Stoma coloproctology nurse specialist: a case study

NURSE SPECIALISTS

Stoma coloproctology nurse specialist: a case study Ursula Chaney

DPSN, BNS, MSc, RGN

Lecturer, Institute of Nursing and Midwifery, University of Ulster, Londonderry, UK

Felicity Hasson

BA, MSc, PG Dip

Research Fellow, Institute of Nursing Research, University of Ulster, Londonderry, UK

Sinead Keeney

BA, Mres

Research Fellow, Institute of Nursing Research, School of Nursing, University of Ulster, Londonderry, UK

Marlene Sinclair

BSc, RNT, RM, RN, MEd, Dase, PhD

Professor, Midwifery and Nursing, University of Ulster, Londonderry, UK

Brenda Poulton

BA, MSc, PhD, RGN, RHV, RHVT

Professor, University of Ulster, Londonderry, UK

Hugh P McKenna

DipN, AdvDipEd, BSc, PhD, RGN, RMN, RNT, FRCSI, FEANS, FRCN

Dean of Faculty of Life and Health Sciences, University of Ulster, Londonderry, UK

Submitted for publication: 27 July 2005 Accepted for publication: 11 February 2006

Correspondence: Ursula Chaney Nursing & Midwifery University of Ulster Magee Campus Londonderry, BT48 7JL UK Telephone: þ44 028 71375026 E-mail: [email protected]

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CHANEY U, HASSON F, KEENEY S, SINCLAIR M, POULTON B & McKENNA HP

Journal of Clinical Nursing 16, 1088–1098 Stoma coloproctology nurse specialist: a case study Aims and objectives. The aim of this paper is to provide insight into the role of a Stoma Coloproctology Nurse Specialist. This paper presents the findings of an in-depth case study of a stoma coloproctology nurse specialist employed in one health board area in Northern Ireland. This case study was part of a larger study exploring innovative nursing and midwifery roles in Northern Ireland. Background. Specialist nursing roles have evolved and developed in response to changing health care needs, patient expectations, changes in professional regulation and government initiatives. Design. A case study approach was adopted. Method. Semi-structured interviews with the post holder (PH), her line manager and the human resource manager were undertaken. Non-participant observation of the PH’s practice was also carried out. Analysis was undertaken on secondary data such as job specification, annual reports and other documentation relating to the post. Results. Findings illustrate the PH’s function and the impact of the role on patient care. Examples of innovative practices relating to providing care, support and guidance for patients and their families were identified; however, limitations to her role were also identified. (2007)

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Conclusions. The PH provides an invaluable service to patients, demonstrating a positive impact on care. However, the findings suggest the importance of establishing clear role boundaries, which may lead to professional growth and practice development. Relevance to clinical practice. Although this study provides a valuable insight into the role of a Stoma Coloproctology Nurse Specialist a number of challenges exist, as the CNS role requires policy and appropriate educational preparation to practice at an advanced level. Further research investigating the development of the CNS role in the clinical setting and its relationship to members of the multi-professional team would be beneficial. Key words: advanced nursing practice, case study, innovative, nurse specialist, nursing role, Stoma Coloproctology

Introduction In recent years, new and innovative nursing roles have been introduced across a range of specialisms. Such roles have been developed in response to changing health care needs, patient expectations, professional regulation/licensure and government initiatives (Roberts-Davis et al. 1998, Department of Health (DH) 1999, McKenna et al. 2003). Today, many nurses undertake a range of complex health care interventions addressing healthcare needs within hospital and community settings (Royal College of Nursing (RCN) 2004). Many of these roles are new to nursing and require advanced knowledge and expertise. With new roles, a proliferation of titles has emerged (McKenna et al. 2005). These include, clinical nurse specialist (CNS), nurse practitioner, advanced nurse practitioner and, more recently, nurse consultant (Daly & Carnwell 2003, Lloyd Jones 2005). The advent of so many new specialist roles with overlapping titles and boundaries has led to role confusion (Cattini & Knowles 1999, Martin 1999, Mills et al. 2002, McKenna et al. 2004, RCN 2004). Redekopp (1997) claims that ambiguity of roles may hamper collaboration, contribute to conflict and even prevent the CNS from optimising knowledge and skills. Nevertheless, while there are many examples of new roles in nursing and midwifery across the UK (West 1998), there is a paucity of research exploring their nature, scope and impact on practice. In 1995, the UK DH commissioned The Exploring New Roles in Practice (ENRiP) project (Read et al. 2001) investigating innovative roles in nursing and midwifery in England. The findings revealed that inadequate resources can undermine the effectiveness of new roles and recommended a clear support and management framework with logical lines of accountability and responsibility.

