The influence of outreach in the development of the nurse consultant role in critical care: Cause or...

Intensive and Critical Care Nursing (2006) 22, 4—11

ORIGINAL ARTICLE

The influence of outreach in the developmentof the nurse consultant role in critical care:Cause or effect?

Deborah Dawsona,∗, Andy McEwenb

a General Critical Care, 1st Floor St. Jame’s Wing, St. George’s Hospital NHS Trust, Blackshaw Road,London SW17 0QT, UKb Cancer Research UK Health Behaviour Unit, University College London, 2-16 Torrington Place, London
WC1E 6BT, UK
Accepted 24 June 2005

KEYWORDSNurse consultant;Critical care outreach;Role involvement;Survey

SummaryBackground: Critical care nurse consultant roles have evolved against a backgroundof service innovation that has resulted in the development of critical care outreachservices. Despite compelling evidence that there was a serious problem with themanagement of critically ill patients in the ward environment, there is little evi-dence to support outreach as a concept or as a role for nurse consultants.Aims: The aims for this part of the study were to:

• investigate what critical care outreach functions have developed in acutehospitals;

• analyse whether there was a significant role difference between the whole groupof critical care nurse consultants and those defined as critical care outreach.

Methods: A national postal survey of all 72 critical care nurse consultants in postin England by August 2003; response rate 72% (n = 52). All data was entered on toa computer anonymously and analysed using SPSS version 11.5. A factor analysisrevealed a sub-set of nurse consultants who had a significantly greater involvementin outreach activity.Results: Critical care nurse consultants have a high involvement in the developmentof care for critically ill patients outside the traditional boundaries of critical care.A sub-set emerged that has a significantly greater involvement in outreach activity.This includes roles such as working with an individual or team to develop their prac-tice (whole group mean involvement score M = 4.45, outreach M = 4.88, p < 0.001);

DOI of related article:10.1016/j.iccn.2005.06.007.∗ Corresponding author. Tel.: +44 208 725 3129.

E-mail address: [email protected] (D. Dawson).

0964-3397/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2005.06.008

The influence of outreach in the development of the nurse consultant 5

developing education outside the ICU/HDU (whole group M = 4.13, outreach M = 4.88,p < 0.001) and receiving nurse led referrals from the wards (whole group M = 3.92,outreach M = 4.81, p < 0.001).Conclusions: Given the lack of evidence for outreach, organisations should considerthe high level of involvement of the nurse consultant outside the traditional bound-aries of the ICU/HDU.© 2005 Elsevier Ltd. All rights reserved.

Prelude

A fuller description of the literature, background tothe role of the nurse consultant and the methodscan be found in Dawson and McEwen (2005).

Introduction

When nurse consultant posts were first announcedin the United Kingdom (UK) (Department of Health(DH) 1999a,b) they were expected to combine thecore functions of expert practitioner with profes-sional leader; educator; practice and service devel-oper and researcher. In April 2000, the new roleof nurse consultant was formally launched (DH,1999b); shortly followed by publication of an adultcritical care review (DH, 2000). This review pro-posed that critical care should no longer be seenpurely in terms of a geographical location but as alevel of illness and associated patient need. Newsystems, leadership and expertise were requiredto deliver the aims and recommendations of thereview and many acute hospitals used this report,adRcfr

tac2oee2eSss1aep

provided compelling evidence that there was aserious problem with the management of criti-cally ill patients in the ward environment, butoutreach remained an unproven set of responsesto these problems (Robson, 2002). However, fol-lowing an Audit Commission report (1999) and areview of adult critical care services (DH, 2000),there was a rapid expansion of these services. In2000, there were six outreach services and by 2002there were 119 (Welch, 2004); this rapid growth ofcritical care outreach is surprising given the lim-ited evidence base (Cuthbertson, 2003). The out-reach service in the UK is characterised by beingalmost entirely delivered and led by nursing staff(National Outreach Survey, 2002), suffering fromdifficulties in service provision (Welch, 2004), avariety of service configuration (DH, 2003; Coombs,2002) and lack of funding (DH, 2003; Welch,2004).

The critical care outreach initiative occurredat the same time as the development of thenurse consultant role, and the subsequent callfor financial bids to support the objectives of thecritical care review. This has led to speculationthat many acute hospitals have deployed criticalcotcTnnscv

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nd the subsequent funding, as an opportunity toevelop the nurse consultant role in critical care.ecommendations were made that the roles of theritical care nurse consultant should be patientocused (Ball, 2001) and concentrate on patientelated outcomes (Coombs, 2000).

