Nurse-Led Clinics

Practical Issues

Richard Hatchett

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135260200
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

In recent years there has been a huge growth in nurse-led clinics within hospital outpatient departments, general practitioner surgeries and health centres. The government has endorsed the use of such clinics as a way for the public to access specialist health care and treatment more quickly and also as an effective way to manage chronic ill health. However, there is a lack of uniform structure in educational preparation for nurses interested in taking up nurse-led practice and a dearth of literature offering practical guidance. This text provides a much-needed overview of this new arena for nursing and includes case studies from practitioners running nurse-led clinics. Topics covered include: * Setting up a clinic
* Public protection issues
* Nurse education
* Managing medicines
* Effectiveness and evaluation.The text allows the reader to explore key practice issues which directly affect the quality of service provided. It will be an invaluable handbook for nurses directly involved in running clinics, for those responsible for the provision of nurse-led services and for nurse educators.

Chapter 1

The emergence of the modern nurse-led clinic

Richard Hatchett

The term ‘nurse-led clinic’ emerged predominately within the nursing literature in the 1980s. Although historically, nurses had been running clinics of some sort before this time, there was a clear growth in a large variety of nursing disciplines of this form of healthcare provision. In addition, the clinics have coincided with an expansion of practice, which has encroached into areas normally reserved for medicine. This has included detailed physiological assessment, together with the manipulation and prescribing of medications. The rise of the nurse-led clinic has notably accelerated in the 1990s. A review of the Catalogue of International Nursing and Allied Healthcare Literature (CINAHL) database back to 1982, and utilising the term ‘nurse-led clinic’ reveals 41 papers, but only one prior to 1995. The British Nursing Index provides 18 papers in the seven years to 2002, while the Royal College of Nursing (RCN) Journals Database offers 11 papers from 1985 to 1996. Only three appear to occur before 1994. From this literature a useful and broad definition of the modern nurse-led clinic emerges (see Box 1.1).

This introductory chapter explores the concept of the nurse-led clinic and the areas where it has emerged. Key elements in the changing face of healthcare are presented, which are suggested as influencing the development of this form of healthcare provision. The issues in Box 1.1 generally refer to patients who have been previously diagnosed by a doctor. Here, the value of the nurse-led clinic fits into an era of an ageing population, and one which lives with chronic, rather than curable, ill health. In line with this, the 2001 census revealed that in the last 50 years the UK population has aged considerably. The proportion of those less than 16 years has now decreased from 24 per cent to 20 per cent, while those over 60 years has increased from 16 per cent to 21 per cent.

Notably, in 1951 there were 0.2 million people aged over 85 years, while the figure in 2001 was 1.1 million. This figure represents a five-fold increase (Office for National Statistics 2002). The diabetic, cardiac or respiratory patient, together with those with dermatological or rheumatology problems, may not need to see a doctor each time a deterioration in their condition occurs or for ongoing assessment. The aim of the nurse-led clinic is to monitor the condition and to maintain the patient in their optimal state of health. Increasingly, this has meant a move towards empowering the patient to identify the signs of deterioration themselves, and to take appropriate action. Such action may include the use of more easily accessible specialist advice through the nurse-led clinic, a ‘drop in service’, or via a telephone helpline. It is pointless altering the hierarchical power boundaries between patient and service providers, if there is no readily accessible service to respond promptly to what the patient discovers.

Box 1.1 Broad definition of a nurse-led clinic

A clinic where the nurse has his or her own patient case load. This involves an increase in the autonomy of the nursing role, with the ability to admit and discharge patients from the clinic, or to refer on to other more appropriate healthcare colleagues. This power to refer to others is often highly variable between clinics, but can include referrals to professionals allied to medicine, such as dieticians, physiotherapists, chiropodists and social work teams, through to medical teams or consultants.

An educative role – explaining the illness to the patient and carers. This includes the significance of symptoms, differentiating between those of concern that require further treatment or adjustment of medication and those that may be from alternative causes. The issues of health education and promotion fall into this category.

Psychological support – this does not appear in all of the literature focussing on nurse-led clinics, but listening to the patient's concerns, fears and perceived improvements in health is clearly an important role.

Monitoring the patient's condition – this is an area which has developed rapidly in recent years. This involves the skills of history taking and physical assessment, considering the significance of assessment and ordering further investigations. This will also involve referring on to more appropriate colleagues or initiating treatments. The emergence of Patient Group Directions (PGDs)^* and nurse prescribing has meant that manipulating medications is an increasing role of the nurse-led clinic.

