umication ana debate
Role of the night nurse practitioner ‘I suppose they will be rather like mini-doctors.’ This and similar observations were the understandable reactions of some nursing colleagues, when I voiced my intention to introduce nurse practitioners onto night duty.
Betsy Morley is Senior Nurse Manager of night services at Guy’s Hospital, St Thomas' Street, London SEl 9RT
c
Betsy M orley, G u y ’s H o sp ital, L ondon
urrently the National Health Ser vice is undergoing major change. But the recent review undertaken by the King Ed ward Hospital Fund for London (1992) and the current review of the London teaching hospitals chaired by Sir Bernard Tomlinson (Department of Health, 1992) confirm that the environment in which patient care is de livered will continue to experience farreaching changes this decade (Davidson, 1992). Evaluation of the resource management initiative confirmed the benefits of decen tralization and devolvement of responsibil ity to clinical staff at ward and departmental Jevel (Buxton et al, 1989). Guy’s Hospital was one of the resource management pilot sites. The local objective of this initiative was to introduce decentralized management by combining the clinical responsibilities of doctors with managerial responsibility for resources. This would achieve greater effi ciency, by making those directly respon sible for patient care also responsible for the resources to provide that care (Buxton et al, 1989). Following 4 years of successful resource management and towards the end of its first year as a trust, the Guy’s and Lewisham Trust reviewed the management structure. The existing shape of clinical directorates raised concerns about questions of clinical responsibility and effectiveness of com munication. Against the background of these changes it became evident that the night sisters/charge nurses in their present form no longer provided a useful function. We were well aware that there were other hospitals throughout the UK where the idea of a single site manager had been adopted, and that this individual was not always a nurse. However, we were convinc ed that there remained a need for experi enced and skilled back-up for the wards at night. Reduced numbers of staff and a high stress factor have not added to the popular ity of this shift (Adey, 1987). This present ed a unique opportunity for the hospital to make greater and more appropriate use
British Journal of Nursing, 1992, Voi l.N o 14
of the many and varied talents of the senior night nursing personnel. O ur aim was to introduce practitioners whose role would combine quality care, site management and general administration. It would also include the skills necessary to relieve the medical staff of some of the rou tine •practices carried out at night during what should be their sleeping hours. This would contribute to the hospital’s commit ment to reduce junior doctors’ hours ahead of the Government deadline of December 1994 (Department of Health, 1991a).
Enhancement of nursing skills The unreasonably long hours worked by junior medical staff are at present being vig orously addressed at all levels within the National Health Service (Department of Health, 1991a). There are inevitably fewer doctors on duty at night. The possibility of specially trained senior nursing staff with the skills to carry out extra clinical tasks, thus enhancing patient care, seemed advan tageous. To collect the required information on the duties that junior doctors carried out at night and to confirm how time was being utilized, a survey was undertaken over a period of 2 weeks. Its aim was to calculate the nature of junior doctors’ visits to the wards between the hours of 23.30 and 06.00 and to determine the length of time that patients were kept waiting. Our goal was to improve the continuity of patient care. We felt that an experienced skilled nurse could reasonably undertake, for example, the reinsertion of an intra venous cannula when an infusion extravasated. We monitored all calls made to the medical staff during the 7 hours between 23.30 and 06.30 on 17 of the general wards. The nightly list, which was completed by the ward nurses, included the time the call was made, the reason for the call and the approximate length of the visit. Six house officers covering the most de manding areas were interviewed informally, and gave their individual estimations of the
719
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Role of the night nurse practitioner
time that various tasks might take to com plete. An allowance was made for the amount of time it took the doctor to get out of bed and prepare before going to the ward. Certain additional factors were taken into consideration. These included routine evening ward rounds which were carried out after midnight as a result of responsibil ities in specialized fields such as: 1. Admissions through the accident and emergency department 2. Cardiac arrest calls 3. Emergency operating sessions. At the end of the allotted period of 2 weeks, all 17 wards involved returned their lists, confident that the information con tained therein was accurate. The results were divided into the categories shown in Table 1. During this 14-night period a total of 130 calls were made within the time span
T a b le 2. In v o lv e m e n t o f ke y p e rso n n e l in th e in tro d u c tio n o f n ig h t n u rse p ra c titio n e rs The D irector o f Nursing was involved from the start of the venture. The response of the night sisters/charge nurses in post proved a valuable indication o f interest in the change in role with its additional responsibilities. Their reaction was because they had been given inadequate explanations of what was required of them. A t this stage the idea was still in its infancy. The implications of the changes were discussed with all the ward sisters and senior nurses. Concerns voiced by them were noted. We arranged to meet with them at regular intervals to communicate and to monitor any problems that might arise. A meeting with the Head of the Department of Advanced Professional, Technical and NVQ (National Vocational Qualifications) studies in the Nightingale and Guy’s College of Health confirmed the considerable interest in our project. We outlined the areas proposed to be included in the period of study, incorporating a balance of practical instruction and appreciation of the professional implications of the role.
