Aim of the study
The main aim of the evaluation was to examine the extent to which a work-based learning programme for trainee consultant nurses (known as nurse registrars) in Emergency Care assisted the trainees to develop the skills, knowledge and expertise to competently undertake a consultant nurse role. Specifically the aims were:
- to ascertain how the trainee consultant nurse participants developed through the programme in terms of their personal development, knowledge skills and attitudes
- to evaluate the effectiveness of the programme in developing the four functions of the role
- to investigate the effect of the trainee posts and post holders on the existing workforces
- to gain insights into the effectiveness of work-based learning using this programme as an exemplar.
Research design
The evaluation was conducted using a staged iterative design and was divided into two phases:
- In Phase 1 the first 18 months of the programme were evaluated using a range of data collection methods including: documentary analysis; interviews and observation.
- In Phase 2 the final 18 months of the programme were evaluated using the same data collection techniques as Phase 1.
Findings
Phase 1: Interviews with nurse registrars and stakeholders
Semi-structured interviews were carried out with nurse registrars (n=4), wider stakeholders (n=10), including Programme developers and funders and clinical stakeholders (n=14) comprising nursing and medical staff from the three main settings in which the nurse registrars undertook their placements. Interviews were complimented by documentary evidence and observation.
- Effectiveness of the programme
- The structure of the programme had not been pre-determined at the outset and the nurse registrars had a dual role of programme participants and designers in collaboration with the Programme Lead.
- The work-based nature of the programme provided the nurse registrars with the time and access to a wider range of learning opportunities which otherwise would have been restricted.
- The one-to-one teaching sessions (TONTO) and medical consultant mentorship was considered to be a successful learning strategy for the nurse registrars.
Programme Leadership
- The Programme Lead was perceived as a well-known and respected individual with unique qualities. However, given these unique abilities the sustainability of the role was questioned.
- The Lead was seen as easily accessible and a great source of support for the nurse registrars. While the Lead's leadership style was viewed as ‘flexible', some criticism was levelled that the Lead was not assertive enough with the nurse registrars.
- The multifaceted nature of the role, with a higher workload than anticipated, resulted in a more ‘hands-off' style of leadership.
MSc Nurse Practitioner course
- The MSc Nurse Practitioner course was considered to provide a recognised qualification as expected of a consultant nurse.
- Finding an MSc programme to meet the knowledge and skills at a level required by the nurse registrars was a challenge.
- The two year time period for completing the MSc within the overall programme proved to be a difficult challenge with the other demands of the programme.
Rotational placements
- The nurse registrars rotated through a series of three month placements during the first half of the programme.
- Different placements offered varying benefits and challenges. While the UTH was considered to offer more opportunities for development of clinical knowledge due to the availability of senior medical staff supervision, the Walk-in Centre and DGH facilitated clinical knowledge development through more autonomous working and the ability to increase scope of practice. The latter were also felt to be the best environments for service development work.
- The placement settings gained from the knowledge and experience of the nurse registrars and had high expectations of the rewards of having the nurse registrars in the practice environment.
- The placements were not without their challenges. Lack of medical supervision at the DGH posed difficulties for some nurse registrars.
- The need for longer placements was identified by both nurse registrars and stakeholders to ensure better integration into the setting and to complete service development projects.
Progress of the nurse registrars
- As a cohort the nurse registrars were well liked and valued for their skills and contribution in all placements. The nurse registrars were supportive of each other, though at times their reluctance to make and act on decisions was considered to hinder their progress.
- Ambiguity regarding the boundaries of the role resulted in uncertainty and developing in all four consultant nurse role domains was felt to be a lot to achieve.
- However, their progression was evident in the size and breadth of their portfolios and IPR documentation which showed common core achievements and individual gains in knowledge, skills, attitudes and contributions to service.
Impact on patient care
- All patient feedback was positive, with patients impressed and reassured by the expertise of the nurse registrars. None were concerned about the lack of presence of a doctor.
- Patients agreed that the nurse registrars had provided explanations and these were comprehensive and pitched at the appropriate level.
