I have worked in cardiovascular nursing since qualifying in 1985 at St Mary's Hospital in London and have been a consultant nurse in cardiology at Harefield Hospital, London, since June 2000, the first such cardiology post in the UK.
The consultant nurse role was first proposed by the Prime Minister, Tony Blair, in 1998 with the aim of strengthening leadership in nursing, improving patient outcomes, and enhancing the quality of healthcare services. The announcement of the new role was made at the Nursing Standard Nurse 98 Awards (Martell, 2000). The role was designed to ideally share the same status as a medical consultant (Renshaw, 2005). Consultant nurse posts needed to be constructed to satisfy the needs of the specialty or service in which they were to be established. However, irrespective of the field or practice, setting or service, each post had to be structured around four core functions that exemplified the role (Department of Health (DH), 1999):
- Expert practice
- Professional leadership and consultancy
- Education and development function
- Practice and service development, linked to research and evaluation.
These were not viewed as discrete elements but closely interrelated functions as part of a coherent whole. The weight attributable to each function and the time allocated to carry out the tasks and responsibilities associated with that function would vary from post to post and within the same post over time. All posts were to be firmly based in nursing, midwifery and health visiting practice and involve directly working with patients, clients or communities for at least 50% of the time.
Taking on this role was a steep learning curve and involved several challenges, including setting up cardiology clinics which, in 2000, were not run by nurses.
Nurse-led services
Over the past 22 years, I have established some of the first nurse-led services in cardiology including follow-up clinics for patients post percutaneous coronary intervention (PCI), pre-admission clinics, a rapid access chest pain clinic (RACPC) and nurse-led discharge.
There was no national guidance detailing frequency or length of follow-up required for patients post PCI and I therefore had to write a protocol, with input from my medical colleagues, to ensure there was a standard pathway. It was important to ensure that nurse-led clinics added something more than medical clinics, and I therefore ensured the clinic appointment time was longer so that psychological wellbeing and secondary prevention could be addressed, as well as the medical aspects of patient care.
Telephone clinics, which have become an accepted way of reviewing patients since the COVID-19 pandemic, were not commonly used in the early 2000s but I implemented these to facilitate longer term follow-up without the need for patients to travel to the hospital. The PCI clinic is now run by my team of clinical nurse specialists (CNSs) who carry out over 1500 appointments each year. I frequently receive requests for nurses at other hospitals to come and observe our clinics so they can use our experience in establishing their own nurse-led services.
The RACPC was a new initiative suggested in the National Service Framework for Coronary Heart Disease (DH, 2000), enabling patients with a suspected diagnosis of angina to be reviewed by a specialist within 2 weeks of referral. There was no stipulation within the document as to who the specialist should be, and it was agreed that I could fulfil this role. This would require me to develop diagnostic skills, which was a departure from the usual nursing role. The clinic has continued to be completely nurse-led, with increasing demand for the service year on year. The number of patients seen annually has more than trebled since 2001. One significant development was the implementation of a same-day CT coronary angiography for some patients. This has not only reduced waiting times, but also enabled faster diagnosis, leading to more timely treatment for those who need it, and reassurance for those with a normal test, therefore preventing the increased anxiety caused by having to wait for an investigation. We are one of only a few, if not the only RACPC able to offer this same-day service, which has been positively evaluated by numerous patients.
Lipoprotein apheresis is a dialysis-type treatment for patients with lipid levels that remain above national target levels, despite maximally tolerated diet and medical therapy. Prior to my consultant nurse role, I had no knowledge of this treatment and although research had been published based on a study at the hospital in the 1980s (Jefford, 1993), the hospital did not offer this service. I undertook the first clinical treatment in November 2000 and for the first 2 years we had just one patient. The unit at Harefield is now the largest in the UK, offering treatment to 36 patients who attend either weekly or every 2 weeks. I have established a team of apheresis CNSs who have become experts in this treatment, and I also work closely with HEART UK, the cholesterol charity, to help improve the detection and treatment of patients with raised cholesterol.
Challenges of the consultant nurse role
Changing from the role of a ward sister to that of a consultant nurse was a difficult adjustment. However, being already established within the organisation allowed me to spend time establishing the role, rather than establishing myself and made identifying the needs of the cardiology service easier. There was a degree of antagonism in the early days from some medical colleagues, particularly those who were also applying for consultant posts, who were not happy that a nurse had achieved this goal first! There has also continued to be the interesting question as to what I should be called, which remains unresolved. I am no longer a ward sister, but I am not a doctor. I sometimes felt a little negative and isolated in the early days as I felt I had to justify my position and prove that I was able to take on these new roles, especially as I was working in areas that had previously been seen to be medical responsibilities. Nurses also had varying responses to this new role. Some saw it as a positive development for nursing, whereas others felt that being a consultant was moving away from the whole idea of being a nurse. I spent time in the first few years of the post promoting the role, but I think being in a small, specialised hospital helped me to win over at least some of the sceptics and I would hope now that the role is not only accepted but also seen to be of great benefit.
Contribution to patient care
There has been a significant improvement in patient care, evidenced by data from annual audits of all the services I run. The nurse-led clinics have facilitated consistent management of patients and has enabled the care given in the outpatient consultation to focus on the holistic care of the patient, including psychological and social aspects, together with a review of the patient's medical condition. I have also established nurse-led discharge for both acute and elective patients, which has enabled a smoother discharge process and has been proven to reduce length of stay. Patients receive a combination of medical and lifestyle information, together with comprehensive documentation from their stay in hospital. As a non-medical prescriber, I can also ensure that patients are discharged with the optimum secondary prevention medication. Audit data has found that this is better achieved with nurse-led discharge when compared with medical discharge.
Benefit to cardiovascular nursing
My role has been pivotal in pushing the boundaries of nursing roles and I am passionate about encouraging nurses to expand their remit, both clinically and academically. The continuing development of my nurse-led services has resulted in the creation of numerous specialist nurse roles, which have enabled other nurses to take their careers forwards. Teamwork is key to the success of what we do. I am keen to encourage nurses to see research as part of their job and to assist in the identification of areas for improvement and potential topics for research. I have been instrumental in establishing collaboration between the different apheresis units in the UK, helping to foster sharing of ideas and discussion about joint research projects.
Key successes
I have been credentialed in Advanced Practice by the Royal College of Nursing and was awarded first prize for Excellence in Primary and Secondary prevention in the Cardiac Nursing Awards in 2008 as well as the Silver Award in the BJN Awards 2023. I present at a variety of national and international conferences and feel it is vital that I share my experiences and help others to develop their roles, not only in the UK but in other countries. I have developed a comprehensive audit and service evaluation programme within my team. All the nurse-led services are reviewed annually and data from these audits has continued to prove the positive contribution these services make towards patient care. I am widely published with over 45 articles in peer-reviewed journals, four book chapters and over 65 abstract presentations in national and international conferences. My publications have helped to showcase the work that can be done by cardiac nurses.
Conclusion
The nurse consultant initiative has provided one of the greatest career-defining opportunities within the nursing profession in modern times. Working as a consultant has enabled me to achieve areas as a nurse that I never dreamed was possible when I qualified. I feel the post is an important part of nursing and should not be lost so that we can maintain a defined career structure to keep experienced nurses in clinical practice. It is up to all of us to make sure consultant roles continue to enable us to provide the best quality care to patients. I still have more to give and am hoping to start my PhD next year.