This issue of empowerment is an important component of the nurse-led clinic. In evaluating the worth of the service, it has to be considered whether the aim is to redistribute work amongst healthcare professionals, and make accessibility to those services easier for the patient, or whether there is an aim to enable the patient to deal more effectively themselves with a variety of healthcare problems. The measurement of such empowerment needs to be off set against the frequency with which the patient comes into contact with the clinic. Such frequent contact could be seen as the factor which prevents deterioration, as opposed to an increased patient awareness of their own condition and the significance of symptoms.

Many nurse-led clinics are found either in General Practice in the community, or in the outpatients department of the hospital setting (Hatchett 2000). In the latter, the nurse tends to be specialised within one area. These can be in a large variety of quite specific but varied areas. This can include back pain management (Wallis 2000), peritoneal dialysis (Denning 2000), intermittent claudication (Binnie et al. 1999), leg ulcer management (Vowden 1997), intractable childhood constipation (Muir and Burnett 1999) and pre-admission clinics (Alderman 1997; Newton 1996; Ryan, P. 2000). The majority of this literature exploring nurse-led clinics tends to be found within the popular nursing press and often extends to only a few pages. Such papers tend to be highly positive regarding the clinics, but are generally descriptive and lack the deeper analysis, which provides insight into how and why the clinic has formed. Two important issues are how the nurse demonstrates, maintains and further develops competence in often expanding areas of practice and how the worth of the clinic is demonstrated. Professional competence is a recurring theme within this text, because of its link to both public protection and to ensuring the clinic is a valued contribution to managing health-care, and not a second rate service emerging due to over worked medical colleagues.

In the late 1990s and early twenty-first century a new form of nurse-led clinic emerged which went beyond the boundaries of the diagnosed patient. In contrast to the clinics above, these were the services that dealt with undifferentiated, undiagnosed patients. These were basically those with a new health concern, who walked in off the street. Such services were seen with the emergence of the National Health Service (NHS) walk-in centres, 40 of which developed in the first few years of their launch in 2000, 12 alone in London. These were quite unique, and the nurses who undertook such services need praise for their bravery in initiating such ground breaking work. The centres occurred in a variety of settings, sometimes in hospital grounds, in high streets and even at an airport. They were nurse-led, although general practitioner (GP) services were available for a limited time period at some, and they were open for extended times, although not for 24 hours.

The service provided treatment for a large variety of usually self-limiting conditions such as minor wounds and burns, muscle and joint injuries, headaches, high temperature, minor infections including urinary tract, ear and nose, eye care such as conjunctivitis, emergency contraception, family planning and pregnancy testing. In increasing healthcare access, they were aimed at groups who found accessing primary care difficult, as well as the working public whose jobs often clashed with the usual general practice hours. They also aimed to relieve the overcrowding of accident and emergency departments of essentially non-emergency conditions.

An important addition has been the NHS (Primary Care) Act of 1997 (DOH 1997). This offered the opportunity for innovations in the delivery of primary care services. This was notably by creating more flexible ways of offering primary healthcare and inevitably meant an opportunity to set up services which were nurse-led. A series of personal medical services (PMS) pilot schemes were launched in April 1998, following finalisation in December of the previous year. Some started later than the April date, due to the shortage of time to recruit staff, create protocols and in some cases find premises (Moore 1999). Only two of the initial nine nurse-led pilot sites commenced on 1 April 1998 (Lewis 2001). A second wave of 106 projects was launched in October 1999, with a second series of 80 projects from April 2000. The third series in two parts, began in April 2001, with a total of 1,100 pilot schemes. A fourth series, again in two parts, was launched in 2002 (DOH 2002).

One of the main initiatives of the PMS pilots which were nurse-led, was to provide healthcare access to those who were regarded as living on the margins of society. This included refugees, the homeless and those with challenging behaviour, particularly if continually moved on by the police, and which made accessing healthcare difficult (Gardner 1998). A small number of the pilot schemes aimed to provide comprehensive primary care services predominately by a nurse or nursing team supported, rather than led, by GPs. Baraniak (2001) described the philosophy of her nurse-led general practice as allowing the patient to be seen by the most appropriate person to help them with their problem. This is determined by the nurse, who is the first point of contact for the patient. He/she assesses the problem, treats if skilled to do so, initiates tests or further investigations, and if appropriate refers the patient to another professional. Choice is offered to the patient regarding who they wish to see (Baraniak 2001). However, for a variety of logistical reasons, such as the failure to recruit a general practitioner or gain adequate patient numbers, some nurse-led pilot schemes floundered (Moore 1999).

