Is there a Critical Care (Nurse) Practitioner in the House? 1

Editor (Jesse): It is with very humble pleasure that injectableorange.com plays host to a great insight into the strategic, organisational and personal history of critical care nurse practitioner role in the UK. @ccpractitioner himself shares an insight into his world. I have long been a fan of Jonathan’s website. Jonathan is a living example of the ethos of critical care, tirelessly working to better himself and in the process raising the bar and sharing resources for others. Without further ado, over to Jonathan.

The NHS Plan (2000) identified the need to undertake some experiments regarding skill mix in the National Health Service. This was followed by the Modernisation Agency establishing a New Ways of Working team in 2001. The Changing Workforce Programme subsequently developed into the National Practitioner Programme and consequently a number of new ways of working, streams were established. These covered surgery, medical care, anaesthesia, critical care, endoscopy and assistant roles in theatre.

It is widely accepted that the reduction in junior doctors’ hours (Council Directive, 2000), coupled with career development, namely Modernizing Medical Careers (SEHD, 2005), could result in a reduction in the number of hours junior doctors are available for service provision. These changes may have specific implications for the provision of medical care for critically ill patients.

A major component of this strategy was the development and introduction of the Advanced Practitioner roles. It had been recognised already that there were many healthcare professionals who wanted to use their extended skills in new ways of working. There were consequently four main ways in which roles were redesigned to offer practitioners more potential for development.

The International Council of Nursing defines an advanced nurse practitioner as;

“A registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which she/he is credentialed to practice”

There were several goals for the development of the new roles, which included ensuring the necessary skills and competencies required by care pathways or interventions are present in the workforce, encouraging working across professional boundaries, matching skill mix to service delivery models, reducing workforce cost and attracting a new workforce where shortages exist.

The advanced practitioner role often requires management of own caseloads with high levels of decision-making and diagnostic reasoning. The development of these roles has required substantial investment and as a consequence evidence of added value has been essential when considering developing these roles.

Both the Royal College of Nursing (RCN) and the Department of Health (DoH) have reiterated the need for advanced practitioners to be educated to Masters level and in order to achieve this I first undertook a post graduate diploma in Anaesthetic practice which I then went on to convert to a Masters degree by completing a research dissertation over another year.

The current critical care practitioners within my trust study towards their Masters degree by undertaking several modules. These include Clinical History Taking and Examination, Clinical Diagnostics, Clinical Investigations, Non-Medical Prescribing (which entitles them to prescribe anything a doctor can) and a research module teaching them how to critically analyse and formulate a research plan. These modules are also backed up by achieving a series of clinical competencies related to the intensive care unit, supervised by their consultant mentor.

They are also required to keep a logbook of the procedures they have undertaken, which initially they have to be supervised for. It is only when they are assessed as competent by their consultant mentor in that particular skill that they are able to undertake it independently. These skills include Arterial line placement, central venous catheter insertion, dialysis line placement and intubations. All the practitioners are also Advanced Life Support providers and most are also Advanced Life Support instructors.

Once considered qualified the practitioner works alongside the junior doctors on their rota on both the day and the night shift, providing valuable support to the team.

It would not be true to say that the advance practitioner role has been taken up across the entire health service. Decisions to develop the advance practitioner role have often been taken at a local level within the health service and often depends upon the championing of extended or advance practitioner roles by one or more key individuals, commonly heads of department or chief executives. It is probably fair to say that the development of the role requires a lot of support because without it there can be resentment among staff and the feeling that the advance practice role has been introduced simply to increase volume rather than the scope of practice.

The path has not always been a smooth one during my experience as a practitioner. Initially I found it very difficult to adjust to my change in role. With my many years experience in the intensive care environment, I initially felt myself going from expert to non-expert quite quickly. Whilst I felt that I already had a lot of relevant knowledge, I very quickly became aware of the steep learning curve. Occasionally some of the junior doctors also seem to have been a little confused about the new role. I think it was hard for them to understand where nursing input stops and our practitioner role began. I do believe, however, that the practitioner now offers more teaching opportunities and learning situations for the junior doctor, rather than less. Certainly, for some of the procedures there is more likely to be support to offer them when they are trying to learn.

I think the greatest benefit to having the critical care practitioner is the continuity that they offer to the medical team. Many of the junior doctors rotate through the intensive care unit fairly quickly. This results in a team of doctors with reduced levels of experience in intensive care every few months. The critical care practitioner is able to bridge this gap and ensure that the care in the intensive care unit is led by current practice and research and carried out in a safe and consistent manner.

One of the issues mentioned with the advance practitioner role is that there are few further routes for career advancement. In the current climate I find this a slightly pointless argument. I was at band seven in my nursing role in critical care and without going into either education or management I was unlikely to achieve a higher grade without a major change. That major change came about when I was offered the opportunity to take up the advance practice training. Once qualified I was then able to achieve a higher band, 8a, which I otherwise was not going to get. In my trust there are now some senior advance practitioners at even higher grades, so I feel that this change in my career pathway has only raised the ceiling for me.

It is difficult to foresee where the advance practice roles will go, but I can only say that it is been a huge developmental step for me personally.

Reading List

Advanced nursing roles in critical care- a natural or forced evolution? Coombs et al. Journal of Professional Nursing Vol 23, No 2 2007: pp 83- 90.

Practitioner role in a hospital setting. Dalton, M. British Journal of Nursing Vol 22, No 1 2013 : pp 48- 53

Advanced level nursing- a position statement. Department of Health 2010

Exploring advanced nursing practice: past, present and future. Duke, N. British Journal of Nursing Vol 21 No 17 2012 : pp 1026-1031

Steering a course to advanced nursing practice. Nursing in Critical Care Vol 16 No 2 2011 : pp67-76

Evaluation of advanced practitioner roles. Institute for Employment studies. 2009

Advanced nurse practitioners. Royal College of Nursing. 2012.