720
and approximately 63 hours were spent by junior doctors in dealing with them. The majority of the work was carried out by the house officers covering the medical, surgical and orthopaedic units. These results confirmed that the demands on junior doctors’ time were very great. The indications were that the continuity of patient care could be significantly improved if skilled nurse practitioners undertook some of these activities at night. Junior doc tors would also benefit from fewer inter ruptions to their sleep, thus leaving them more time to attend to acutely ill patients who require medical intervention. Alongside the number of doctors’ hours spent performing routine tasks at night we noted the amount of time patients waited for these treatments to be carried out. The Patient’s Charter — Raising the Standard (Department of Health, 1991b) lays great emphasis on waiting times. It was noticed that emergency situations elsewhere result ed in unacceptable delays of anything up to 2-3 hours for patients requiring, for example, the resiting of an intravenous cannula or the administration of the first dose of an intravenous drug. When the al ready overstretched house officer eventual ly gets the time to attend to the ever-increasing number of patients’ needs which have piled up during an emergency, he/she is tired, longing for bed and unlikely to carry out the procedures to the highest standard. A carefully trained nurse practi tioner resiting a venous cannula at 03.00 must surely offer a higher quality of care than that provided by a junior doctor after only an hour or two’s sleep over a 24-hour shift. An administrative presence on site at all times to provide a source of help and infor mation for patients, relatives and visitors is an important contribution to the general as pect of quality in any hospital. It is essential to deal sympathetically with patients’ and relatives’ concerns and queries, and to handle press enquiries professionally, as well as facilitating the smooth running of the hospital at night. The combination of all the issues mentioned seemed sufficient reason to supply an alternative to the night sister/charge nurse.
Implications of the role Scrupulous preparation of the night practi tioners was crucial to the effectiveness of their performance and the safety of their practice. The new document published by the United Kingdom Central Council for
British Journal of Nursing, 1992, Voi l.N o 14 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on March 9, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
Role of the night nurse practitioner
Nursing, Midwifery and Health Visiting’s The Scope o f Professional Practice (UKCC, 1992) confirmed our understanding of the term extended role, now defined as expand ed role, and proved useful as a guide and source of information. Its six principles covering additional skills practised by nurses highlight the importance of issues such as competence and accountability, and the need to use professional judgment when deciding whether to expand the role. A no table aspect of the document was the em phasis on the need for activities to benefit the patient, to be within the practitioner’s knowledge and skill limits, and not to frag ment existing care. Successful introduction of the night nurse practitioners depended on several groups of people (Table 2). The first train ing course for the practitioners was run in June 1992. A detailed account of the educa tional programme is given by Haynes et al
KEY POINTS • Major changes within the health service both nationally and locally demanded a closer look at the relevance of the night sister/charge nurse role. • Research into particular issues such as quality of patient care, junior doctors’ hours and general night administration confirm the most appropriate use of nurse practitioner skills. • Careful consideration of the implications of the role and the necessary preparatory training formed a crucial part of the planning. • A detailed evaluation of the new night nurse practitioner role is essential to review the effectiveness of this role and its contribution to quality patient care.
in the article on page 722. Our aims for the week of the course were achieved and the benefits to patients as a result of the course can be easily seen, even at this early stage.