Critical care outreach (subsequently referredo as outreach) is defined as ‘an organisationalpproach to ensure equity of care for all criti-ally ill patients irrespective of their location’ (DH,003). Outreach in the UK developed from numer-us sources including the introduction of medicalmergency teams (MET) in Australian hospitals (Leet al., 1995; Hourihan et al., 1995; Buist et al.,002); physiological scoring systems such as thearly warning system (EWS) (Morgan et al., 1997;tenhouse et al., 2000; Subbe et al., 2001); sub-tandard ward care of patients prior to admis-ion to a critical care facility (McQuillan et al.,998; Mc Gloin et al., 1999; Goldhill et al., 1999)nd an identified need to develop skills in gen-ral ward areas in caring for the acutely unwellatient (Coad and Haines, 1999). These sources

are nurse consultants almost solely to developutreach services (Fairley, 2003). In August 2003,here were approximately 70 critical care nurseonsultant posts with no evaluation of their roles.his paper reports on some of the findings of aational survey of role involvement of critical careurse consultants in England (Dawson, 2004). Thetudy aimed to elicit the perceived level of criticalare nurse consultant participation across a wideariety of critical care activities.

he Study

ims

he aims for this part of the study were to:

investigate what critical care outreach functionshave developed in acute hospitals;analyse whether there was a significant role dif-ference between the whole group of critical care

6 D. Dawson, A. McEwen

Box 1• Receiving nurse led patient referrals from the

ward areas*• Receiving medically led patient referrals from the

ward areas*• Receiving referrals from another members of the

multi-disciplinary team*• Outreach rounds in the ward areas (on your own)*• Outreach rounds with the multi-disciplinary team• Developing clinical guidelines/protocols/

procedures for use outside the ICU/HDU*• Working with individuals or teams outside the

ICU/HDU to develop their practice*• Developing education for your hospital, but

outside the ICU/HDU (including ward basedprogrammes)*

• Delivering education for your hospital (includingward based programmes)*

• Mentoring/clinical supervision outside theICU/HDU but within the hospital

nurse consultants and those defined as criticalcare outreach.

Summary methods

A postal survey of all 72 nurse consultants incritical care in England was carried out duringAugust 2003. Fifty-five (76%) questionnaires werereturned; three were not complete thus providinga usable sample of 52 and an effective response rateof 72% (Dawson and McEwen, 2005). The 112-itemquestionnaire was designed to elicit informationfrom respondents on the four key functions of thenurse consultant role (DH, 1999b) as well as theirattitudes and behaviours, demographic and bio-graphic data. The outreach sub-sets were formedusing factor analysis on a previously identified setof 10 items associated with outreach activity fromthe 50 role statements (Box 1). This resulted in

eight items across the four key roles, marked withan asterisk in Box 1.

A chi-squared test was used to compare the out-reach sub-set against categorical variables in thedemographic and biographic responses. Other anal-yses were as described in Dawson and McEwen,(2005).

Results

Critical care nurse consultant roles inpractice

Amongst all nurse consultant respondents therewas a high involvement with activities outside thetraditional boundaries of the ICU/HDU, and manyof these were associated with outreach activity(Dawson and McEwen, 2005). There were sevenroles where a significant number (40% or more)of nurse consultants stated they ‘took the lead’(Table 1).

Due to the apparent high involvement with activ-ities outside the ICU/HDU a set of items were iden-ttisiorsiscrtrftl

Table 1 Roles for which 40% or more of nurse consultants

Role

Outreach rounds in the ward area (on your own)to

butes)

use

Working with individuals or teams outside the ICU/HDUdevelop their practice

Developing education programmes for your hospital,outside your ICU/HDU (including ward based programm

Receiving nurse led referrals from the ward areasDeveloping clinical guidelines/protocols/procedures for

outside your ICU/HDUDeveloping clinical auditCollecting data for clinical audit

ified through factor analyses, which were commono working practice in outreach situations (denotedn Tables 2—4 by an asterisk (*)). Out of the totalample of 52 critical care nurse consultants; thendividuals who responded with ‘to a great extent’r ‘take the lead’ to all of these items wereecoded to form a sub-set of outreach nurse con-ultants (n = 16). The outreach nurse consultantsncluded all those respondents who defined them-elves as nurse consultants for outreach/expandedritical care/patient at risk, when asked their cur-ent job title (n = 8). For each of the core func-ions there were a number of roles where theesponses of the outreach nurse consultants dif-ered significantly from non-outreach nurse consul-ants. Whereas nurse consultants as a whole had aarge involvement with Practice and Service Devel-

stated they ‘took the lead’.

