Finance and management
Outpatient nurses must adapt to survive Edwin Marsden, National Audit Office, London
Outpatient nursing has long been considered a clinical backwater. However, recent critical reports, the NHS reforms and other trends in healthcare are likely to change this. Outpatient nurses must move quickly to develop a new role for themselves or the opportunity will be lost. They should aim to make the best possible use of their nursing skills, given that outpatients need nursing care.
utpatient nursing is rapidly ap proaching a watershed. Different forces have brought this about, including the NHS Management Executive’s (1990) re port on the role of nurses in outpatient de partments and the National Audit Office’s (1991) report on outpatient services. The introduction of contracting has added a fur ther dimension as hospitals that provide acute services become increasingly con cerned about reducing staff costs. To date, outpatient nurses have provided an obvious target. The immediate challenge to outpatient nurses is to justify their presence in out patient departments. To say that nurses have always been in outpatients is now not good enough; instead their justification should centre around the need of out patients for nursing care. Outpatient nurses will also need to put forward a well-reason ed view of their future role if they are to influence the direction and outcome of skill mix reviews. Who then should determine the future role of the outpatient nurse and how should it be done? Outpatient nurses and those nurses who manage them are ultimately re sponsible for their own destiny; but NHS managers and doctors must also contribute if nurses are to continue to work in this increasingly important NHS service. The challenges to these groups are as follows. Nurses
Mr Marsden is Professional Adviser, Health Area, in the National Audit Office, Buckingham Palace Road, Victoria, London SW1W 9SP
356
Outpatient nurses need to think creatively and innovatively about the nature and scope of their future clinical practice. This must include developing a systematic means by which the nursing needs of outpatients can be identified. Nurses will also have to identify the skills and knowledge base needed to meet any future role. It is difficult to believe that this work •can take place in every hospital’s outpatient department, and such work done in isola tion may well founder. Consequently,
nurses need to find another way of develop ing and promoting clinical excellence in outpatient nursing. This could include the establishment of a nursing development unit with an outpatient focus, which would allow nurses to draw on existing good prac tice in outpatient departments (Glasper, 1992; Laurent, 1992) and give them the freedom to experiment and make mistakes. It would also provide a much-needed pro fessional focus for a group of nurses who are uncertain as to how to break out of their present situation. NHS managers
NHS managers need to consider whether their plans should include outpatient nurses when determining the future shape of out patient services. They should not assume that, because in the past qualified nurses in outpatient departments have not performed much work that required nursing skills, there will inevitably be little work for quali fied nurses in the future. If there is a role for nurses in outpatient departments, man agers need to discuss with nurses how to make the best use of their skills, and what training the nurses will require to fulfil their new role. The incentives for managers are many. GPs, particularly fund-holders, are now thinking carefully before purchasing out patient services for their patients. Specialist outpatient nurses may be able to comple ment outpatient services that are already available from hospital doctors, thereby adding to the depth and breadth of out patient services that providers have to offer. In particular, outpatient nurses may be able to play a leading role in health promotion. Also, following the introduction of The Patient’s Charter (Department of Health, 1992) waiting times have become a key per formance indicator for outpatient services. Better use of nursing skills, e.g. nurse-led clinics in outpatient departments, could lead to waiting time targets being realized. British Journal of Nursing, 1992, Vol 1, No 7
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Outpatient nurses must adapt to survive
‘In 10 years time, today's outpatient nurse may have evolved into the specialist nurse in “ambulatory” care. Outpatient nurses should strike out now with this end in view
Doctors
Doctors will also play a crucial part in de termining whether or not nurses have a fu ture role in outpatient departments. Devel opments in nursing practice in other spe cialties, e.g. nurse practitioners in accident and emergency departments, have only been possible through the cooperation and willing support of senior medical staff. Outpatient nursing will also depend on such support. Some doctors like the notion of nurses working in outpatient departments, but only if they are there to carry out their more traditional role, e.g. clinic administra tion and chaperoning. It is increasingly dif ficult to justify a nurse doing work that could be carried out by a trained outpatient assistant. Consequently, doctors need to consider with their nursing colleagues how best to use both sets of skills in the future. In doing so, doctors may come to recognize that there are discrete areas of clinical work that are well suited to the skills of nurses. More challenging still, it may be the case that nurses are able to deliver better clinical outcomes than junior doctors. KEY POINTS • Outpatient nurses must adapt to survive. Their future role must centre around the fact that outpatients need nursing care.
• The development and promotion of clinical excellence in outpatient nursing needs a central focus, e.g. a nursing development unit.
