce junior doctors' hours), Clinical Nurse Specialists, Advanced Practitioners and Practice Development Facilitators.

The roles described by Laurenson (1997) sound very similar to those found in England by the ENRiP team, with "hands-on" practitioners and practice developers, with substitutionary and complementary roles as well as niche developments, and with similar benefits and hazards identified.

More recently, work in Scottish Accident and Emergency services by Cooper and colleagues has identified the increasingly valued role of Nurse Practitioners (NPs) (Cooper et al 2001 and 2003) and demonstrated through a randomised controlled trial that NPs are as effective in managing patients with minor injuries as are Senior House Officers. (Cooper et al 2002), confirming the results of a similar but larger trial in England (Sakr et al 1999).

In a literature review prepared initially for evidence to the Nursing Pay Review Body, a colleague and I wrote:

"The term 'role developments' covers a range of meanings. The most easily understood and identified are discrete new roles such as those for nurse practitioners (NPs) and clinical nurse specialists (CNS). The creation of such roles is sometimes part of a movement towards 'nurse-led care'."

Shewan and Read 1999

The connection between role development and nurse-led care has been formalised more recently in a Scottish study which will also be explored later in this conference.

"Role development was defined as 'an endeavour which has facilitated the creation of a nurse/midwife led service"

Armstrong et al 2002

The term "nurse led care" has become widely used in the last few years. Here are some examples from the review which was summarised in Shewan and Read (1999).

"Hill et al (1994) is a well-researched example of nurse led care in the field of rheumatology. The rheumatology nurse practitioner (NP) managed an outpatient clinic in parallel with the consultant rheumatologist, seeing over 80% of patients without recourse to medical advice. The NP's patients suffered less pain, were more knowledgeable about their condition, and were more satisfied than the consultant's patients. Another good example of well evaluated nurse-led care is Griffiths (1996) study which focused on a nurse led unit providing therapeutic nursing care to medical patients being prepared for discharge. The author concluded that patients who received nurse-managed care 'fared considerably better' than the control group who remained under medical management. Other studies of nurse-led care relate to acute pain services (Mackintosh and Bowles, 1997), breast care (Poole, 1996), anticoagulation clinics (Mackie, 1996), tissue viability (Flanagan, 1998), multiple sclerosis liaison (Kirker et al, 1995), surgical pre-admission clinics (Newton, 1996; Neasham, 1996; Reed, 1997), and minor injury units (Dale and Dolan, 1994; Read, 1994; Brown, 1995; Beales and Baker, 1995). Significant issues commonly highlighted are the nurse's focus on patient education and providing psychological support. Improvements are often seen in administrative efficiency. This is measured for nurses in pre-admission clinics by reduced numbers of last minute cancellations for surgery leading to significant cost savings. Reduction in patient waiting times is another benefit, particularly in minor injury units and out-patient clinic settings, leading to improved patient satisfaction ratings. Nurse-led care of the elderly in a day hospital is demonstrated in a small study by Booth and Waters (1995), who focus on the nurse's central co-ordinating role.

Midwife-led or midwife managed care is a term that has come into great prominence since 'Changing Childbirth' promised mothers greater choice between 'high tech' and 'low tech' maternity care. Hundley et al (1994 and 1995) report a controlled trial of nearly 3000 women described as 'low risk' obstetrically who were randomised in a ratio of 2:1 between a midwife managed unit and an adjacent consultant led unit. Women in the midwifery led unit experienced better use of natural pain relief, greater mobility and a lower incidence of episiotomy. Staff in that unit expressed greater satisfaction related to being able to give more continuity of care. Woodcock and Baston (1996) report a year long audit of a midwife-led service in a small rural unit some 13 miles away from the district hospital. Maternal and neonatal outcomes demonstrated no problems for the patients cared for entirely by midwives, and maternal satisfaction levels were high, even for mothers who were transferred to consultant care because of complications either antenatally or intra partum. Carter (1994) gives a descriptive account of the development and functioning of one of the pioneering midwifery-led units. Walsh and Crompton (1997) combine results from the three projects just discussed with some results of their own. They conclude that 'Changing Childbirth ' has played a large part in increasing demand for midwife-led care and that there has been a major shift in clinical workload from obstetricians to midwives since 1990 without a corresponding shift in resources."