This paper reports on an in-depth case study, undertaken as part of a larger research programme, exploring innovative nursing and midwifery roles in Northern Ireland (McKenna et al. 2005); the case study explored the role of a Stoma Coloproctology Nurse Specialist in an Acute Health and Social Services Hospital in Northern Ireland. The main foci of the case study were to explore ways in which the post holder (PH) is innovative within the role, her educational preparation and the effect on the role of changes in health care delivery, issues related to accountability and how the role is addressing healthcare needs.

Background Specialist nursing practice is defined as ‘exercising higher levels of judgement, discretion and decision making in clinical care’ (United Kingdom Central Council for Nursing, Midwifery & Health Visiting (UKCC) 2001, p. 1). Practitioners are expected to demonstrate higher levels of clinical decisionmaking that will, ultimately, have an impact on standards of patient care. Clinical audits, practice development, undertaking research, teaching, supporting professional colleagues and providing skilled professional leadership are expected components of the specialist practitioner’s role (UKCC 2001). Achievement of competencies for specialist practice will, undoubtedly, require sound clinical experience and postregistration educational preparation (Cattini & Knowles 1999, UKCC 2001). Today, specialist roles permeate all spectrums of health care and all areas of nursing practice. They are a central aspect in managing patients with both chronic and acute illnesses (Mills et al. 2002). Consequently, clinical nurse specialist (CNS) roles have been identified as making a significant contribution to better health outcomes (McKenna et al. 2003). Benefits demonstrated include increased adherence of

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patients to treatment, prevention of hospital readmissions and reduced complication rates (McKenna et al. 2003), reduced waiting times and increased patient satisfaction (Daly & Carnwell 2003).

Innovative roles Reflecting the increasing rise of CNS roles, some studies have been undertaken to explore barriers and facilitators to the role. Attention has been given to the practitioners’ personal characteristics such as confidence, assertiveness and motivation (Glen & Waddington 1998, Ball 1999, Bamford & Gibson 1999a) acting as a facilitator to role development. In addition, previous experience and prior knowledge of the specific service have also been seen to be important (Bamford & Gibson 2000, Marsden 2000). More recently, educational preparation for the role incorporating generic as well as speciality-specific skills was highlighted as crucial to role development (Lloyd-Jones 2005). As some roles cross traditional practice boundaries, role conflict is a potential barrier to effective working. While inter professional relationships are important, medical staff (Marsden 2000, Tye & Ross 2000) and nursing staff (Tye & Ross 2000) have been found to display resistance to their development. Research findings have shown that some managers are supportive of new roles (Waters 1998) and others are unsupportive (Tye & Ross 2000). The DH (1999, 2003) has recommended the importance of establishing clear role boundaries to enable professional growth and practice development. This lack of support can be a barrier to role transition and can limit effective practice (Flanagan 1998). Glen and Waddington (1998) reported similar findings and recommended the development of a CNS support network to facilitate role transition, whilst gaining peer support (Bamford & Gibson 1999b). Although previous research has demonstrated that professional autonomy is also important for role development (Bousfield 1997, Bamford & Gibson 2000), research by Waters (1998) in the US, reported that nurse practitioners’ professional autonomy was diminished by their inability to charge for their services, resulting in a need for medical supervision. Similarly, in the UK, Flanagan (1998) suggested that seeking support from medical staff diminished the CNS’s professional autonomy. Although some studies have explored the role of the CNS (Bass et al. 1993, McFadden & Miller 1994), there has been a dearth of literature and an absence of empirical studies investigating their experiences within the role (Bousfield 1997). 1090