- The continuity of care offered by the nurse registrars was valued by patients, as was the speed at which they were seen, and the efficiency of the process.
- It was felt the nurse registrars provided care above and beyond that they would expect, and felt it was more in-depth and personal.
The programme and service needs: politics if the work-based education programme
- Supernumerary status provided an opportunity fir the nurse registrars to follow patients and seek out experiences relevant to their individual needs.
- At times the nurse registrars felt pulled between their needs and the programme and their keenness to provide value to the service.
- Changes in the health economy during the first half of the programme increased tension and expectations that the nurse registrars would contribute to the service.
Role definition, boundaries and ambiguity: defining a scope of practice
- The nurse registrar title was felt to reflect medical career terminology.
- Clinical stakeholders had been uncertain as to what expect from the nurse registrars.
- While it was recognised that the nurse registrars required a level of knowledge there was debate over the amount and type of knowledge they needed.
- Lack of clarity regarding boundaries of the nurse registrar role resulted in some medical staff feeling uncomfortable about them working with more complex patients and in the Majors area. Some nurse registrars chose to exclude themselves from clinical areas where their role was unclear.
o Ambiguity regarding role boundaries also led some medics and nurse registrars to be concerned about their accountability.
Phase 2: Observations of nurse registrars in clinical practice
Unstructured observations were undertaken with four nurse registrars in two placement settings to explore the dimensions and boundaries of their ‘every day' clinical role and the extent of activity across the four role domains.
- The nurse registrars were engaged in direct patient care and saw a range of patient types and conditions. Some variations were observed in the range of conditions treated in the UTH Emergency Department and those at the Walk-in Centre.
- Consultations with patients involved a process of assessment, diagnosis and treatment, with physical examinations often carried out to aid diagnosis.
- In the Emergency Department diagnostic tests were used as a means of confirming a diagnosis, where as at the Walk-in Centre the same tests were not available and nurse registrars had to rely on the presenting symptoms of patients.
- Nurse registrars demonstrated comprehensive communications skills with patients, with the latter provided with comprehensive and appropriate explanations regarding their assessment, diagnosis and treatment.
- In both placement settings nurse registrars tended to work autonomously, particularly at the Walk-in Centre.
- There were some opportunities for the nurse registrars to develop their skills and knowledge. However, most of the patients treated did not appear to ‘stretch' their clinical skills and expertise.
- There was some evidence of nurse registrars fulfilling aspects of the education domain by engaging in impromptu teaching with junior nursing staff. There was little evidence to show activity in the other functions of the role, although these were not always possible to capture in the clinical setting.
Phase 2: Interviews with nurse registrars and stakeholders
Semi-structured interviews were carried out with the nurse registrars (n=5), clinical stakeholders (n=11) who had worked with the nurse registrars in their rotational placements during the observation period and included nursing and medical staff, and wider stakeholders (n=5) comprising the Programme Lead, programme developers and advisors, and academic personnel from the MSc Nurse Practitioner course. Interviews were complimented with evidence from the nurse registrars programme documentation.
Effectiveness of the programme
The programme was considered a unique opportunity for the nurse registrars to develop the skills, experience and expertise needed for the consultant nurse role.
Lack of programme structure was criticised by the nurse registrars and this was felt to have impacted on their training. However, the Programme Lead suggested that attempts to impose structure mid-way through the programme had been resisted by the nurse registrars.
- The nurse registrars reported positively on the quality of medical mentorship provided at the programme base site.
- The role of the Programme Lead remained unchanged throughout, although was reported to have presented different challenges in the second half of the programme. The Programme Lead was considered by the nurse registrars to be supportive and accessible but they would have welcomed increased opportunities to work alongside this person clinically.
- The rotational placements presented the nurse registrars with different benefits and challenges. All three placements enabled them to gain experience as autonomous practitioners, although at the DGH this sometimes meant working in the role of a doctor.
- The nurse registrars held mixed views regarding the contribution of the MSc Nurse Practitioner course. While some modules had been useful for their clinical practice, overall the curriculum was felt to be disappointing. The timescale for completing the Master's was felt to be unrealistic and added to the heavy demands of the programme.
