The advanced nursing role in urology is currently a popular topic, which was also discussed at EAUN22 in Amsterdam. There are different understandings, requirements and applicability with regard to the topic in various countries. Some commonality does exist, however. This is exemplified by the role of the Clinical Nurse Specialist (CNS), which is defined by the International Council of Nurses (ICN) in its ‘Nursing Care Curriculum Framework and Competences’: a nurse who has obtained an elevated level of education (WebMD, 2021) and possesses advanced expertise in a nursing field.
The European Specialist Nurses Organisation (ESNO) (2015) extends this and suggests that the area of practice also involves ‘clinical, educational, administrative, research and consultant roles’.
In the United Kingdom, the organisation Health Education England (HEE), which was established to support the delivery of excellent healthcare and health improvement through intelligent workforce planning, has commissioned the development of a Framework for Cancer CNS. It aims to help define the scope and responsibilities of the Cancer CNS work force (Sobrepera, et al 2021).
As the delivery of health care is a complex process involving multiple specialists with the aim to cure by adopting a holistic approach, in many clinical settings the Urology CNS is increasingly recognised as a key member of the specialist Multidisciplinary Team Meeting (sMDT) (Lam, et al., 2011). In literature some people argue that the role of the urology advance nurse practitioner is progressing in both pre and postoperative practice (Marley, 2021). However, it might equally be argued that the role of the perioperative nurse in urology is not well known.
Reflecting an extension of roles, a recent article by Pika et.al., published in 2021 in the British Journal of Nursing, has shed light on the emerging role of the registered nurse first assistant (RNFA). The RNFA is a non-medical practitioner who performs agreed surgical interventions during surgery and works in the perioperative setting (Pika, et al., 2021). The RNFA, also called Surgical Care Practitioner (SCP) in the UK, has a scope of practice extending over the perioperative care spectrum. It incorporates aspects of the roles of the perioperative nurse and medical practitioner (Quick and Hall, 2014). The SCPs perform one of the four roles under the Medical Associate Professional’s (MAP) (BMA, 2022).
Deliver safe and effective care
In the UK, the nursing professionals body (the Nursing and Midwifery Council (NMC)) requires nurses to be consistently educated according to a high standard, so that they are able to deliver safe and effective care (NMC, 2022). Reflecting a cross-professional approach, the Royal College of Surgeons of England (RCSNEng) took on the educational responsibility of establishing the Curriculum Framework and accrediting appropriate courses in 2014 (RCSEng, 2014). The framework clearly underlined the involvement of an SCP in surgical procedures and intra and perioperative care. It shows how non-medical professionals merge in the surgical team. The curriculum framework not only describes the role, but also the competences and the responsibilities of the specialty. In addition, it explains how doctors of any grade will gain benefit from these professionals (RCSEng, 2016). This is vital for further collaboration and understanding roles in teams, now and in the future.
“In the UK, the nursing professionals body (the Nursing and Midwifery Council (NMC)) requires nurses to be consistently educated according to a high standard, so that they are able to deliver safe and effective care.”
Unique dual role of the SCP/CNS for kidney cancer
In 2017, the Royal Free London NHS Foundation Trust (London (UK)), Specialist Centre for Kidney Cancer, has introduced the unique dual role of the SCP/CNS for kidney cancer. The role combines the specialised skills of the CNS working in the perioperative pathway for urological cancer and the intraoperative advance surgical practice of the SCP. This pioneering dual role sees the SCP/CNS involved with the entire cancer care. Key aspects of the role include: triage new referrals from General Practitioners (GPs) and referring centres, contribute to numerous sMDT, plan surgical activities and facilitate governance requirements. Furthermore, it includes practical planning to ensure patient’s safety and the provision of intraoperative bedside assistance.
Postoperatively, the SCP/CNS actively participates on the ward round and further contributes by performing advanced nursing activities (for example, administering intravesical chemotherapy) and by facilitating a safe and efficient discharge of the patient. As part of the CNS role, the SCP/CNS also leads a follow-up clinic for patients on active surveillance for kidney tumours.
