The findings are presented in the following order: firstly, information on the case study site with details of the nurse consultant posts, their activities and the reduction in numbers, and secondly, a thematic analysis of the factors which influenced that decline.
The case study site
The case study site was a primary care organisation (PCO) providing ambulatory, domiciliary and some inpatient services for 300,000 residents in an English city. It employed over 1,000 staff. It also provided clinical training placements for medical, nursing and allied health professions students. The PCO was judged by the external regulatory processes to provide good quality services, have good financial management and its achievements in innovative human resource policies were recognised by the Department of Health. A NHS administrative reorganisation, one year after the study commenced, resulted in the PCO subsequently dividing into two new independent organisations.
The nurse consultant posts and activities
The PCO established ten nurse consultant posts over a period of two years (from 2002-2004). The posts were in: palliative care, older people, tissue viability, tuberculosis, sexual health, children, long term conditions, continence, primary care and public health. The job descriptions emphasised four areas of duties and responsibilities: expert clinical practice, education and continuing professional development, research & audit and leadership and consultancy. All the job descriptions stated that the purpose of the role was to develop both services in the named speciality and also excellence in the quality of the nursing. The scope and extent of the speciality varied between the posts. For example the nurse consultant in sexual health was based within a multi-disciplinary, ambulatory single clinic setting while the long term conditions post was within the PCO community nursing services but expected to work with over 30 general practices in the area. Five of the nurse consultants were already working in the organisation at appointment. Three were recruited from outside the organisation. The post for tuberculosis services was never advertised, suggesting some ambivalence in the service to these posts, and for the post for continence was advertised twice but the post was not filled. Within two years of the ten nurse consultant posts being created only five remained and within five years (2009) only two part time posts, with the original appointees, remained. The details of each post are listed below.
• Post 1. Established in 2002 and the post holder left after 6 months. The nurse consultant post was not replaced.
• Post 2, Permission given to establish the post but not progressed. The service remained staffed by clinical nurse specialists.
• Post 3. The post was advertised, interviews were held but no appointment was made. The service remained staffed by clinical nurse specialists.
• Post 4. Established in 2002 and the initial post holder remained in post. The post holder was appointed part time to undertake another senior nursing role across the organisation in 2008. The hours given to the senior organisational role were not replaced by another nurse consultant,
• Post 5.Established in 2003. The initial post holder left in 2009. The nurse consultant post was not replaced.
• Post 6. Established in 2003. The post holder moved to a senior position in the service in 2005. The nurse consultant post was not replaced.
• Post 7. Established in 2003. The post holder moved to a senior position in the organisation in 2005. The nurse consultant post was not replaced.
• Post 8. Established in 2003. The post holder left in 2004. The nurse consultant post was not replaced.
• Post 9 Established in 2002. The post holder left in 2009. The nurse consultant post was not replaced.
• Post 10. Established in 2004 and the initial post holder remained in post. The post holder was appointed to undertake another senior role part time at a national level in 2009. The part-time hours given to the national role were not replaced by another nurse consultant.
When the individuals left their posts, the posts were not replaced. The nurse consultants left to either join other organisations in more senior management positions or to leave the NHS. None left their posts for other nurse consultant posts.
All the nurse consultants undertook activities in the four key areas of their job descriptions. The extent to which they engaged in all of them reflected something of their service context and length of time in the organisation. All but one undertook direct patient clinical activity. While most commenced their posts with the intention of having 50% of their time in clinical activity only one of them achieved and sustained this level. The direct clinical activity ranged from being part of the medical consultant on-call rota, conducting their own clinics (i.e. nurse led clinics) to being the key worker/case manager for a small group of patients. Indirect clinical activity undertaken by the nurse consultants included clinical supervision of other nurses, providing specialist advice on specific patients or families to nurses or other professional staff, and undertaking review of services from a clinical or professional perspective.
Two nurse consultants became the clinical lead for their multi-disciplinary team, including medical services. One of these was for a temporary period of some months while the medical consultant was on long term sickness leave, the other was appointed following a medical consultant stepping down.