The review quoted above (Shewan and Read 1999) was brought up to date this year for a conference on nurse led care (Read and Waskett 2003, and Waskett and Read 2003 in preparation). The definition of nurse led care adopted for that presentation was:

"Nurse led care can provide an opportunity for nurses to develop enhanced nursing roles in which they can have autonomy over an area of practice and in which they can develop nurse /patient partnerships distinct and separate from doctor /patient partnerships."

Wiles et al 2001

Well researched papers on nurse led care were discussed. The areas of care covered were:

  • Nurse led in patient care/ intermediate care (Evans and Griffiths 1994, Griffiths and Wilson-Barnett 1998 and 2000, Griffiths et al 2000 and 2001, Griffiths 2002, Steiner et al 2001, Walsh et al 2003, Wiles et al 2001 and 2003.

  • Cardiac and respiratory care (Blue et al 2001, Caine et al 2002, Murchie et 2003)

  • Cancer treatment and care (Bredin et al 1999, Campbell et al 1999, Corner 1997 and 1999, Loftus and Weston 2001, Moore et al 2002)

  • Minor injury care (Sakr et al 1999)

  • Pre-operative assessment (Kinley et al 2001 and 2002)

  • Primary care (Kinnersley et al 2000, Shum et al 2000, Venning et al 2000)

  • Sexual health (Miles et 2002 and 2003)

The roles described as practising nurse-led care could all be classed as expanded roles; although some do in fact lead to substituting nurses for doctors, for instance in providing "same day" assessment of minor illness in GP surgeries. The papers quoted make it clear however that nurses deliver that care differently from doctors - particularly in their explanations given to patients.

There has until recently been greater concentration on role development in acute care, than on other aspects of nursing. But at least in Scotland this has been remedied recently. "Nursing for Health: a review of the contribution of nurses, midwives and health visitors to improving the public's health", and "Nursing for Health: Two Years On" (Scottish Executive 2001 and 2003) describe the part that Public Health Practitioners, Nurse Consultants, Family Health Nurses and Public Health Nurses can play in improving health for individuals and communities and in working strategically to shift the emphasis from illness to health in the population. This initiative was based on a review of systematic reviews on public health nursing by Elliott and colleagues from the University of Dundee. (2001)

Further work on role development, this time in the field of learning disabilities, was carried out in Scotland, and published in "Promoting Health, Supporting Inclusion". (Scottish Executive 2002). This policy document focuses on the health needs of all children and adults with learning disabilities, in the context of a model of care consisting of five tiers or levels:

  • Tier 0 - Community, public health and strategic approaches

  • Tier 1 - Primary care and directly accessed services

  • Tier 2 - Health services accessed via primary care

  • Tier 3 - Specialist locality health services

  • Tier 4 - Specialist area health services

Not only does this model give ample scope for nurses qualified in the specialty of learning disabilities to develop new roles, often overlapping with other disciplines in nursing (eg paediatrics or mental health) and outside it (eg social work), but also aiming for nurses in other specialties to take a special interest in helping clients with learning disabilities to feel truly included and to have their health needs met.

Conclusions

We have covered much ground in the area of nursing roles in this paper, and my personal view is that it is hard to separate and differentiate between role development and role expansion. Looking again at the definitions with which we began, we can see that nursing has become…"bigger, fuller, more elaborate or systematic, and more mature. And we could use the musical terminology of elaborating a theme by modification of melody, harmony, or rhythm. All these were included under "Develop" in the dictionary. Similarly, terms used in "Expansion" such as "An enlargement of scale or scope, or an increase in area of control", also apply to nursing. However, we do need to take some of the terms given under "Extension" as a warning; "to stretch or lay out at full length, or to tax the powers of (an athlete) to the utmost. If nurses continue to accept additional roles that are more to enable management to comply with directives or meet targets rather than enhancing the care of patients, then that stretching or testing endurance may result in damage to individual nurses through "burnout", and ultimately damage the profession and the patients for whom we care.

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