• Provider managers should note that the imaginative use of nursing skills could make outpatient services more attractive to purchasers, e.g. by expanding health promotion.
• Outpatient departments have the potential to be the point of delivery of much healthcare in the future. Nurses are best suited to provide some of this care. • Nurses, NHS managers and doctors hold the key to the future of the outpatient nurse.
British Journal of Nursing, 1992, Vol 1, No 7
However, if senior clinicians need a more pragmatic motive for holding these dis cussions, then the proposed reduction in junior doctors’ hours should raise questions about how outpatient clinics are to be staff ed in the future to provide high-quality pa tient care. Conclusion
Is outpatient nursing worth all this effort? I would suggest that it is. Outpatient de partments have the potential to be the point of delivery for much healthcare in the fu ture, as medical technology and practice continue to evolve and the NHS attempts to deliver more healthcare with the avail able resources. They may also provide an important bridge between hospital and community health services. Whether out patient departments meet this expectation depends on how imaginative provider hos pitals are in their planning. Nonetheless, a more active role for nurses may help out patient departments provide a better quality and more efficient service. In 10 years time, today’s outpatient nurse may have evolved into the specialist nurse in ‘ambulatory’ care. Outpatient nurses should strike out now with this end in view, otherwise the price of failure may be the gradual demise of the outpatient nurse in many hospitals. That failure would reflect badly not only on nurses but also on NHS managers and doctors and may not be in the longer-term interest of the NHS. The time is ripe for change; will the challenge be met? # Glasper A (1992) Sick kids: healthy ideas. Nun Times 88 (20): 30-2 Department of Health (1992) The Patient’s Charter. HMSO, London Laurent C (1992) Fresh outlooks. Nurs Times 88 (20): 26-8 National Audit Office (1991) NHS Outpatient Ser vices. HC 191, HMSO, London NHS Management Executive (1990) The Role of Nurses and Other Non-Medical Staff in Out patients Departments. DoH Health Publications, Middlesex
C a r e stu d y If y o u w o u ld like to w rite a care stu d y fo r the British Jo u rn al o f N ursin g please refer to the instruction s to authors fo r care studies on page 3 40
357
Downloaded from magonlinelibrary.com by 129.215.017.190 on January 13, 2019.
Outpatient nurses must adapt to survive Edwin Marsden, National Audit Office, London
Outpatient nursing has long been considered a clinical backwater. However, recent critical reports, the NHS reforms and other trends in healthcare are likely to change this. Outpatient nurses must move quickly to develop a new role for themselves or the opportunity will be lost. They should aim to make the best possible use of their nursing skills, given that outpatients need nursing care.
utpatient nursing is rapidly ap proaching a watershed. Different forces have brought this about, including the NHS Management Executive’s (1990) re port on the role of nurses in outpatient de partments and the National Audit Office’s (1991) report on outpatient services. The introduction of contracting has added a fur ther dimension as hospitals that provide acute services become increasingly con cerned about reducing staff costs. To date, outpatient nurses have provided an obvious target. The immediate challenge to outpatient nurses is to justify their presence in out patient departments. To say that nurses have always been in outpatients is now not good enough; instead their justification should centre around the need of out patients for nursing care. Outpatient nurses will also need to put forward a well-reason ed view of their future role if they are to influence the direction and outcome of skill mix reviews. Who then should determine the future role of the outpatient nurse and how should it be done? Outpatient nurses and those nurses who manage them are ultimately re sponsible for their own destiny; but NHS managers and doctors must also contribute if nurses are to continue to work in this increasingly important NHS service. The challenges to these groups are as follows. Nurses
Mr Marsden is Professional Adviser, Health Area, in the National Audit Office, Buckingham Palace Road, Victoria, London SW1W 9SP
356
Outpatient nurses need to think creatively and innovatively about the nature and scope of their future clinical practice. This must include developing a systematic means by which the nursing needs of outpatients can be identified. Nurses will also have to identify the skills and knowledge base needed to meet any future role. It is difficult to believe that this work •can take place in every hospital’s outpatient department, and such work done in isola tion may well founder. Consequently,
nurses need to find another way of develop ing and promoting clinical excellence in outpatient nursing. This could include the establishment of a nursing development unit with an outpatient focus, which would allow nurses to draw on existing good prac tice in outpatient departments (Glasper, 1992; Laurent, 1992) and give them the freedom to experiment and make mistakes. It would also provide a much-needed pro fessional focus for a group of nurses who are uncertain as to how to break out of their present situation. NHS managers
NHS managers need to consider whether their plans should include outpatient nurses when determining the future shape of out patient services. They should not assume that, because in the past qualified nurses in outpatient departments have not performed much work that required nursing skills, there will inevitably be little work for quali fied nurses in the future. If there is a role for nurses in outpatient departments, man agers need to discuss with nurses how to make the best use of their skills, and what training the nurses will require to fulfil their new role. The incentives for managers are many. GPs, particularly fund-holders, are now thinking carefully before purchasing out patient services for their patients. Specialist outpatient nurses may be able to comple ment outpatient services that are already available from hospital doctors, thereby adding to the depth and breadth of out patient services that providers have to offer. In particular, outpatient nurses may be able to play a leading role in health promotion. Also, following the introduction of The Patient’s Charter (Department of Health, 1992) waiting times have become a key per formance indicator for outpatient services. Better use of nursing skills, e.g. nurse-led clinics in outpatient departments, could lead to waiting time targets being realized. British Journal of Nursing, 1992, Vol 1, No 7
Downloaded from magonlinelibrary.com by 129.215.017.190 on January 13, 2019.