All of the nurse consultants were participants, often in leading roles, in service and organisation wide, quality assurance and development committees. Three nurse consultants were part of regional and national networks formed to improve the quality of care to specific patient groups through benchmarking, setting clinical standards, describing staff competencies and providing training. Most were involved, sometimes leading, in audit, clinical review and service evaluation activities at various points
Half of them undertook education and teaching activities in work based sessions and University programmes. Five undertook some research activities at some time over the period, mainly through the pursuit of higher degrees. Two nurse consultants gained masters degrees, one gained a PhD by research and one gained entry to the national Public Health Register. Four nurse consultants had articles published, including research publications, descriptions of audits and reflections on the experience of becoming a nurse consultant. Two nurse consultants had their activities reported in the national nursing press and one was publicly named and thanked by a patient in a feature article in a national newspaper. One nurse consultant was recognised in the UK Honour System.
Five of the nurse consultant posts were established with the intention that they were direct line managers for other nurses. A further two nurse consultants took on the operational management of staff and services for some months at points when the service manager was absent through vacancy or long term sickness absence. Two nurse consultants were part of the service management team engaged in regular negotiations and review with the commissioners of their services. Two nurse consultants became members of service commissioning review mechanisms.
The thematic analysis identified the following issues influencing the extent to which the nurse consultant posts were embedded and sustained in the organisation: support for individual nurses rather than the post of nurse consultant, the contested nature of the nurse consultant roles and finally the resource implications of new roles.
Support for the person not the post
The importance of the personality and competence of the initial post holder in the new nurse consultant role was evident early on in the evaluation: for example in one speciality the medical consultants reported that if the current nurse consultant left it was not certain that they would advertise the post to be exactly the same. As she said:
"It is not automatic that we'd continue. It is so much about Z [name]. Someone else couldn't fulfil what Z is doing exactly. So we have not had discussions about the other nurse consultants or about Z's role". Medical consultant 1
Senior staff observed that some individuals had greatly over-performed in their previous specialist nurse roles so that they were able to hit the ground running when they were appointed to nurse consultant posts,
"Y [name of post holder] was straining at the leash but didn't have the teeth, so much of the development of the nurse consultant post was already taking place, but it didn't have the mandate the post bought. Y was acting as a nurse consultant (prior to the post being established) and we could capitalise on this". Medical consultant 3
Individual factors were important for the development of the posts. Senior managers and medical consultants linked specific successes of the posts with the particular attributes of the post holder.
"It is more X [name of post holder] than the role-X was doing some of it before. The nurse consultant role confers recognition and status. I'm not sure we'd have had the impetus to create the post if we hadn't had X. X is a champion for nurses in the multi-disciplinary team, and that is all to the good". Medical consultant 6
While the Director of Nursing and some of the nurse consultants highlighted early on the need to develop other nurses to be ready to take new nurse consultant posts, it was not evident that any work was progressed in this area. Succession planning for nurse consultants was a topic raised briefly on one occasion in the nurse consultant group interviews but not pursued. Therapy and medical consultants in interviews contrasted this with the specified routes of training and examinations provided by their professional bodies to the absence of such for nurse consultants in the UK.
Supported, Contested and Ambiguous Roles
The motivation for establishing the posts were described variously by the senior executive team members but included: a willingness to test a workforce innovation that would be an explicit change agent for nursing and concerns as to how to retain experienced nurses in clinical leadership roles. For those senior managers with nursing backgrounds there was also an aspiration for the profession of nursing as indicated here:
"It started from a dream-a belief that we need clinical leadership at the highest level, integrated with teaching and research. It is about senior practice, linked into service provision. It can be the highest point of a nursing career."Executive Team member 3
While the establishment of the nurse consultant posts had support at the highest level in the organisation there was evidence of greater uncertainty from other groups within the organisation. This was expressed initially by doctors, clinical nurse specialists and clinical service managers, in the main, centred around concerns of encroachment of work roles and spheres of influence. One medical consultant who was generally very enthusiastic about nurse consultants expressed this concern:
"If nurse consultants see themselves as leading lights in the nursing world, that's great: if the nurse consultants see themselves in the medical camp that is not so helpful". Medical consultant 5
These types of role boundary concerns were shared by some of the nurses particularly clinical nurse specialists. When the nurse consultant posts were created, some clinical nurse specialists lost lead responsibilities for activities such as nursing practice policy development and audit to the nurse consultant.
"The scope of my role, for which I was awarded 3 discretionary points [on the salary scale] has been substantially reduced because of this [nurse consultant] post". Clinical nurse specialist 3
In some services this caused initial resentment which disappeared over time; in others the clinical nurse specialists continued to dispute the impact of this new role on their potential contribution and job satisfaction.
The clinical service managers, the majority of whom came from nursing backgrounds, could initially see more potential for contested ground.