Progress of the nurse registrars
- Overall the nurse registrars had made significant process within the four domains of the role, although achieving across all areas was difficult.
- Clinical practice was considered the main focus of the role and the function which had been the most developed.
- There was evidence of activity within the other domains of the role, with all nurse registrars involved in the training and development of other staff which contributed to the Education function; evidence of involvement in service development projects and in research and audit. In terms of leadership, the registrars saw themselves as transformational rather than clinical leaders.
Impact on patient care
- The nurse registrars considered their role to have impacted positively on patient care and were felt to result from widening their scope of practice as this enabled them to see patients with conditions other nurses would not be able to treat. Stakeholders felt that the nurse registrars had improved the patient experience by offering them more holistic care.
- The nurse registrars' potential to increase the throughput of patients in the Emergency Department meant that patients were seen more quickly and efficiently.
Impact on and integration with the existing workforce
- The nurse registrars were viewed as having a positive impact on the existing team and were seen as assets to the team because of the clinical skills they provided for patients and their willingness to share expertise with colleagues.
- While some colleagues felt that the inexperience of some nurse registrars within the primary care setting had added to their workload because of the high levels of support they require, this was felt to be less noticeable in the second half of the programme.
- The presence of the nurse registrars was felt to have raised the profile of nursing amongst the medics in the Emergency Department and improved communication between the nursing and medical teams.
- Some of the earlier tensions that had characterised the relationship between the nurse registrars and senior nursing team had been resolved, although full integration had not been achieved by the end of the programme.
- Lack of integration was felt to result from the registrars being perceived as elitist, uncertainty of the responsibilities of their role, and their strength as a cohort which to some degree had isolated them from the rest of the nursing team.
Definitions, dimensions and boundaries of the nurse registrar role
- By the end of the programme the nurse registrars felt less ambiguity regarding their role, although it was felt that some clinical colleagues continued to have a lack of insight into the responsibilities of the post. However, generally clinical stakeholders appeared to demonstrate an awareness of functions of the role.
- Opinion was divided regarding the appropriateness of the nurse registrar title. It was felt to be meaningless for patients and there some clinical stakeholders considered that the association with medical titles were unsuitable.
- All nurse registrars felt they had been able to challenges the boundaries of their role and had been provided with opportunities during the programme to widen their scope of practice. However, extending their scope of practice led some clinical stakeholders to question the level of influence medicine had on the programme and the nurse registrars themselves.
Evaluating the success of the programme
- Overall it was felt that the programme had prepared the nurse registrars for the consultant nurse role, although some nurse registrars questioned whether they could have become consultant nurses without the programme.
- Limitations of the programme were seen to include: a lack of employment opportunities at the end of the programme; failure of the programme to equip adequately the nurse registrars in all four domains; the heavy demands of the programme; and the difficulties faced by some nurse registrars when faced with re-integration with the nursing team.
- Experiences from the pilot programme had highlighted ways of improving and developing future programmes, particularly the need for a more structured and decentralised programme; improved workforce integration; and improved career pathway planning.
Conclusion
Overall the findings indicate that the programme has been successful in assisting the nurse registrars in developing the skills, knowledge, attitudes and experience needed to carry out the four functions of the consultant nurse role. In particular, the work-based nature of the programme provided its participants with protected time and opportunities to acquire such expertise which may otherwise have been difficult if training had been carried in parallel to their existing posts. The nurse registrar role appeared to have a positive effect on patient care, which included contributing to the quality of care and providing a holistic approach to treatment. In regard to their impact on the existing workforce, the nurse registrars were considered in the main as a valuable resource because of their skills, knowledge and expertise and potential to ease the workload of the team. Furthermore, they were viewed as good role models for their nursing peers and junior medical colleagues, and their presence in some placement settings was felt to have raised the profile of nursing among the medical team.
Nevertheless, there were a number of issues that warrant consideration for the development and implementation of future trainee consultant practitioner programmes.
Project team
Professor Judith Lathlean
Project funder
Southampton University Hospital Trust, Wessex Deanery