Outpatient nurses must adapt to survive
‘In 10 years time, today's outpatient nurse may have evolved into the specialist nurse in “ambulatory” care. Outpatient nurses should strike out now with this end in view
Doctors
Doctors will also play a crucial part in de termining whether or not nurses have a fu ture role in outpatient departments. Devel opments in nursing practice in other spe cialties, e.g. nurse practitioners in accident and emergency departments, have only been possible through the cooperation and willing support of senior medical staff. Outpatient nursing will also depend on such support. Some doctors like the notion of nurses working in outpatient departments, but only if they are there to carry out their more traditional role, e.g. clinic administra tion and chaperoning. It is increasingly dif ficult to justify a nurse doing work that could be carried out by a trained outpatient assistant. Consequently, doctors need to consider with their nursing colleagues how best to use both sets of skills in the future. In doing so, doctors may come to recognize that there are discrete areas of clinical work that are well suited to the skills of nurses. More challenging still, it may be the case that nurses are able to deliver better clinical outcomes than junior doctors. KEY POINTS • Outpatient nurses must adapt to survive. Their future role must centre around the fact that outpatients need nursing care.
• The development and promotion of clinical excellence in outpatient nursing needs a central focus, e.g. a nursing development unit.
• Provider managers should note that the imaginative use of nursing skills could make outpatient services more attractive to purchasers, e.g. by expanding health promotion.
• Outpatient departments have the potential to be the point of delivery of much healthcare in the future. Nurses are best suited to provide some of this care. • Nurses, NHS managers and doctors hold the key to the future of the outpatient nurse.
British Journal of Nursing, 1992, Vol 1, No 7
However, if senior clinicians need a more pragmatic motive for holding these dis cussions, then the proposed reduction in junior doctors’ hours should raise questions about how outpatient clinics are to be staff ed in the future to provide high-quality pa tient care. Conclusion
Is outpatient nursing worth all this effort? I would suggest that it is. Outpatient de partments have the potential to be the point of delivery for much healthcare in the fu ture, as medical technology and practice continue to evolve and the NHS attempts to deliver more healthcare with the avail able resources. They may also provide an important bridge between hospital and community health services. Whether out patient departments meet this expectation depends on how imaginative provider hos pitals are in their planning. Nonetheless, a more active role for nurses may help out patient departments provide a better quality and more efficient service. In 10 years time, today’s outpatient nurse may have evolved into the specialist nurse in ‘ambulatory’ care. Outpatient nurses should strike out now with this end in view, otherwise the price of failure may be the gradual demise of the outpatient nurse in many hospitals. That failure would reflect badly not only on nurses but also on NHS managers and doctors and may not be in the longer-term interest of the NHS. The time is ripe for change; will the challenge be met? # Glasper A (1992) Sick kids: healthy ideas. Nun Times 88 (20): 30-2 Department of Health (1992) The Patient’s Charter. HMSO, London Laurent C (1992) Fresh outlooks. Nurs Times 88 (20): 26-8 National Audit Office (1991) NHS Outpatient Ser vices. HC 191, HMSO, London NHS Management Executive (1990) The Role of Nurses and Other Non-Medical Staff in Out patients Departments. DoH Health Publications, Middlesex
C a r e stu d y If y o u w o u ld like to w rite a care stu d y fo r the British Jo u rn al o f N ursin g please refer to the instruction s to authors fo r care studies on page 3 40
357
Downloaded from magonlinelibrary.com by 129.215.017.190 on January 13, 2019.