Stoma colorectal nurse specialists Stoma care nursing originated in the United States and has been part of specialist nursing practice for over 20 years. Further to service developments, the role now encompasses colorectal nurse specialists and stoma coloproctolgy nurses (Baxter & Salter 2000). Expert competencies identified for stoma care nurses include advocacy, autonomy, initiation of new work, team management, research, working beyond the organization and consultancy (RCN 2001). This is a multifaceted role (Bamford & Gibson 2000) and the facets include being an expert practitioner, an educator, a consultant and a researcher. This delineates the depth and breadth of the work stoma nurse specialists are expected to undertake. Brown and Randle (2005) claim that stoma care nurses are in the best position to maintain continuity of care for patients. Often, stoma care nurses are one of the main links between the multidisciplinary team members, the patient and family, hospital and community and, accordingly, are an ideal conduit for effective communication. Counselling is also highlighted as a key element within the role (Marks & Clinical Services Committee Association of Coloproctology of Great Britain & Ireland 2001, Skingley 2004). This is vital as patients undergoing stoma formation will undoubtedly experience psychological issues concerning altered body image and sexual activity (Black 2004). Conversely, individuals with chronic illnesses such as Crohn’s disease or ulcerative colitis will also experience acute exacerbations, suffer years of a painful illness and frequent consultations with doctors before a stoma is ultimately formed (Persson et al. 2005). Thus, the need for counselling is required throughout the disease trajectory. The aim of this study is, therefore, to provide insight into the role of a Stoma Coloproctology Nurse Specialist. Although this case study is set in the context of a larger study, it is anticipated that it will provide further insight into the role, practice and impact of a Stoma Coloproctology Nurse Specialist.

Methodology The PH was required to be in post for a minimum of six months prior to the start of data collection. Criteria for inclusion of roles were based on role specification and not job title alone. Purposive sampling was employed to select participants. Purposive sampling is based on the belief that a researcher’s knowledge about the population can be used to select the cases to be included in the study (Polit & Hungler 1999). Three participants, the PH, line manager and the human resources manager were initially contacted in writing,

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informing them of the study and asking them to take part in the research. Selected participants were approached to determine if they would be willing to participate in the study with returned signed consent forms accepted as willingness to participate. A case study can be employed to focus on specific circumstances such as individuals, groups or phenomena (Parahoo 1997). Multiple sources of information can be used when undertaking a case study (Creswell 1998). Case studies use in-depth data collection techniques that allow for the detailed study of all aspects of a case and the exploration of a perspective that may have been missed when using other methods. Mills et al. (2002) noted that case studies are particularly useful where there is a dearth of research that considers the experience and difficulties faced by a specialist nurse providing a new or enhanced service. However, it is acknowledged that a frequent criticism of case study methodology, the dependence on a single case, renders it incapable of providing a generalizing conclusion. Nevertheless, for the purpose of this case study in the anticipation of yielding rich data regarding this role, interviews, observation and analysis of relevant reports and documentation were also included.

Data collection Semi-structured interviews were undertaken with the PH, line manager and human resource manager. During the interviews, questions followed a schedule formulated from the extant literature (including Read et al. 2001). When necessary, probes were used to add clarity to respondents’ answers or to try and elicit further information. Table 1 presents interview schedules. The length of the interviews ranged from 30 to 60 minutes. With permission, interviews were tape recorded. To gain a better understanding of the innovative role and the environment in which the PH operates, a continuous fivehour non-participant observation of the PH was also undertaken. This involved the PH enacting her role, including interaction with patients, staff and other professional colleagues. During the observation period patients were given a full explanation of the study with written and verbal consent being obtained. Detailed notes from the observation were formulated. After transcribing the PH’s interview and writing up the field notes from the observation period, the data were given to the PH for verification. This was an attempt at adding credibility to the findings (Creswell 1998). Minor adjustments were made following this procedure, with the PH confirming that an accurate reflection of her role was obtained. Review of secondary data comprised of annual reports, a publication by the PH and her job specification.

