The benefits of nurse-led pre-assessment: a nurse-led pre-assessment clinic in the cardiology day unit at Christchurch Hospital has proved to be an efficient use of resources, a satisfying experience for patients and a way for experienced nurses to extend their practice.

How can nurses extend their practice while retaining their essential nursing role? Nurse-led pre-assessment clinics are one such example. These clinics provide nurses with the opportunity to apply and integrate advanced health assessment skills into their everyday practice. Such a clinic was established in the cardiology day unit (CDU) at Christchurch Hospital in July 2003. This article describes the process of establishing the clinic and presents the findings of an evaluation by patients, medical and nursing staff, completed 12 months after the start of the clinic.

The CDU is a seven-bed unit attached to two procedures laboratories. It services the Canterbury area for cardiac investigations and treatment. The client population is inpatients from the cardiology wards and outpatient day cases from the waiting lists. Each week, about ten outpatients present for pre-admission, prior to procedures. The work culture is one of collaboration between nursing staff, technicians and consulting cardiologists. There are no house surgeons based in CDU. However house surgeons based on cardiology wards were rostered to perform the outpatient pre-admissions. The house surgeons' role included taking the medical history, physical examination, charting current medications and obtaining consent for the procedure. But there were difficulties: house surgeons were often delayed by the demands of their ward responsibilities; they were unfamiliar with the procedures; and they rotated to other areas every three months. The senior nurses in CDU were actively involved in the care of the patients during the procedures and have detailed knowledge about the procedures. They were already meeting the patient at pre-admission to gather baseline data. The motivation for the nurse- led clinic in CDU grew out of a perceived opportunity for nurses to improve the quality of the pre-admission service and to use their health assessment skills gained through health assessment courses.

Literature review

Research has demonstrated that education for registered nurses (RNs) about health assessment skills has a positive affect on their use of those skills in practice. (1,2,3,4) However, there is limited New Zealand literature regarding RNs' use of health assessment skills in everyday practice. Health assessment skills have only recently been required nationally as a core component of the undergraduate nursing curriculum. (5) In contrast, health assessment skills have been part of the undergraduate nursing curriculum at Christchurch Polytechnic Institute of Technology (CPIT) since 1987. (2) This led to a situation where student nurses were taught health assessment skills but did not see RNs using them in practice. (6)

Advanced health assessment skills are identified as an integral part of clinical nurse specialist and nurse practitioner roles. (7,8) As these roles develop, RNs are more likely to be using health assessment skills in their practice.

As nurses in these roles extend the boundaries of their practice, emphasis must be on the benefits to the patient and the essential nursing role. Nurses extending their practice should be "maxi nurses" rather than "mini doctors" (9)

Nursing needs to control how nursing practice is extended and to develop protocols and guidelines that protect nurses who extend their practice. (10) However, collaboration between nurses and doctors in planning extended nursing roles, and agreement on training, supervision and competency requirements may reduce the tension that can occur at the boundaries between nursing and medicine. (11)

A number of authors recommend nurses gain clinical experience in health assessment through clinical mentorship, which includes working alongside medical staff on ward rounds and clinics. (12,13,14)

Nurse-led pre-assessment clinics are an opportunity for nurses to use assessment skills in practice. The purpose of pre-admission assessment is to check that the patient's condition has not changed since the last assessment, screen for problems that may affect the planned procedure and to give pre-procedure information. (15) The benefits of nurse-led clinics include the provision of holistic care, reduced waiting times and increased patient satisfaction. (16)

These themes from the literature guided the proposal to establish a nurse-led pre-assessment clinic at the CDU.

Proposal developed

The proposal was to establish a clinic for patients undergoing electrophysiology/ablation (EPS/ABL) and permanent pacemaker insertion (PPI) procedures. The small number of patients--five per week, one patient per day--meant the clinic could be developed within the staffing levels in the CDU. A nurse-led clinic could provide continuity of care, and a quality pre-admission service, with a strong patient focus. There was also the potential to improve documentation, reduce waiting times and expand the role of the nurse, using the CDU nurses' advanced assessment skills.

A proposal was drafted and the benefits of the clinic to patients, nurses and doctors were described. There were no financial implications as the clinic could function on existing staff levels, provided the pre-admissions remained at one per day. There was no further expenditure for equipment or rooms at this time.