It is increasingly imperative that those tasked with planning and providing care demonstrate value, worth and desired outcomes. Since the introduction of this role, the author’s clinical department has assessed its value from different perspectives in the urology department. These include patient experience, through the use of validated surveys, as well as exploring efficiency and productivity through the use of audits.
Extension of urology team
Thus far the results have painted a positive picture. The National Patient Experience Survey has demonstrated an average satisfaction of 9.4 (range 7-10), where ‘0’ is very poor and ‘10’ is very good. The department’s surgical workload and productivity have increased by 47% over the past five years. This has led to the extension of the urology team, with the plan to employ one more SCP/CNS, one more CNS and one consultant surgeon.
With the expansion of the team, further activities could be implemented, including a post-operative SCP/CNS follow-up clinic visit, which would take place within the first two weeks post-discharge. This would facilitate an early detection of surgical complications and could therefore reduce potential re-admissions to the emergency department.
Understood and appreciated
Professional reflection and the results above suggest that the implementation of this new role has enhanced continuity of care, as the patients have interacted with a familiar face (link person) throughout their surgical journey. The standard of care was upheld by the SCP/CNS who work with all the consultant surgeons and contribute to the coaching and education of trainees aiming to pursue the best health care practices and outcomes. There have been a few challenges and even some limitations in implementing this role. It took some time before the role was understood and appreciated by the extended surgical team, with initial clashes emerging on defining the boundaries of action; not an unexpected or undesirable thing.
The role is regulated by the available frameworks. The professional banding (a UK system to denote the employed role of a clinical staff member and the salary for that role) is also based on this, making advance practice erroneously seem more ‘expensive’ for several departments.
However, if the success of the urology department is measured by efficiency or the patient’s outcome, the SCP/CNS dual role is undoubtedly a profitable investment (Leary, 2022). Furthermore, the SCP/CNS is actively involved in multiple aspects of the patient’s cancer care, with multiple activities proceeding simultaneously. This means that the department requires a larger number of practitioners to guarantee appropriate cover and to satisfy clinical demands and requirements. The abundance of SCP/ CNS in the team creates a complex, but safe, structure that can contribute to covering staff absence for short periods of time, thanks to the team’s wide range of action, adaptability and knowledge.
Positive impact of dual role
Advance nursing practice is a dynamic process of constant evolution. This work constantly requires the nursing community to plan and regulate practice by the implementation of frameworks and by engaging with regulatory bodies. New roles are implemented only after having gained the full support of the extended team, that works toward the unanimous goal of delivering agreed high standards of care and measurable outcomes. The team is prepared to anticipate and deal with the constant change of funding and resources.
This article has sought to demonstrate that the dual role of the SCP/CNS has a positive impact on patient’s experience and outcome, productivity and efficiency. Its value has been recognised in the author’s healthcare delivery unit. However, the author also recognises that this is just the latest point in a long journey. Further changes are needed to regulate and bring more consensus to advance practice nursing. From a legal, payment/salary and professional recognition perspective, the introduction of specialised regulatory bodies and a dedicated educational urological framework may bring further advances.
The author’s experience within this pioneering, new role has been extremely positive and satisfying. She has been able to determine and meet the challenges that have led to an improvement in her role. The role is based on agreed educational pathways and gives autonomy to the advance urology nursing role. It also establishes a new career route, which is a balance between managerial and clinical work. This article wants to improve the awareness on the existence of the specialised role of the urology nurse. It aims to encourage the implementation of this job to support best clinical practice, work efficiency and reiterate the value of nurses in the healthcare sector.
I would like to thank Mr. Jerome Marley (Lecturer in Nursing, and Faculty Partnership Manager, Ulster University) for the help provided with the review of this article. I would furthermore like to thank the Renal and Urology Team at Royal Free London Hospital for the support demonstrated over the years with the implementation of this new role.
The reference list of this article is available from the EUT Editorial Office. Please send an e-mail to: firstname.lastname@example.org with reference to the article “The perioperative urology nurse from a UK perspective” by Ms. M. Marchetti, Aug/Sep. issue 2022.
By Ms. Marta Marchetti Surgical Care Practitioner/ CNS Kidney Cancer
Royal Free London NHS Foundation Trust London (GB)