Percentage (n)

53 (27)48 (25)

48 (25)

43 (22)40 (21)

40 (21)40 (21)


Table 2 Mean involvement scores for the Education, Training and Development role items.

Item Whole group (S.D.) Outreach Non-outreach Z-value p-Value*

Working with individuals orteams outside the ICU/HDUto develop their practice**

4.25 (0.84) 4.88 3.97 −3.76 <0.001

Developing education for yourhospital, but outside theICU/HDU (including wardbased programmes)**

4.13 (1.09) 4.88 3.81 −3.74 <0.001

Developing education pro-grammes/courses/modulesfor your University

2.75 (1.28) 3.50 2.42 −2.79 <0.005

Delivering education for yourhospital (including wardbased programmes)**

3.96 (0.91) 4.75 3.61 −4.46 <0.001

Delivering education for yourUniversity

2.75 (1.06) 3.63 2.36 −4.83 <0.001

* p-Values relate to the differences between outreach and non-outreach means; only those significant to <0.05 are reported.** Denotes items identified as common to working practice in outreach situations.

opment (Dawson and McEwen, 2005), this was lessapparent with outreach nurse consultants who hadthe greatest involvement in the Education, Train-ing and Development function. The outreach nurseconsultants did not differ significantly in their atti-tudes and behaviours or in their demographic or bio-graphic data to the non-outreach nurse consultants.

Education, Training and Development

The Education, Training and Development functionappeared to have the greatest involvement for theoutreach nurse consultants. Table 2 shows the 5items from the original 14 contained in the sur-vey associated with this function. All of these itemsidentify a higher involvement for outreach nurseconsultants than for either the whole group or non-outreach nurse consultants. Two items emergedas having the highest mean involvement scores

for all critical care nurse consultants (Dawson andMcEwen, 2005) and also for the outreach nurseconsultants: working with individuals or teams todevelop their practice and developing educationprogrammes for the hospital.

Results from the whole group of 52 nurse consul-tants demonstrate that the length of time a nurseconsultant had been qualified was correlated witha number of Education, Training and Developmentroles (only those differences significant to p < 0.05are shown) (Table 3). Where a nurse had been qual-ified for a greater period of time, it appears thatthey were more likely to be working in the ICU/HDUsetting and developing education for disciplinesother than nursing, but less likely to be workingoutside the ICU/HDU or working with outside bod-ies.

Nurse consultants not working at the same hospi-tal as thy had been before they took up post (n = 18)

Table 3 Correlation between role and length of time qualified.

Item rs-Value p-Value

Working with individuals or teams in the ICU/HDU 0.30 <0.04
to develop their practice
Developing educationprogrammes/courses/modules for disciplinesother than nursing

Developing educationprogrammes/courses/modules for your acutehospital, but outside the ICU/HDU

Developing educationprogrammes/courses/modules with an outsidebody

0.078 <0.03

−0.30 <0.04

−0.34 <0.02


Table 4 Mean involvement scores for the Expert Practice items.


Receiving nurse led patientreferrals from the wardareas**

3.92 (1.13) 4.81 3.51 −3.82 <0.001

Receiving medically ledpatient referrals fromthe ward areas**

3.51 (1.24) 4.50 3.06 −4.01 <0.001

Receiving referrals fromanother member of themulti-disciplinary team(e.g. a physio)**

3.61 (1.30) 4.69 3.11 −4.18 <0.001

Clinical care in acommunity setting

1.56 (0.98) 2.12 1.31 −2.04 <0.05

Making patient referrals toother members of theMDT

3.87 (1.09) 4.56 3.56 −3.20 <0.001

Making patient referrals tomedical staff

3.71 (1.12) 4.63 3.29 −4.18 <0.001

Undertaking interventionsnormally carried out bymedical staff

2.54 (1.09) 3.25 2.22 −3.16 <0.002

* p-Values relate to the differences between outreach and non-outreach means; only those significant to <0.05 are reported.** Denotes items identified as common to working practice in outreach situations.

were more likely to be developing practice insidethe ICU/HDU (M = 3.3, S.D. 1.19) than those whoremained in the same hospital (M = 2.6, S.D. 1.04)(Z = −2.01, p ≤ 0.05)

Expert Practice

For the whole group of nurse consultant respon-dents, two items from the 12 Expert Practice itemshad a high mean involvement score: receiving refer-rals from ward areas and making referrals to othermembers of the multidisciplinary team. Nurse con-sultants reported a low involvement with directcare in the ICU/HDU. Table 4 shows seven items

that had high involvement across the group forExpert Practice outside the ICU/HDU setting; it alsodemonstrates the higher involvement of outreachnurse consultants.