"But that's what I do now, provide clinical leadership to nurses-how is this going to work with me and a nurse consultant? Will I do less? Who will be making decisions about the priorities of the nursing service-me or the nurse consultant? May be I should be called the nurse consultant". Clinical service manager 4
While the senior managers and lead medical consultants were emphatic early on that the nurse consultant role was not to be a management role, the boundary between clinical leadership, service development and management was not clear, either as a concept or in practice. From early on, nurse consultants stepped in to clinical service manager roles when there were gaps caused by illness or re-organisations. As time went by, managers and nurse consultants both shaped the role towards assuming management responsibilities. Overall there seemed to be an inclination to shape the role into a known model of professional leadership:
"The nurse consultant post is slightly anomalous, as it does not fit naturally into the management structure. V [name of post holder] is not a manager and doesn't control other staff. I can understand the reluctance to include management in the post, but V would be ideal to manage some of the specialist nurses. It would be analogous to medical consultant posts, which do include clinical duties and management". Senior manager 5
The nurse consultant roles and work developed most smoothly when a) their sphere of clinical activity did not overlap with others and b) when both service managers and medical colleagues agreed with the direction of their work of the nurse consultant.
"Our nurse consultant has worked well. What reassured us about our post was that what W does is not a role that others were concentrating on". Medical consultant 3
Where there was a lack of clarity and agreement in the sphere of the work and the responsibilities problems and conflicts arose. One post had very early on not worked out as well as expected in its original form: concerns were expressed by a medical consultant and echoed by a manager who considered that the post holder and the service had different perspectives on what it could achieve.
"It is not clear how they interface with medical consultants. No-one was clear what the nurse consultant was there to do clinically". Medical consultant 8
From the individual nurse consultants perspective their service context was significant in decisions to remain or not. Opportunities to innovate within and improve their services were important to the individual nurse consultants, as was the sense of organisational support. Nurse consultants who left relatively quickly from their posts were in services where other senior staff or commissioners contested their desired work activities and proposed developments. Aspirations of individual nurse consultants to provide nurse led specialist clinics in primary care were often frustrated by lack of support both from general practitioners and by hospital consultants arguing that this was not best use of resources.
The resource implications of new roles
While some managers discussed tangential consequences for the organisation of creating these posts such as improving recruitment and retention of nurses, in the main the aspiration was that the nurse consultants would contribute to both quality improvements and cost reductions.
"Nurse consultants will lead to new initiatives, making the most of high-tech and low-tech opportunities, and making better use of scarce resources". Executive team member 5
However, the resource implications of the nurse consultant posts were an area of uncertainty within the organisation;
"We have taken money out from various sources [to fund the nurse consultant post], but we don't yet know if nurse consultants save or cost money. It is more about raising standards of care". Senior manager 2
While one senior manager described it as "an act of faith" in financing the posts with the hope that they would assist in reducing costs, a medical consultant pointed out that if they fulfilled the aspiration to develop services they might actually increase costs. Much more of the resource implication debate articulated by senior staff in the organisation centred on the degree to which nurse consultants would substitute for doctors and how to judge the cost consequences. The difficulty the organisation had in doing this is expressed in this exemplar quote:
"They are cheaper than medical consultants and that is part of the push [to employ nurse consultants]. 90% of our work can be done by nurses working to guidelines. If nurses are used for routine work they are cheaper than doctors. But it is hard to say exactly, as most doctors' work is done by junior grades and not by consultants. And nurses have longer appointment times. If we had to level that out, what would the costs be?" Medical consultant 4
Senior managers were cognisant of the challenge in evaluating both financial and service quality consequences of these posts in specific service contexts.
"There are financial implications. The posts cost money. But we are not sure if it saves money and that's the question we need to be able to answer. Is it a more effective way of managing patients? It is complicated and may be a similar dilemma to NHS Direct [a national telephone helpline] i.e. at worst it can be another built-on layer. It may improve quality or nurse consultants may duplicate what doctors already do and the patients may have to see the doctor anyway". Senior manager 4
Throughout the period of the study, the primary care organisations were required by their commissioners to identify cash releasing efficiency savings for reinvestment elsewhere. In such an environment, every service was reviewed internally and all posts that became vacant, including those of the nurse consultants, was scrutinised as to whether the financial resource was being used to best effect. Within individual service budgets as each nurse consultant left their post, the monies were re-deployed to other posts and the post deleted.