Conclusion Night nurse practitioners are able to apply the theory gained from the training course in their nightly practice. Currently we are monitoring the role as it is developing. Al ready we can see benefits to the patients who have less time to wait during the night for certain procedures. In this way patients’ sleep, so essential to recovery, is less dis turbed. The night nurse practitioners report that they have greater job satisfaction as they are able to develop and utilize skills to en hance the quality of patient care. Finally, junior doctors get fewer calls for minor tasks. We intend to collate our findings over the next 6-9 months, when we will be able to evaluate formally the role of the night nurse practitioners at Guy’s Hospital.
Adey C (1987) Stress - who cares? Nursing Times/Nursing Mirror 8(4): 52-3 Buxton M, Packwood T, Keen J (1989) Resource Man agement Process and Progress. Health Economics Research Group. Department of Health, London Davidson L (1992) Shrinking capital (Editorial). Nurs ing Times 88(24): 10-16 Department of Health (1991a) Junior Doctors — The New Deal. NHS Management Executive, London Department of Health (1991b) The Patient's Charter — Raising the Standard. HMSO, London Department of Health (1992) Report o f the Inquiry into London's Health Service, Medical Education and Research. HMSO, London King Edward Hospital Fund for London (1992) Lon don Healthcare 2010: Changing the Future of Ser vices in the Capital. King’s Fund London Initiative Publications, London UKCC (1992) The Scope o f Professional Practice. UKCC, London
CORRESPONDENCE If you have any comments on this or any other article in the Journal, please write to: Joy Notter/Paula McGee, The Nursing Editors, Department of Nursing and Community Health, Fac ulty of Health and Social Sciences, University of Central Eng land in Birmingham, Birmingham B42 2SU.
British Journal of Nursing, 1992, Vol I,No 14
721
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on March 9, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
Role of the night nurse practitioner ‘I suppose they will be rather like mini-doctors.’ This and similar observations were the understandable reactions of some nursing colleagues, when I voiced my intention to introduce nurse practitioners onto night duty.
Betsy Morley is Senior Nurse Manager of night services at Guy’s Hospital, St Thomas' Street, London SEl 9RT
c
Betsy M orley, G u y ’s H o sp ital, L ondon
urrently the National Health Ser vice is undergoing major change. But the recent review undertaken by the King Ed ward Hospital Fund for London (1992) and the current review of the London teaching hospitals chaired by Sir Bernard Tomlinson (Department of Health, 1992) confirm that the environment in which patient care is de livered will continue to experience farreaching changes this decade (Davidson, 1992). Evaluation of the resource management initiative confirmed the benefits of decen tralization and devolvement of responsibil ity to clinical staff at ward and departmental Jevel (Buxton et al, 1989). Guy’s Hospital was one of the resource management pilot sites. The local objective of this initiative was to introduce decentralized management by combining the clinical responsibilities of doctors with managerial responsibility for resources. This would achieve greater effi ciency, by making those directly respon sible for patient care also responsible for the resources to provide that care (Buxton et al, 1989). Following 4 years of successful resource management and towards the end of its first year as a trust, the Guy’s and Lewisham Trust reviewed the management structure. The existing shape of clinical directorates raised concerns about questions of clinical responsibility and effectiveness of com munication. Against the background of these changes it became evident that the night sisters/charge nurses in their present form no longer provided a useful function. We were well aware that there were other hospitals throughout the UK where the idea of a single site manager had been adopted, and that this individual was not always a nurse. However, we were convinc ed that there remained a need for experi enced and skilled back-up for the wards at night. Reduced numbers of staff and a high stress factor have not added to the popular ity of this shift (Adey, 1987). This present ed a unique opportunity for the hospital to make greater and more appropriate use
British Journal of Nursing, 1992, Voi l.N o 14
of the many and varied talents of the senior night nursing personnel. O ur aim was to introduce practitioners whose role would combine quality care, site management and general administration. It would also include the skills necessary to relieve the medical staff of some of the rou tine •practices carried out at night during what should be their sleeping hours. This would contribute to the hospital’s commit ment to reduce junior doctors’ hours ahead of the Government deadline of December 1994 (Department of Health, 1991a).