Stoma coloproctology nurse specialist

Data analysis Content analysis was employed to analyse the data. This is a widely used method to generate meaning from qualitative text (Priest et al. 2002), in the hope of identifying key issues (Burnard 1991, 1996). The interviews with the PH, line manager and human resource manager were transcribed verbatim and data were analysed utilising Burnard’s (1996) framework. Giving the simplest explanation, the first stage consisted of reading the text and ‘open coding’ words and phrases. The second stage entailed the reduction of repetitive words and phrases. Stage three involved colour coding each category and grouping all the categories together. The final stage was to give meaning to the findings. After repeated reading of the transcripts, similarities, differences and extremes were identified. From this, statements were identified to find patterns and associations resulting in recurrent themes relating to the aims of the study. During observation periods the researcher took detailed field notes, which were written up immediately after the observation. Secondary data were also reviewed.

Ethical considerations Ethical approval was obtained from the Office for Research Ethics Committee for Northern Ireland. Written permission was also obtained from the relevant care organization. Informed consent was obtained from the participant and from any patients encountered during the non-participant observation phase. All participants were given written and verbal information and had the right to withdraw from the study at any time.

Findings This post has formally existed for almost 6Æ5 years, with the PH being in post from inception. This is a full time permanent post. Findings are structured under several headings: background, qualifications and experience, management and support, authority and accountability and perceived impact of the role. Two main themes emerged within all interviews: teaching/education and patient support and were clearly integral components of the PH’s role. Aims and objectives of the post Aims and objectives identified included providing information and support, education, being a resource for primary and secondary care, collaborating with colorectal clinicians and providing a seamless service:

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U Chaney et al. Table 1 The PH interview schedule

Table 1 (Continued)

Section A: Background 1 Please could you describe your role and identify what makes your role innovative? 2 What are your contracted hours of work? 3 How long have you been in this post? 4 How long has your post existed? 5 (a) Does your post have permanent or temporary funding? (b) If the post has temporary funding please explain the source e.g. charitable donation, NHS initiative (Taskforce, waiting list) or drug company monies. 6 Do you know why your post was established? Please explain?

16 Do you have the authority to assess patients autonomously? i.e., assess patients beyond the routine level of your profession (nursing) a) If yes, please provide an example? 17 Do you have the authority to manage complete episodes of care? a) If yes, please give an example? b) If yes, is this defined by protocol? 18 Do you have the authority to manage complete clinical procedures? a) If yes, give an example b) If yes, is this defined by protocol? 19 Do you have the authority to order investigations? a) If yes, please give an example? b) If yes, is this defined by protocol? 20 Do you have the authority to discharge patients from: a) Your caseload? b) From the service? c) If yes to a) or b) to either of the above questions is this defined by protocol?

Section B: Qualifications and experience 1 What was the minimum qualification stipulated for this post? 2 What was the experience stipulated for this post? 3 What professional qualifications do you have? 4 What experience do you have relevant to your post? 5 What pay scale are you on? (For example Whitley or a professional pay scale) 6 Please indicate what grade you are on? 7 What training did you receive for this post? a) What academic level was this training at? b) What length was the training? c) Who provided this training? 8 Have you been assessed for competency in this post? a) If yes, please describe how it was undertaken? 9 Has any evaluation been done on this post? a) If yes, please describe the process? Section C: Management and support 10 Do you receive any support from your colleagues with regard to your role? a) From whom do you receive it? b) How frequently does it take place? c) Formally or informally organised? 11 Do you receive any clinical advice? a) From whom do you receive it? b) How frequently does it take place? c) Formally or informally organised? 12 Do you receive any clinical supervision? a) From whom do you receive it? b) How frequently does it take place? c) Formally or informally organised? 13 What post does your line manager hold?

Section F: Additional comments 27 Do you have anything further that you would like to add? 28 Do you have any questions that you would like to ask? 29 Do you think you role has extended into that of another profession or that it is the expansion of an existing nursing or midwifery role?

Section D: Authority and accountability 14 Do you have the authority to: a) Accept patients onto your personal workload/caseload? b) Accept patients into the service? c) If yes to a) or b) to the above questions is this defined by protocol? 15 Do you have the authority to refer patients directly to other health professionals? a) If yes, please indicate to which professionals you can refer? b) If yes, is this defined by protocol?

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Section E: Perceived impact of the role 21 What impact do you think your role has had on: a) patient care b) your work environment c) your colleagues d) the development of nursing/midwifery practice 22 Do you think you are effective in what you do? a) If yes, how do you know? 23 Do you think you are efficient in what you do? a) If yes, how do you know? 24 Do you feel that your role has had any other impact? 25 Do you feel that your role has promoted the development of good practice? a) If yes, can you give examples of this? 26 Is your role strictly nursing/midwifery or is it more related to the work of another profession? a) If yes, please identify the profession?