The clinical director and the clinical charge nurse of the CDU supported the proposal and an initial meeting was called with the nursing director medical services and the staff nurses of the CDU to explain the project. There was to be a three-month trial to establish the project. During that time, one nurse would conduct the pre-admissions. NZNO was contacted to confirm that the initiative would fall within acceptable boundaries of the nurses' employment agreement, provided the nurses agreed to take on the expanded role.

The final proposal was signed by the clinical director, nursing director medical services, clinical charge nurse, and the nurse preparing the proposal. A protocol to support the pre-admission procedure was drafted and circulated to interested parties, including quality assurance, infection control, consultant cardiologists and nurses in CDU. Amendments were made and the protocol was then submitted to the Hospital Standards Committee.

Preparation, roles and responsibilities

Based on the nursing literature, training and competency requirements were compiled. There was a prerequisite for the nurse to have a minimum of two years' experience in CDU and to have completed a health assessment course, preferably at masters level. Although the graduate health assessment course covered some of the same material learning at masters level is learner driven, with a greater degree of depth and experience. It includes learning alongside a clinical associate or mentor on ward rounds and at outpatient clinics. The emphasis at masters level is also on integrating assessment skills with decision making and critical thinking.

A written guideline for physical examination was drawn up and nurses agreed to "shadow" house surgeons as they performed pre-admissions. When the nurses were confident with their skills, they performed three pre-admissions under supervision using the protocol Two pre-admissions were supervised by house surgeons, the third by the clinical director.

The patient needed to agree to the nurse conducting the pre-admission. The nurse was to explain the new nursing role to the patient. Nursing tasks included:

* Reviewing patient notes and gathering baseline data such as vital signs, blood tests, ECG and arranging for other tests ordered by the consultant, eg echocardiograph or chest x-ray.

* Obtaining a medical history, including allergy status, pregnancy status in the case of patients of child-bearing age, and current medications, with attention to anticoagulant therapy and anti-arrhythmic therapy to ensure these had been discontinued prior to the procedure.

* Performing a physical examination of relevant body systems, such as cardiovascular, respiratory, abdominal and peripheral vascular systems and documenting findings.

* Explaining the procedure to the patient, with reference to discomfort, pain management, the recovery times and admission and fasting times.

* Allowing time for patient questions.

* Liaising with the consultant and informing him if there were abnormal physical findings. The consultant explained risks and benefits of the procedure, obtained written consent and charted medications.

Evaluation of the service was completed a year after its implementation.

Methodology

The patient sample comprised a total of 30 patients who presented for pre-admission over a two-month period. After pre-admission, the patients were invited by the nurse to take part in the survey. They were asked to complete the questionnaire after their procedure and to hand the completed form to ward staff when they were discharged. Patients were assured of confidentiality and told whether they completed the form or not would have no bearing on their care.

The questions covered four main areas: the waiting times for pre-admission (three questions), the quality of the relationship with the nurse (six questions), professional care and competence of physical examination by the nurse (three questions), and the appropriateness of the information given about the procedure (three questions).

For each of the 15 questions, the patients selected one of six responses ranging from strongly disagree (score=1) to strongly agree (score=5). Percentages noted relate to the numbers of responses.

A survey questionnaire was handed to the two EPS/ABL consultants and the senior registrar who conducted procedures. The questionnaire was also given to the five house surgeons who were rostered to conduct pre-admissions and eight CDU nurses, including the two nurses who had conducted the pre-admissions. Themes explored included how the clinic benefited/ negatively affected the CDU, the quality of pre-assessment documentation, the appropriateness of physical examination by the nurse, patient understanding of what to expect during the procedure, the (ever of training required for nurses to conduct pre-admission assessment, and any suggestions for improvements.

Findings from the survey

Nineteen of the patient surveys were returned, a response rate of 63 percent.

For all but one patient, the waiting time at pre-admission was ten minutes, which was shorter than their expectations. One person waited P0 minutes. All respondents were happy with the nurse-led pre-admission process.

Ninety per cent of patients "strongly agreed" that the nurse performing the examination was competent, with the remaining ten percent "agreeing". A very similar pattern of response was found for the six questions related to the nurse's relationship with the patient.

However, the pattern of response for the questions relating to information about the procedure, while still positive, was not as strong. Sixty-three percent of respondents "strongly agreed" that the information given accurately reflected theft experience and 27 percent "agreed".

