Nurses take specialist skills to another level

A talented and vital profession is being recognised at last with university training

Today's patients know what they want and they are not afraid to say so. But rather than making nurses run for the hills in frustration, it is a change that most welcome, says Susan Moody, community matron at West Sussex NHS Trust. She should know. A top priority for most patients, she explains, is to stay at home and avoid hospitals at all costs and it is her job to make that happen. "It's incredibly satisfying to see, for example, people manage long-term conditions themselves rather than bouncing in and out of hospital, which was the situation in the past. You often see massive changes in patients' confidence as they understand what is actually happening to them and having some influence over it," she says.

The increase in community nursing is just one example of how nursing is changing beyond recognition to meet patients' shifting needs, and the best news for nurses is that just about every area of this transformation focuses on them gaining and using advanced skills. Indeed, nurses now prescribe drugs, act as consultants, sit on NHS boards and are often as knowledgeable about certain areas of care as doctors.

No wonder the profession is becoming all-graduate. From 2013 all new nurses will be educated to degree level. Saffron Brown, a third year student of a nursing degree at Northumbria University, welcomes the news. "The level of analysis and critical thinking involved in today's nursing is immense. Everything has to be evidence based," she says. "Yes, we still do the holding patients' hands bit - nursing is, after all, about caring - but we also get involved in things such as research and management and we specialise in certain areas, and the nursing degree is all about gearing people up towards that."

Brown is adamant that wannabe nurses should not be put off if the thought of academia leaves them cold, however. "There's so much support on offer in the university and a major part of the degree is work placements. I've done placements in intensive care, a district hospital general ward, in theatre, and in a mental health setting. The degree isn't just about sitting in a classroom - it's about putting what you learn into practice straight away."

The announcement that nursing is becoming all-graduate - and indeed that community nursing is to become more common - are both among the 20 recommendations in the recent Prime Minister's Commission on the Future of Nursing and Midwifery. And although the Commission only applies to England, similar changes are also happening elsewhere in the UK.

For Steve Jamieson, head of nursing at the Royal College of Nursing (RCN), it is the focus on autonomy for nurses that is most pleasing. "The upshot of this focus is not only that nurses in all roles are bound to have more job satisfaction, but that those who want to can practise at very senior levels in areas where they feel their strengths lie - in education, at clinical practice level or management level," he says.

It is not just nurses who are affected by the Commission. The Royal College of Midwives welcomes the news that 4,000 new midwives are to be sought and that the most senior midwife in any unit should report directly to the board as opposed to having to go through endless levels of management to reach the "top table". "Healthcare assistants play a key role in patient care," adds Jamieson. "But as it is, they are not regulated. The Commission aims to change that so that they are all practising at an agreed level."

The same applies to advance practitioner nursing, he says. As it is, anyone can call themselves an advanced nurse, meaning that someone in London and Manchester with the same job title might have very different capabilities and qualifications. The Commission will protect the title by ensuring the qualifications required to call yourself an advanced practitioner are clearly outlined.

Jamieson also welcomes the changes around leadership. What the scandals at Mid Staffordshire and Tunbridge Wells NHS Trusts - whereby patients died needlessly because of hospital negligence - demonstrate is that there have not been enough nurses at the top, he says. "It's alarming to find that events such as this happened in this day and age in a modern hospital. As the Commission makes clear, senior nurses need to sit on boards with people such as the chief executive and finance directors to say, 'This is what we should be doing.' Thankfully the Commission makes sure that all boards now have to appoint a nurse so that their voice can be heard."

Nurses of the future will be particularly pleased about the increase in nurse prescribing. In fact, Ghislaine Young has long been prescribing medication to patients as part of her role as a salaried partner in a general practice in West Yorkshire. "I'm on the board of the practice and when a patient comes to the surgery, they're as likely to see me as a GP. I therefore often write out prescriptions. What's different is that I no longer have to get them signed off by a doctor. " she explains. She has also been given more autonomy over treatment plans. "Now, if I see a patient with asthma, I can see them through the whole journey - see them, diagnose them, organise a treatment plan and prescribe for them."

Young also exemplifies the way in which nurses now often find themselves advising doctors. "I am the clinical supervisor for a Foundation Year Two Doctor. I also do some teaching to medical students and then there's my specialism of respiratory conditions, which means doctors sometimes ask my advice in that area," she explains.