The main objectives of this post are to provide information, advice, education and support for patients who are about to undergo or who have undergone surgery resulting in the formation of a stoma… Provide information, advice and support for patients suffering a range of colorectal diseases for example, cancer, inflammatory bowel diseases… Provides a resource for primary care as well as secondary

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care and education of hospital staff in the area of colorectal disease is a fundamental objective of the post (human resource manager). She works in collaboration with the lead clinician in colorectal diseases (line manager). Qualifications and experience The minimum qualifications and experience required for this post were RGN, the ENB 216 (stoma care nursing) and five years experience in caring for patients with colorectal diseases. The PH exceeded the minimum stipulated, having also obtained a BSc (Hons) Nursing, Postgraduate Diploma in Advanced Nursing, MSc Nursing, Specialist coloproctology course and a counselling certificate. Undertaking the relevant coloproctology courses required assessment of competency, which was undertaken by the Hospital’s lead colorectal surgeon. Sound clinical experience was apparent from the observation, with the PH expertly assessing patient’s psychological and clinical needs. Management and support The PH receives support from several sources including her colleagues, other specialist nurses within the hospital, an established network of colorectal nurse specialists within Northern Ireland and members of the multidisciplinary team, in particular the colorectal surgeons. The main sources of clinical advice and support to her role were from colleagues and the colorectal surgeons. Clinical supervision is not formal and does not occur regularly, but depends on how often advice would be sought: I would receive informal clinical supervision from my colleague and from other colorectal nurses… from …the consultants and … my Line Manager. How frequently does it take place would depend on … how frequently I would seek their advice but it is not a formal thing. (PH) All support mechanisms available are informal with the exception of the network of colorectal nurses

Authority and accountability It was evident the PH did have authority beyond the generalist nurse. She was able to accept patients autonomously onto her caseload or into the service and refer patients to other members of the multidisciplinary team. This is not defined by protocol but was within the job description: I would have the authority to refer patients onwards. I can refer them to for example… to see a consultant in dermatology… a clinical psychologist …the … liaison psychiatrist or… back to their consultant. (PH)

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One of the questions focused on whether the PH had the authority to assess patients autonomously, beyond the level of a generic nurse. Observation showed that assessment is continuing through all stages of interaction with patients and is in-depth. Decision-making by the PH is also the role of patient assessment: Yes I would assess patients autonomously…These patients would be assessed within the level of nursing; however, they would be assessed for … how they have adapted to … their new stoma, …, psychologically adapted … The patients would often be referred to me preoperatively for assessment psychologically to see what … my opinion would be whether they would cope psychologically or not, with a stoma. … Assess patients post-operatively using … tools like the HAD tool for depression… level of understanding of their diagnosis. We would autonomously assess patients’ practical …competency with stoma care and this would determine whether they get home or not. … Often patients are medically fit or surgically fit for discharge, but will not be fit for discharge in terms of competency. So the decision will be left … to us to discharge that patient when we feel that they are psychologically and practically fit to be discharged and to be able to manage their stoma. (PH)

The Hospital Anxiety and Depression scale (HAD) tool can be used to assess a patient’s anxiety and depression. The scale alerts the clinician to possible psychological problems (Black 2000). The PH has the authority to manage complete episodes of care and complete clinical procedures such as bowel washouts through the distal loop of a stoma. These are not defined by protocol rather by job description. Twelve clinical protocols have been devised by the Stoma Nurses’ Network in Northern Ireland (led by the PH) on how to manage certain clinical situations. Seven of these protocols have been published. The discharge of patients from the caseload and the service is within the remit of the PH, this again being defined by protocol. Ordering investigations was not within the remit of the stoma coloproctolgy nurse specialist: No, I do not order any investigations; sometimes I can suggest that a particular investigation would be pertinent, but I do not order it. (PH)

During the observational period an assessment of a patient’s wound took place, with the PH deciding a fistulogram was required to elicit the cause of the patient’s problem. The PH contacted the patient’s consultant, giving an explanation of her thoughts and diagnosis. The consultant subsequently gave consent to have this investigation ordered.