Practice and Service Development

Only one item in the Practice and Service Devel-opment function showed a significant differencein the roles between outreach nurse consul-tants (M = 4.81) and non-outreach nurse consultants(M = 3.64): developing clinical guidelines for useoutside the ICU/HDU* (Z = −4.09; p < 0.001).

Table 5 Mean involvement scores for the Leadership and Consultancy items.


Outreach rounds in theward areas on your own**

3.78 (1.59) 4.94 3.26 −3.85 <0.001

Outreach rounds with themultidisciplinary team

2.43 (1.46) 3.31 2.03 −2.76 <0.006

Managing the budget for aclinical area

1.70 (1.45) 2.53 1.34 −2.78 <0.005

Representing critical care 3.94 (1.04) 4.31 3.78 −2.13 <0.04

on-on out

on senior managementcommittees within thehospital* p-Values relate to the differences between outreach and n

** Denotes items identified as common to working practice i
utreach means; only those significant to <0.05 are reported.reach situations.


Leadership and Consultancy

For the whole group of nurse consultants, 7 roleitems from 13 showed a low involvement forthe Leadership and Consultancy function. Theseincluded nursing ward rounds in the ICU/HDU(M = 1.88; S.D. 1.16) and strategic working with Pri-mary Care Trusts (PCT) (M = 1.49; S.D. 0.78), theDepartment of Health (DH) (M = 1.63; S.D. 0.74) andthe Strategic Health Authorities (SHA) (M = 1.54;S.D. 0.58) (Dawson and McEwen, 2005). Table 5shows four role items with a significantly differ-ent mean involvement score reported for outreachnurse consultants and non-outreach nurse consul-tants.

Discussion

Limitations

The use of self-reporting, the use of involvementscores rather than estimations of time and a lackof conceptual clarity in the terms used to describenursing roles limited this study. The limitations ofta

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date that compared hospitals with or without anoutreach service did not demonstrate a positiveimprovement in patient outcome (Hillman et al.,2005). Despite the quantity of non-unit basedactivity amongst nurse consultants as a whole(Dawson and McEwen, 2005), the outreach sub-setdemonstrated a significant difference in their pat-tern of working to the non-outreach sub-set. Theseincluded highly significant patterns across the eightoutreach items but also across nine other items.The outreach sub-set had a pattern of working thatinvolved mainly items from the Education, Trainingand Development and Expert Practice functions,but also were more likely to be managing a budgetfor a clinical area, representing critical care onsenior management committees and performingoutreach rounds. This pattern of work fits withthe documented services outreach is providing:critical care education and training for generalward staff; audit and evaluation of key issues inindividual organisations; use of physiological trackand trigger systems; and direct support at the bedside for varying periods (Coad and Haines, 1999;DH, 2000, 2003; Robson, 2002; Welch, 2004).

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his study are discussed in greater detail in (Dawsonnd McEwen, 2005).

ritical care nurse consultant roles inractice

he self-reported involvement scores of nurse con-ultants in critical care who responded to this sur-ey, across a range of role functions, demonstratestrong commitment to outreach activities. Itemshere nurse consultants stated ‘they took the lead’ere more likely to be associated with activityutside the critical care unit. This is not surpris-ng given the amount of professional (Cuthbertson,003; Coombs, 2002; Welch, 2004) and politicalttention (DH, 2000, 2003; Audit Commission, 1999;ilburn, 2003), this aspect of critical care has

eceived and the issues it sought to address. Addi-ional funding has enabled acute hospitals to sup-ort a number of critical care nurse consultants andhis had contributed to the provision of care for theritically ill patient outside the traditional bound-ries. However, the focus on funding posts ratherhan on the impact of the roles themselves may notave necessarily provided improved patient careKeighley, 2002).