A limitation of the survey was that it did not compare patients pre-admitted by doctors with those pre-admitted by nurses. Therefore there is no evidence to suggest nurse-led pre-admission is better or worse than pre-admission by medical staff.

The staff response rate was 100 percent. All staff supported the initiative and respondents stated pre-admission by nurses was a more efficient use of resources. Perceived benefits to patients were that they experienced fewer delays, they were better informed, and they had more time to ask questions. Pre-admission by the nurse enhanced rapport between patient and nurse and promoted continuity of care, especially when the pre-admission nurse also cared for the patient during the procedure.

In the three questions that asked staff to rate aspects of the examination and documentation conducted by the nurse, 94 percent rated them as either "good" or "very good", with the remainder rated as "average". There was unanimous support for the appropriateness of the service and all respondents believed completion of health assessment at post-graduate level was required. A concern was that the service was not supported by dedicated nursing hours, so that pre-admission by nurses was performed only when unit work loads and staffing allowed. The CDU nurses were concerned that the unit may be compromised by staff shortages, if all pre-admissions were performed by nurses.

Suggested improvements included training more staff in health assessment, so patients' experience could be enhanced by having the pre-admission nurse involved in their care during the procedure; to explore the potential to expand the service to angioplasty patients; and to extend nurse-led pre-admission to other areas within the hospital

Conclusion

Our experience with establishing the nurse-led pre-assessment clinic revealed that the nurse brings to the clinic a quality of caring, which includes forming a personal relationship based on an understanding of the patient's needs. The nurse/patient relationship is enhanced by the intimacy of the physical examination, which creates a climate for asking questions and articulating patient anxieties. Benefits to the patient include less waiting time and the provision of information about the procedure provided by nurses experienced with the procedure. The survey revealed high levels of patient satisfaction with the pre-admission service. All doctors and nurses supported the role. Our experience in Christchurch demonstrates that nurses' advanced assessment skills can be used to benefit patients.

References

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(2) Bullock, L., Peterson, P., Fox, B., & Bennett, C. (1996) New skirls advance practice. Kai Tiaki Nursing New Zealand; 2: 8, 13-15.

(3) Reaby, L. (1991) Use of physical assessment skills by Australian Nurses. International Nursing Review; 38: 6, 181-184.

(4) Wilson, M., & Lillibridge, J. (1995) Health assessment: A study of registered nurses' knowledge and skill level. Contemporary Nurse; 4; 3, 116-122

(5) KPMG Consulting. (2001) Strategic review of undergraduate nursing education. Wellington: Nursing Council of New Zealand.

(6) Milligan, K., & Neville, S. (2001). Health assessment and its relationship to nursing practice in New Zealand. Contemporary Nurse; 10: ], 7 11.

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(8) Nursing Council of New Zealand. (2001) Framework for post-registration nursing education. Wellington: Author.

(9) Castledine, G. (1995) Will the nurse practitioner be a mini doctor or a maxi nurse? British Journal of Nursing; 4: 16, 938 939.

(10) Carroll, L. (2004) Clinical skills for nurses in medical assessment units. Nursing Standard; 18: 42, 33-40.

(11) Dowling, S., Martin, R., Skidmore, P., & Doyal, L. (1996) Nurses taking on junior doctors' work: A confusion of accountability. British Medical Journal; 3120: 7040, 1211-1220.

(12) Loftus, L., & Weston, V. (2001) The development of nurse led clinics in cancer care. Journal of Clinical Nursing; 1: 10, 215-220.

(13) Murray, S. (1997) A nurse led clinic for patients with peripheral vascular disease. British Journal of Nursing; 6: 13, 726-736.

(14) Wadsworth, L., Smith, A., & Waterman, H. (2002) The nurse practitioner's role in day case pre-operative assessment. Nursing Standard; 16: 47, 41.

(15) Neasham, J. (1996) Nurse led pre-assessment clinics. British Journal of Theatre Nursing; 6: 8, 5-10.

(16) Nursing and Midwifery Council. (2002) Code of Professional Conduct. London: NMC.

Carmel Harris, RN, RM, is a senior staff nurse in the cardiology day unit at Christchurch Hospital.

Paul Watson, RN, BA, is a senior Lecturer in the School of Nursing, Christchurch Polytechnic Institute of Technology.