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Perceived impact of the role The PH perceived her role as having a positive impact on patient care: I feel my role has a positive impact on patient care. Patients’ feel well supported, well educated in terms of stoma care. Patients’ with colorectal cancer feel well supported and informed and are getting the appropriate advice if necessary… Also patients who have a new diagnosis of Crohn’s or Ulcerative Colitis are provided with information, advice and support, which is invaluable when someone has just being diagnosed with a chronic illness. (PH)

Providing a seamless service, being with patients throughout the disease trajectory, earlier discharges, expert specialist nursing care and providing a complete service were identified as having a positive impact on patient care: The most relevant one (impact) at the moment is that this has facilitated earlier discharge of patients and … these group of patients can be facilitated in the community quickly with the support of the specialist nurse. (line manager) This role has provided patients and their families with expert specialist colorectal nursing care, which boosts the service provision

…I have had a significant impact in the way people are cared for. My role has also had a significant impact on developing this area, in terms of undertaking research, developing protocols…publishing, being involved in action learning, being a facilitator in action learning. …My role has gone a long way to developing … nursing practice, in this area. (PH)

Efficiency and effectiveness Efficiency was demonstrated through a number of initiatives including the management of her case load, reducing unnecessary admissions, the ability to undertake research, publishing, speaking at conferences, raising the profile of the job and facilitating action learning sets for colleagues. While there was no formal evaluation of this, it has been demonstrated informally through annual reports and patient consultations. Effectiveness was demonstrated by a reduction in the number of patients requiring admission to hospital because patients’ problems in certain instances can be managed as outpatients: If I, I was not here to provide that information and advice that the patient would go to A and E and would end up being admitted. (PH)

for the Hospital… The service to colorectal patients is a complete

Yes she is effective in what she does number one academic

service. (human resource manager)

achievement. I think that she can apply that … to the care of her

Observation of the PH’s interaction with patients supports her view of having a positive impact on patient care. It was evident that she has developed therapeutic and meaningful relationships, ensuring a patient-centred approach to care. She was a familiar face who explained everything in an open and honest manner and through knowing these patients she has insight into their needs. Patients observed within the fivehour period with the exception of one (who was new to the service) knew the PH from diagnosis, through the preoperative and postoperative period and subsequent care. The patients already known to the PH appeared very confident in her care, it was obvious that they trusted her opinion and wanted her advice during consultations. Patients were supported in their consultations through her verbal and nonverbal communication skills. Despite the perception of time pressures to the observer, this was not translated to the patients, who were listened to intently, had their needs and anxieties addressed and collaborated and negotiated as a partner in their plan of care. The PH had developed nursing practice in her field and this was perceived as having a positive impact on patient care by her line manager. In addition, good practice had arisen from this role through the development of protocols, undertaking research and the dissemination of findings, at local and national level:

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patients … she has facilitated the early discharge of patients … but the evidence … patients have not required to be readmitted … substantially … supports that … it’s obvious (PH) effectively and efficiently undertakes the workload … patient satisfaction is frequently expressed by this group of patients indicates that she is both efficient and effective. (line manager)

Value for money The PH is currently employed at H grade. Within the United Kingdom nurses’ pay, roles and responsibilities are structured using a grading system. A nurse who is a D grade would be a newly qualified nurse; each subsequent grade there after (E–I) entails a higher salary alongside more responsibility. Thus an H grade nurse would be awarded for a senior or very specialized role such as that undertaken by the PH. The Human Resource Manager highlighted this post provides value for money and identified further benefits to patients: There is absolutely no doubt about it, that there is actually a real cost benefit to these posts. The specialist nurse can … prevent hospital admissions saving considerable amount of money… Troubleshoot problems from stoma patients, which GP’s are not able to do. …Save money by providing intensive education for new patients with new stomas, which can result in early discharge, in some cases 5–7 days earlier than would normally be expected and… follow these patients up in the community. If they were not in post, this would just simply