The lack of evidence to support outreach assolution to some of the problems experienced

n critical care remains a concern (Welch, 2004).ndeed the largest randomised controlled study to

ducation, Training and Development

he majority of activity in this function across thehole group appeared to be to do with developingractice outside the ICU/HDU, with practice devel-pment within the ICU/HDU appearing to having aower involvement. Of particular interest is that theutreach sub-set was significantly more involved inhese functions than the non-outreach sub-set. Theesults suggest that nurse consultants are meetingneed for a significant amount of ward-based andore formal education for staff involved in caring

or these vulnerable patients.The results demonstrate a relationship between

ength of time qualified and working with teamsn the ICU/HDU and being less likely to be provid-ng educational programmes outside the ICU/HDU.here is no obvious explanation for this in the sur-ey or the literature; however, a more experiencedurse may take a more strategic view and be deliv-ring a wider range of programmes through otherembers of staff, rather than working directly on

utreach activities. Nurse consultants who do notork in the same hospital as they did prior to theirurse consultant role were more likely to be work-ng within the ICU/HDU. This may be because out-each facilities were developed prior to their arrivalnd that they are thus able to develop their roleithin critical care areas (Fairley, 2003).


Expert Practice

There is evidence within this study to show thatthe critical care nurse consultant is providing moredirect care in outreach settings. This evidence isderived from the role responses, as the survey didnot ask individuals to state how much time theyspent delivering care to a patient. It is possiblethat once outreach is established and an evidencebase developed, priorities for nurse consultants willchange. It is also apparent that there is low involve-ment with other recommendations from ‘Compre-hensive Critical Care’ (DH, 2000) such as follow-upservices (Jones et al., 2003), with the majority ofnurse consultants having no involvement at all withthese activities. Follow-up activity received similarattention to outreach in both the Audit Commissionreport (1999) and ‘Comprehensive Critical Care’(DH, 2000); however, it has not developed at sucha speed. The results indicate that nurse consultantactivity in this area is similar to the general uptakeof follow-up in acute hospitals (DH, 2003).

Practice and Service Development

outreach sub-set, although the whole had a mod-erate involvement. This again highlights the biastowards activity outside the ICU/HDU. The surveydemonstrated that nurse consultants had a highinvolvement with critical care senior managementcommittees, which was greater still in the outreachsub-set. However, it revealed low involvement withstrategic activities with organisations outside theacute hospital (Dawson and McEwen, 2005). This isespecially important given the proposed changesto commissioning practices and the present lackof funding for critically ill patient cared for in theward environment. This lack of activity is surpris-ing given that in the future Primary Care Trusts willcommission the volume of activity from a plural-ity of providers on the basis of a national stan-dard price tariff (DH, 2002). At present, the deliv-ery of ward based critical care is not funded noraccurately assessed throughout the NHS, this isgoing to be an important task to ensure outreachteams and critical care units are appropriatelyfinanced.

Conclusions

OtspnNefficactogtttdsab

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There was only one significant difference betweenthe outreach and non-outreach sub-sets within thisfunction. This was related to the development ofclinical guidelines outside the ICU/HDU, which isof no surprise and is consistent with providing edu-cation and development to ward staff. The resultsdo not show a significant difference for nurse con-sultants in the outreach and non-outreach sub-setsfor clinical audit, despite 70% of outreach teamsbeing led by a nurse and 33% by a nurse consultant(National Outreach Survey, 2002). This may be dueto the large amount of practice development ledby all nurse consultants whether they demonstratea high involvement with outreach or not (Dawsonand McEwen, 2005). Of more concern is the evi-dence that critical care nurse consultants demon-strate a low engagement with research activities(Dawson and McEwen, 2005), these results were notsignificantly different across the outreach and non-outreach sub-sets. In order to provide the evidencefor outreach, nurse consultants need to engagein outcomes research (Oermann and Floyd, 2001).Audit will assist in the definition of outreach rolesbut evidence is required to develop patient care toeffect outcome.

Leadership and Consultancy

The outreach sub-set had a significantly higherinvolvement with outreach rounds as individualsand with the multidisciplinary team than the non-

rganisations and nurse consultants should look athe benefits and risks of having so much nurse con-ultant time involved with care of the critically illatients outside of the ICU/HDU compared with theeeds of the staff and patients within the ICU/HDU.urse consultants are especially involved with theducation and training for staff involved in caringor critically ill patients in the ward environment,urther study is required to assess whether thisnput is delivering improved patient services. It is aoncern that despite the changes in commissioningnd the need for resources to improve patientare outside the ICU/HDU outreach nurse consul-ants are not more engaged with their strategicrganisation than critical care nurse consultants ineneral. Despite good evidence of a problem withhe care of the critically ill patient, at presenthere is little evidence for outreach. It appearshat nurse consultants are in a good position toevelop this work; however, this study demon-trated little evidence that nurse consultantsre undertaking research to provide an evidencease.

cknowledgements

would like to thank all the nurse consultants whoave up their time to complete this survey, withouthom the study would not of been possible.


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