Enhancement of nursing skills The unreasonably long hours worked by junior medical staff are at present being vig orously addressed at all levels within the National Health Service (Department of Health, 1991a). There are inevitably fewer doctors on duty at night. The possibility of specially trained senior nursing staff with the skills to carry out extra clinical tasks, thus enhancing patient care, seemed advan tageous. To collect the required information on the duties that junior doctors carried out at night and to confirm how time was being utilized, a survey was undertaken over a period of 2 weeks. Its aim was to calculate the nature of junior doctors’ visits to the wards between the hours of 23.30 and 06.00 and to determine the length of time that patients were kept waiting. Our goal was to improve the continuity of patient care. We felt that an experienced skilled nurse could reasonably undertake, for example, the reinsertion of an intra venous cannula when an infusion extravasated. We monitored all calls made to the medical staff during the 7 hours between 23.30 and 06.30 on 17 of the general wards. The nightly list, which was completed by the ward nurses, included the time the call was made, the reason for the call and the approximate length of the visit. Six house officers covering the most de manding areas were interviewed informally, and gave their individual estimations of the
719
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Role of the night nurse practitioner
time that various tasks might take to com plete. An allowance was made for the amount of time it took the doctor to get out of bed and prepare before going to the ward. Certain additional factors were taken into consideration. These included routine evening ward rounds which were carried out after midnight as a result of responsibil ities in specialized fields such as: 1. Admissions through the accident and emergency department 2. Cardiac arrest calls 3. Emergency operating sessions. At the end of the allotted period of 2 weeks, all 17 wards involved returned their lists, confident that the information con tained therein was accurate. The results were divided into the categories shown in Table 1. During this 14-night period a total of 130 calls were made within the time span
T a b le 2. In v o lv e m e n t o f ke y p e rso n n e l in th e in tro d u c tio n o f n ig h t n u rse p ra c titio n e rs The D irector o f Nursing was involved from the start of the venture. The response of the night sisters/charge nurses in post proved a valuable indication o f interest in the change in role with its additional responsibilities. Their reaction was because they had been given inadequate explanations of what was required of them. A t this stage the idea was still in its infancy. The implications of the changes were discussed with all the ward sisters and senior nurses. Concerns voiced by them were noted. We arranged to meet with them at regular intervals to communicate and to monitor any problems that might arise. A meeting with the Head of the Department of Advanced Professional, Technical and NVQ (National Vocational Qualifications) studies in the Nightingale and Guy’s College of Health confirmed the considerable interest in our project. We outlined the areas proposed to be included in the period of study, incorporating a balance of practical instruction and appreciation of the professional implications of the role.
720
and approximately 63 hours were spent by junior doctors in dealing with them. The majority of the work was carried out by the house officers covering the medical, surgical and orthopaedic units. These results confirmed that the demands on junior doctors’ time were very great. The indications were that the continuity of patient care could be significantly improved if skilled nurse practitioners undertook some of these activities at night. Junior doc tors would also benefit from fewer inter ruptions to their sleep, thus leaving them more time to attend to acutely ill patients who require medical intervention. Alongside the number of doctors’ hours spent performing routine tasks at night we noted the amount of time patients waited for these treatments to be carried out. The Patient’s Charter — Raising the Standard (Department of Health, 1991b) lays great emphasis on waiting times. It was noticed that emergency situations elsewhere result ed in unacceptable delays of anything up to 2-3 hours for patients requiring, for example, the resiting of an intravenous cannula or the administration of the first dose of an intravenous drug. When the al ready overstretched house officer eventual ly gets the time to attend to the ever-increasing number of patients’ needs which have piled up during an emergency, he/she is tired, longing for bed and unlikely to carry out the procedures to the highest standard. A carefully trained nurse practi tioner resiting a venous cannula at 03.00 must surely offer a higher quality of care than that provided by a junior doctor after only an hour or two’s sleep over a 24-hour shift. An administrative presence on site at all times to provide a source of help and infor mation for patients, relatives and visitors is an important contribution to the general as pect of quality in any hospital. It is essential to deal sympathetically with patients’ and relatives’ concerns and queries, and to handle press enquiries professionally, as well as facilitating the smooth running of the hospital at night. The combination of all the issues mentioned seemed sufficient reason to supply an alternative to the night sister/charge nurse.