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A nursing role? Both the PH and the Line Manager perceive this role as being purely nursing. They recognised that boundaries have expanded and developed to encompass other nursing elements but this had enabled care to be provided at a more indepth level: I think it is an expansion of an existing nursing role …it is obviously a development from the care of this group of patients at ward level,… these patients have specialists’ needs and … need that protected provision of care at a more in-depth level. (line manager) … It has not extended into another profession, but yes it has expanded and developed more so into an, existing nursing role. The role has been further developed to encompass other aspects but it is still very much a nursing role. (PH)

Innovations within the role – secondary data It is apparent the workload has multiplied since the formalisation of this role six years ago, with increased patient numbers and developments such as home visits, having an impact on the workload. Review of secondary data (annual reports since 1998) reveals many activities, which the PH has been involved in since the start of the role. In the first year, a local ostomy support group was established following recommendations from former patients. Through this group, open days have been organised involving commercial companies and voluntary organisations. Other annual events organized include table quizzes, information sessions for stoma patients, public awareness talks to the general public (risks of bowel cancer), demonstration of reflexology and aromatherapy and talks from the citizens’ advice bureau regarding benefits and entitlements. In conjunction with a large cancer charity in Northern Ireland (Ulster Cancer Foundation) the PH assisted in developing a Volunteer Befriender Service. The PH was integral in recruiting and training volunteers. This service has been established for five years and is still flourishing. One of the patients involved in the observation stage of the case study had used this service and had found it very beneficial. The PH maintains a record of all visits and has a debriefing session with the volunteer, thus ensuring any issues that may arise are addressed with the client and/or the volunteer. A follow-up post discharge service for patients has also been developed in conjunction with the Macmillan nurse specialist. This was set up to aid referral to the PH from which an evidence based flow chart/protocol has been developed in conjunction with the hospital Macmillan nurse.

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Secondary data revealed that the PH has also been involved in curriculum planning for the specialist pathway in stoma care nursing. Teaching and education of staff feature heavily in the annual report, demonstrating that this is a fundamental component of her role. Educational activities include teaching of nurses, doctors, Allied Health Professionals (AHP), health care assistants and students (nursing and medical). Teaching is also undertaken external to the Hospital; examples include the Provider Support Unit, the Macmillan PH’s training day and postgraduate Pharmacist education stoma workshops for a local university. The PH has established home visits to ensure continuity of care between hospital and the community, enabling the assessment of patient competency and adaptation within the home environment. This allows for the detection of any problems, assessment of the stoma site, bathroom facilities and safe disposal of used appliances within the patients’ home. An observation of a home visit supported this role, demonstrating a seamless service with reinforcement of previous education, psychological assessment and continued support and advice. It was observed that patients have open access to the service and that nurse-led clinics are patient directed. This enables patients to telephone the clinic at any time and arrange an appointment with the PH if they feel they need to be seen. Research undertaken by the PH (in collaboration with colleagues) explored patients’ views and perceptions on information received following a diagnosis of cancer. From the findings, information leaflets were reviewed and applications were made to various organizations to fund an information centre. One of the recommendations from the study included the establishment of a multidisciplinary working group. An analysis of the Annual Report for 2004 showed that monthly multidisciplinary team meetings for colorectal cancer patients have commenced. The PH helped to lead, organise and co-ordinate meetings.

Discussion The PH undoubtedly functions outside the traditional role of nursing. She has the authority to accept patients onto her caseload, into the service, assess them autonomously, refer them on if necessary and discharge them. Non-participant observation and review of secondary data provided rich information, providing extra clarity on the impact that the role has on patient care. The PH’s positive influence on the patients observed was obvious. In one instance a patient was so pleased to see the PH and discuss her condition that initially the observer was not even noticed.