Lewis (2001) provided a valuable review of the first nine PMS sites that were nurse-led. Two of the nine were run by nurses acting as independent contractors (Baraniak and Gardner 2001). Five of the pilots were managed by community NHS Trusts, and the remaining two were managed by existing general practitioner practices. The term nurse-led can be viewed as a continuum of practice ranging from the nurse having delegated authority to make decisions regarding patient care at one end of the spectrum, to being responsible for all care provided. The latter includes clinical assessment, treatment and management of patients undifferentiated by need (Baraniak and Gardner 2001). There is also however, an implicit non-clinical element, through managerial leadership. The nurse will be the team leader in much the same way that an independent contractor GP is seen as the leader. The notion did appear to cause some confusion and tension in the first wave of PMS sites and may have diminished in later sites. This was because it was never explicitly explored within the team, and therefore cut across traditional power relations between doctors and nurses. Lewis argues that this was one of the reasons behind a shift in terminology from ‘nurse-led’ to ‘team-led’. This terminological shift represented a more fundamental clarification in practice of the values that should underpin the model, as well as a more practical equilibrium in terms of interprofessional power within a team (Richard Lewis: personal correspondence 2003).

Nurse-led primary care reflects a model of service where the nurses have a higher profile in providing care for patients, based on their own assessment of the patient's needs. Such decisions are based on the nurse's level of skill and ability, and their interpretation of the scope of practice. Decision-making is supported by practice protocols or guidelines, or by parameters set by the employer(s). For practice nurses, this employer would normally be the GP (Baraniak and Gardner 2001). Nurse-led primary care and further innovations such as Baraniak and Gardner working as independent contractors, may assist practice nurses in encouraging innovations away from possible restriction through direct employment by GPs.

Baraniak and Gardner (2001), as well as Lewis' work (2001), reviewed PMS sites that were nurse-led, but importantly provided a valuable analytical framework for all nurse-led clinics. The issues that have hindered the services are included in Box 1.2.

The issue of interprofessional relationships, notably between doctors and nurses in the nurse-led PMS sites, has been of interest. Primarily, the sites have aimed to offer the patient the most appropriate healthcare professional to meet their needs. In many cases this may not be a healthcare professional at all, but perhaps a counsellor or marriage guidance service. This is often because patients with non-medical problems, do not know where else to go for help. The philosophy is one of a changed set of relationships between clinicians in the primary care team and those between the team and their patient (Lewis 2001). This does suggest ‘nurse-led’ as a term is misleading, but is about equality of opportunity, mutual respect among team members and a focus on the appropriate needs of the patient. Within the concept of the nurse-led clinic, success will always focus on being a team player and the interprofessional relationships with other colleagues.

Box 1.2 Issues that have hindered the development of PMS nurse-led pilots, with relevance to the development of the nurse-led clinic (adapted from Baraniak and Gardner (2001) and Lewis (2001))

A lack of nationally recognised qualifications for nurses taking on extended nursing roles. This has notably been the lack of regulation of the use of the term ‘advanced nurse practitioner’. Any nurse has been able to call themselves a Nurse Practitioner and run a nurse-led clinic. The Nursing and Midwifery Council (NMC) subsequently began moves in 2003 to protect, via registration and required competencies, roles within the domain of specialist and advanced nursing practice (NMC 2003). Many had previously argued for a clear set of competencies, a specific registration to protect the public, as well as exploring the plethora of other legal issues (Maclaine 1998; RCN 2002; Walsh 2000), but the NMC had been slow to protect the title. The Royal College of Nursing produced a definition and competencies to clarify the situation, together with suggested standards for educational preparation (RCN 2002).

Prescribing rights. These are developing, but it has been a slow process for nursing.

The absence of authority outside of the hospital setting for nurses to sign sick certificates and paperwork relating to welfare benefits.

A lack of recognition of the nurse being able to certify death, even though they, rather than the doctor, may have seen the patient many times during terminal illness. At the present time it is illegal for nurses to certify death.

Securing referral rights to secondary care and other agencies. In Lewis' work, nurses were understanding of hospital doctors and consultants not wishing to receive referrals from anyone other than a doctor, because of the aforementioned lack of recognised standards and competencies to underpin the role of the nurse practitioner. Medical staff have little way of knowing the competence of the nurse who is referring a patient. Only two of the nine initial nurse-led PMS pilot sites had secured formal referral rights with NHS hospital trusts (Lewis 2001). Lewis clarifies this further by reinforcing that while only two of the nine sites in his study had agreed formal referral rights, others had negotiated informal rights with some specialists. In this context, a significant shift in traditional practice had been achieved, although it underlines the veto ability of many doctors over changes to interprofessional relationships (Richard Lewis: p...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Illustrations
• Contributors
• Preface – San Francisco 1992
• Acknowledgements
• Chapter 1 The emergence of the modern nurse-led clinic
• Chapter 2 Professional development in the nurse-led clinic
• Chapter 3 Managing medicines
• Chapter 4 Effectiveness and evaluation of the nurse-led clinic
• Chapter 5 Setting up the nurse-led clinic: a framework for practice
• Case studies
• Index