A particularly popular area of specialism for nurses is cancer and there is good news in the Commission here too, with all cancer patients in the future being offered one-to-one care by a clinical nurse specialist. From the moment of diagnosis, cancer is a subject of fear and distress, explains Jamieson, but more people are now living with it and beating the disease and specialist nurses can help them deal with their emotions and have a high quality of life.

But this is no time to rest on our laurels, says Lynn Young, primary care adviser at the RCN. For the Commission's recommendations to really work, NHS Trusts will need to work hard on culture change too, she says. "Newly qualified nurses are often not encouraged to work in the community. It's assumed that it's for the more mature members of the workforce, but this is something that the RCN is trying hard to change."

Jamieson adds that he would like to see other recommendations. "We need to listen to patient groups, and nurses are central to that collaboration. Patients' groups are the gauge of how things are going in the delivery of healthcare. Patients will often tell their nurse how things could be improved, and the nurse is able to advocate not just for that patient but for the direction of care. It's all part of nurses welcoming patients knowing what they want."

'NURSES WERE HANDMAIDENS TO DOCTORS - THAT IS NOW CHANGING'

Susan Doyle is a final year nursing student at Bangor University

"About 12 years ago, I was asked to teach IT. I enjoyed supporting people, especially those with a vulnerability such as a learning disability. People had always told me I'd make a good nurse and I began to wonder if they were right.

I did a course in mental health and another in nursing at my local college. That convinced me even more. Tentatively, I went to a few open days at universities and was amazed to find that they told me that based on my experience, I'd be able to do a degree. I wasn't confident because it had been 30 years since I left school with fairly poor qualifications, but when I got offered a place, I decided that if the university had faith in me, I should too.

Although the training has been hard and at times stressful, I'm enjoying it, particularly the work placements that the university has geared towards my interest in forensic psychiatric nursing, the specialism of nursing I hope to go into. I worked in a medium secure forensic hospital, which is for people who are mentally unwell and have committed a crime due to their illness or who have deteriorated mentally since being in prison. I've also worked with an assertive outreach team, which aims to get to hard-to-reach patients in the community - ones with an enduring mental illness that don't tend to comply with medication or services and who often then slip through the net and find themselves in court or poor housing.

I'm often asked if I think the new requirement for nurses to do a degree is making us too academic and therefore takes us away from patients. I believe it strengthens our relationship with patients because we are better informed about evidence-based practice and better able to be their advocate. Historically, nurses were handmaidens to doctors and it is good that this is changing. It doesn't mean we're becoming medics - doctors retain that role. We continue working within a therapeutic model, but with growing knowledge."

I ENJOY CONSTANTLY IMPROVING THINGS

Jim Blair is a consultant nurse in learning disabilities at St George's Healthcare NHS Trust

"People with learning disabilities have had a difficult time accessing the health care they need. It was with that in mind that I approached the directors of this hospital with the suggestion of creating my role. It's not as if this hospital had experienced any so-called 'deaths by indifference', whereby people with a learning disability have died as a result of the hospital not picking up on their needs, and yet they said yes.

Since October 2008, when I started, I've had 309 patients and it now works out about 21 a month. They may be people who have no verbal language or people with multiple health issues, and it's my responsibility to assess their mental capacity and work with them and their families to ensure they get the best possible outcomes. This means I am involved in all aspects of the patient's journey throughout their visit and that might involve protecting beds in advance of admission.

It involves other issues such as food too - ensuring, for instance, that if a nurse is told a patient is allergic to eggs, it's clear whether that means a mild rash or an anaphylactic shock.

I also link up closely with my community colleagues so that quality of care continues when patients leave hospital. I work proactively too - ensuring breast screening reaches people with learning disabilities.

"Without this role, there is a real danger of death by indifference. Someone recently didn't understand why they needed dialysis. I explained that without it he would die and looked at what we could do to make him reconsider. We worked out that if he had his mum present and some music playing, he'd do it. He's now a lot better and in a position where he's ready for a kidney transplant.

I enjoy constantly improving things. I also feel that if we get it right for people with learning disabilities, it will get better for everyone else. I think my role shows how bright the future is for nursing. If I can create a post like this from scratch, then that shows how far up the agenda advanced nursing is becoming."