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The two most common themes of patient support and teaching/education were apparent from the observations. Teaching is recognized as an integral component of the CNS role (Martin 1999). Patients were continually supported physically and psychologically. Through innovations in the service (home visits and patient directed clinics) support is extended to the outpatient setting, which appears to be invaluable to patients. The PH’s health promotion activities in detecting bowel cancer cannot be underestimated; DH (2000) initiatives to reduce bowel cancer require such innovation in practice. Patient directed clinics and contact telephone numbers are fundamental aspects of the service provided. Early initiation of such activities highlights the proactive nature of the PH’s role. This proactivity within specialist roles is echoed in the literature (Broughton et al. 2004). Written information received by patients has been identified as an area in need of development by the PH and is further supported within contemporary literature (Persson et al. 2005). To maintain excellence and innovation, stoma care nurses need to be proactive in identifying areas where unmet needs remain (Breeze 1995). The innovative therapeutic activities introduced by the PH have ensured that patients’ previously unmet needs are addressed. This drive for CNS’s to be innovative to changes in health care has been recognised by Longley et al. (2004). Findings show that the PH has substantial clinical experience and formal education, beyond the minimum requirements. Such clinical expertise and formal education are reported to be facilitators to CNS role development (Bamford & Gibson 2000, Marsden 2000). In addition, the PH received support from a range of sources, which is crucial in those roles that are expanding the boundaries of practice. Support is available from an established network of colorectal nurse specialists. Glen and Waddington (1998) and Bamford and Gibson (1999b) recommended such support as being beneficial to facilitating the role. Although management was supportive of the PH, regular clinical supervision was not available. Martin (1999) notes that clinical supervision should be accessible to the CNS and actively encouraged within Trusts, given that they work autonomously, as this will help deflect stress, burnout and the development of unprofessional practices. Therefore, lack of ongoing formal clinical supervision has consequences for role and practice development and is an issue, which needs to be addressed. While the PH had recognized authority and accountability, it was ironic that she was unable to order investigations. Nonetheless, referral to other members of the multidisciplinary team, psychological assessment, admission and discharge of patients without referral to the medical team can be 1096

undertaken. For CNSs to have this level of authority and autonomy, but be unable to order investigations for patients, may be impeding their ability to be innovative and therapeutic. For example, having to request something as simple as a blood test through medical practitioners hinders the authority and autonomy of an expert practitioner. This contradicts sections of the UK NHS Plan (DH 1999), which outlined 10 key roles for nurses, including the ability to order diagnostic investigations. From the observation, there is little doubt that the medical consultants recognize the skills, knowledge, expertise and experience of the PH. With further training and support, Colorectal Nurse Specialists will be able to manage many areas of treatment currently the bailiwick of physicians (Anonymous 2003). Indeed according to the Association of Coloproctology of Great Britain (2005) nurses are increasingly providing essential support for colorectal diagnostic clinics.

Conclusion This study provides insight into the Stoma Coloproctology Nurse Specialist role and the findings indicate that she provides an invaluable service to the patient client group. Although these findings cannot be generalised beyond this case study it does highlight the contribution and benefits of specialist nursing care for patients and the opportunities for stoma care nursing. It is clear that the PH is functioning beyond the traditional role. Innovative activities have ensured the ongoing support of the patient group and of professional colleagues. Undoubtedly the PH is a role model. However, it appears the boundaries could be expanded further to enable further innovations in practice. The study provides an insight and direction to inform policy and management for stoma care in the development of clinical nurse specialist posts.

Contributions Study design: HMcK, SR, FH, MS & PB; data collection and analysis: UC, HMcK, SR, FH, MS & PB; manuscript preparation: UC, FH.

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Human resource/finance interview schedule

Line manager interview schedule 1 What are the aims and objectives of this post? 2 What led to the development of the post? 3 Has there been an infrastructure developed to provide support for this role? If yes how has this been established? 4 What was the induction procedure for this PH? 5 Do you feel the PH of this role is suitability supported? 6 Does or has the post raised any professional or organisational issues? 7 Can you provide an example of good practice arising from this post? 8 What do you feel has been the impact of this role on patient care?

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9 What has been the impact of this role on patient care in the Trust/Organisation? 10 Do you think the role has extended into that of another profession or that it is the expansion of an existing nursing or midwifery role? 11 Do you think the PH is effective in what he/she does? If yes, how do you know? 12 Do you think the PH is efficient in what he/she does? If yes, how do you know?

1 What are the aims and objectives of this post? 2 What led to the development of the post? 3 Has there been an infrastructure developed to provide support for these roles? If yes, how has this been established? 4 What are the induction procedures for new PHs? 5 What pay scale is this post on? What grade? 6 Do these roles provide value for money for the trust? If yes, how? If no, why not? 7 What has been the impact of this role on the work of the Trust/Organisation?

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd