Increasing Roles for Nurses

The burden of coronary heart disease (CHD) has created a challenge to the health service for decades. These effects have been due to a reduction in overall CHD mortality, and an increase in morbidity associated with CHD resulting over 800000 hospital admissions per annum at a cost of over one billion pounds [1]. The current health care demands and models of service delivery are changing in response to the demographic population trends, particularly with increases in the number of elderly and numbers of people living with chronic diseases [2]. The transition to a model encompassing health promotion, disease prevention and management offers unique opportunities for the development of cardiac nurses’ roles in acute, primary and palliative care. Shared care initiatives have also been predominant in the development of nursing roles, which utilise the combined expertise of specialist cardiac liaison nurses and primary care nurses to a range of client groups. This short paper describes some of the current and emerging roles of cardiac nurses. A number of factors have influenced the change in nurses’ roles. This has included changes in patient dependency due to the increased severity of cardiac conditions during acute hospital admissions. At the same time, staff are under pressure to reduce the length of in-patient stay, and facilitate early discharge to the community. The transfer of patients to primary care has therefore, placed a demand on nurses and health visitors in this setting to broaden their remit and offer appropriate care to cardiac patients. The national influence from government strategy and policy has been driven by the agenda to ensure high quality care through clinical governance. New policies focusing on coronary heart disease have been launched for example the national services framework [3], and the CHD/Stroke Task Force Report [4], which have been pivotal in identifying standards for the development and delivery of services for patients with CHD. In addition, national and international clinical guidelines have been developed to guide evidence-based practice. To meet the recommendations in the guidelines opportunities to review traditional methods of patient management have occurred. Nurses have harnessed this opening to utilise their expertise to ensure high standards of care by optimising pharmacological and non-pharmacological management of cardiac patients. The development of some initiatives has clearly resulted from a devolvement of previously defined medical tasks an issue, which has generated much debate. The interface between new nursing roles and medical practice as a result of the reduction in human resources in nursing and medicine, recruitment and retention problems and the reduction in junior doctors’ hours has been under scrutiny. Such developments must avoid fragmentation of the nurse's roles as occurred with some of the early nurse practitioners roles in the USA in terms of taking over devolved tasks and not the holistic care of the patient. However, in these notes, opportunities have been harnessed by nurses to move beyond this task-orientated approach and provide holistic, individualised care, which must be evaluated in terms of quality. The recent document produced by the CHD Task Force [4] highlights that it is timely to examine the potential for nurses to be more proactive and lead the development of new initiatives to meet the needs of patients with cardiovascular disease, in both primary and acute care settings. Since as a professional group nurses carry out the greatest proportion of care, developing and extending nursing roles will benefit continuity of care. It will be essential before taking on any new areas of responsibility that nurses have the knowledge and clinical competence to meet the requirements of their new role and to ensure that new initiatives are evaluated in terms of clinical effectiveness. A number of initiatives have been outlined in the paper ‘nurse directed services: how can they be made more effective?’ in this issue by Thompson and Stewart [5]. These included the roles of nurses in the early initiation of thrombolytic therapy, cardiac rehabilitation and management of chronic heart failure and atrial fibrillation [5,6]. In addition to these roles there have been recent advances in nurse assessment, stratification and management of chest pain in an elective setting — by the development of nurse led rapid assessment clinics or open access chest pain clinics. There is also potential for development of nursing practice within other acute areas. Nurses working in CCU have considerable clinical expertise and could play a more active role in resuscitation, haemodynamic monitoring and organisation and titration of therapy [4]. Within the area of interventional cardiology, cardiac specialist nurse practitioners have a role in the pre- and post-procedural care of patients admitted for an elective procedures, e.g. coronary angiography or pacemaker insertion. Clinical nurse specialists have expanded their skills beyond the assessment of patients for angiography to perform diagnostic coronary angiography [7,8] and implant permanent pacemakers [9]. In relation to investigations within the United Kingdom, been due to the assumed potential for complications, most exercise tolerance tests (ETTs) remain physician-supervised, and particularly in patients identified as a higher risk, such as unstable angina and post-myocardial infarction. However, ETTs supervised by nurses or cardiac technicians have shown complication rates equivalent to those supervised by physicians [10–12]. The completion of ETTs by nurses with relevant knowledge and skills could release senior medical staff from this role and avoid the supervision of this procedure by a junior inexperienced doctor. Two main areas of nursing intervention in the ongoing management of cardiac patients have been heart failure and atrial fibrillation which have been described in the paper in this issue [6]. New roles are being developed for cardiac nurses in the areas of education, research and practice development. The aim is to ensure that education is up-to-date with advances in clinical practice and to facilitate evaluation of the clinical effectiveness of new roles and services [13]. Joint appointments between the clinical and university services demonstrate examples of integration and collaboration between clinical practice and higher education. Increasingly, academic departments are working in partnership with clinicians at the coal-face to inform the development of and participate in the delivery of new courses. On the other hand, within the clinical area nurses are collaborating with academic staff to develop courses such as ‘fitness to practice’, which aim to provide clinical staff entering new areas of speciality with the theoretical background and competence to practice and deliver appropriate care to patients in different specialities. The future development of cardiac nursing is dependent on the provision of relevant post-registration education for the specialist practitioners of the future. This is currently limited in the UK. Higher education establishments and professional bodies need to work in collaboration with clinical staff to identify educational requirements and deliver appropriate course at post registration and higher degree level, to allow nurses to fulfil their potential in this area as part of a truly multi-professional team [4]. The recent creation of a nursing council of the ESC will involve a group of proactive European nurses to investigate the provision of pre- and post-registration education for cardiac nurses and develop guidelines, standards and recommendations for future practitioners. Increasingly, cardiac nurses have demonstrated their contribution to the development and delivery of cardiac services at national and international level. This has been achieved through their active participation on working groups, which have been established to produce evidence based guidelines to direct patient management. Nurses have also been involved in a number of reviews of service revision for example in areas of prevention via public health, and the national delivery of adult cardiac services [3,4]. Within the European society of cardiology the contribution of nursing is being recognised by the active participation on working groups, e.g. the task forces involved in developing consensus guidelines for the management of acute chest pain and heart failure. Against this context therefore, it is clearly time for nurses to be proactive and lead the development of new initiatives to meet the current and future needs of patients with cardiovascular disease within acute and primary care settings. The concept of CHD as a chronic illness presents a significant health problem and major challenge for health care. One of the difficulties, which exists, has been that many existing services have suffered from the application of therapeutic approaches designed for acute conditions. With no alternative mechanism to manage patients, this resulted in re-admission to hospital encouraging dependency on the system. In addition, patients maybe, lacked information which limited their ability to cope with this as a chronic disease. It is true to say that patients live with, rather than die from, chronic disease therefore, they must cope not only with the manifestations of the disease itself, but the impact it has on their daily lives. Loss of income is often associated with chronic disease and can contribute to low self-esteem and increased stress and distress. Despite the chronicity of this condition, there will still be a need for acute care to manage any exacerbation of the disease. Health care staff need, however, to provide a framework to promote health needs. It has been suggested that their needs may be best met in the community. Whilst this has some truth, it is still essential to consider who can best meet these needs and we may enter into the debate of the specialist nurse vs. the generalist with community care skills. Both undoubtedly to have a place, however, in the development of service it will be essential to ensure whoever provides the care, their knowledge and skills are current and their caseload is large enough to maintain their competence. In summary, in addition to current developments in the roles of cardiac nurses within acute and primary care, this paper addressed the roles of nurses in research and education. The time is right for nurse to harness available opportunities and drive forward initiatives to promote improved patient care.