University Hospital of Wales, Cardiff

There is a long history in Cardiff of looking at alternative roles. The hospital was one of the first to have a surgical first assistant, as the introduction of laparoscopic surgery at the hospital in the early 1990s created a new demand for skilled assistance beyond the level of a scrub nurse. This role was the precursor for the surgical care practitioner roles featured here.

Staff also described how they have been exploring different ways to provide junior doctor cover for 15 years. Recruitment problems, the hospital-at-night system, and the changing medical landscape have all driven a need to examine different roles at the Cardiff and Vale Health Board. For example, a decision by the Wales Deanery to remove core trainees from cardiothoracic surgery had had implications not only for that specialty, but had also created a problem in terms of staffing the on-call rota, which had a particular impact at night. It led the hospital to look at introducing advanced nurse practitioners to fill these gaps.

Today there are 60 nurses working in extended roles in surgery at this hospital, including clinical nurse specialists and research nurses, as well as advanced nurse practitioners.

The models used within Cardiff have evolved over time. Specialist nurse practitioners were originally allocated to firms in general surgery, covering both elective and emergency work. While this model had many positives for consultants and patients, it was thought to have undermined exposure to learning opportunities for doctors in training. The model was revamped so that specialist nurse practitioners were used in the emergency stream only. ‘It is better because they are not overlapping with the firm structure,’ said one consultant.

Senior nurse managers at this site advocated ward-based teams as their favoured model. However, a key aspect of learning from Cardiff is that a number of models will need to coexist, depending on the needs of the service. For example, specialist nurse practitioners in the surgical assessment unit are assigned to the unit. Elsewhere in the hospital, advanced nurse practitioners are assigned to particular consultant teams. Variations in whether surgical care practitioners work along the patient pathway or only in theatre reflect the organic evolution of these roles.

This case study can be found on pages 39-40 of the Question of Balance report