Implications of the role Scrupulous preparation of the night practi tioners was crucial to the effectiveness of their performance and the safety of their practice. The new document published by the United Kingdom Central Council for
British Journal of Nursing, 1992, Voi l.N o 14 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on March 9, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
Role of the night nurse practitioner
Nursing, Midwifery and Health Visiting’s The Scope o f Professional Practice (UKCC, 1992) confirmed our understanding of the term extended role, now defined as expand ed role, and proved useful as a guide and source of information. Its six principles covering additional skills practised by nurses highlight the importance of issues such as competence and accountability, and the need to use professional judgment when deciding whether to expand the role. A no table aspect of the document was the em phasis on the need for activities to benefit the patient, to be within the practitioner’s knowledge and skill limits, and not to frag ment existing care. Successful introduction of the night nurse practitioners depended on several groups of people (Table 2). The first train ing course for the practitioners was run in June 1992. A detailed account of the educa tional programme is given by Haynes et al
KEY POINTS • Major changes within the health service both nationally and locally demanded a closer look at the relevance of the night sister/charge nurse role. • Research into particular issues such as quality of patient care, junior doctors’ hours and general night administration confirm the most appropriate use of nurse practitioner skills. • Careful consideration of the implications of the role and the necessary preparatory training formed a crucial part of the planning. • A detailed evaluation of the new night nurse practitioner role is essential to review the effectiveness of this role and its contribution to quality patient care.
in the article on page 722. Our aims for the week of the course were achieved and the benefits to patients as a result of the course can be easily seen, even at this early stage.
Conclusion Night nurse practitioners are able to apply the theory gained from the training course in their nightly practice. Currently we are monitoring the role as it is developing. Al ready we can see benefits to the patients who have less time to wait during the night for certain procedures. In this way patients’ sleep, so essential to recovery, is less dis turbed. The night nurse practitioners report that they have greater job satisfaction as they are able to develop and utilize skills to en hance the quality of patient care. Finally, junior doctors get fewer calls for minor tasks. We intend to collate our findings over the next 6-9 months, when we will be able to evaluate formally the role of the night nurse practitioners at Guy’s Hospital.
Adey C (1987) Stress - who cares? Nursing Times/Nursing Mirror 8(4): 52-3 Buxton M, Packwood T, Keen J (1989) Resource Man agement Process and Progress. Health Economics Research Group. Department of Health, London Davidson L (1992) Shrinking capital (Editorial). Nurs ing Times 88(24): 10-16 Department of Health (1991a) Junior Doctors — The New Deal. NHS Management Executive, London Department of Health (1991b) The Patient's Charter — Raising the Standard. HMSO, London Department of Health (1992) Report o f the Inquiry into London's Health Service, Medical Education and Research. HMSO, London King Edward Hospital Fund for London (1992) Lon don Healthcare 2010: Changing the Future of Ser vices in the Capital. King’s Fund London Initiative Publications, London UKCC (1992) The Scope o f Professional Practice. UKCC, London
CORRESPONDENCE If you have any comments on this or any other article in the Journal, please write to: Joy Notter/Paula McGee, The Nursing Editors, Department of Nursing and Community Health, Fac ulty of Health and Social Sciences, University of Central Eng land in Birmingham, Birmingham B42 2SU.
British Journal of Nursing, 1992, Vol I,No 14
721
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