Pessimism for specialism

Picture this. It’s 1990. The UK’s Royal College of Anaesthetists is still a Faculty of the Royal College of Surgeons (RCS), not a stand-alone College. Hardly any acute hospitals in the NHS have an inpatient pain service – and certainly not in the private sector. There’s no structured approach to pain assessment, nor pain management. Intravenous patient-controlled analgesia is still a relatively new concept and if your patient has an epidural infusion, they’re taking up a Level 3 ICU bed.

Then things start to change. The Report of the Working Party on Pain after Surgery (RCS, 1990) is the turning point. Professor Kate Seers is the sole voice of nursing and there’s finally widespread recognition that we’re failing our postoperative patients. The revolution in specialist nursing, pain management and analgesia provision had begun.

The report recognised the need to introduce the concept of the Acute Pain Service with a nominated medical lead and the support of specialist nurses. Specialist nursing was evolving through the use of clinical audit (under the umbrella of the newly fashionable ‘Clinical Governance’), the development of research to underpin practice, and by learning from adverse events and education. This specialist role was supported by short courses and later, Master’s level qualifications in Pain Management. Early on in my journey to become a pain specialist, I was blessed to have informal mentors who have influenced and continue to influence my career. My aim is to ensure everyone has access to the same kind of invaluable support that I gained from this.

The introduction of the Nurse Consultant role by the Department of Health in 2000 allowed nurses with expertise to maintain patient contact but to have protected time for education and to lead research. But we are now at a crossroads in education and with the role. The number of specialist pain Master’s programmes has dwindled across the UK and if nurses wish to undertake this qualification, most need to self-fund. The necessary Non-Medical Prescribing and Advanced Physical Assessment Courses are in addition to the Master’s qualification in Pain. In contrast, NHS England is actively championing the generic 3-year Master’s in Advanced Practice. This is a fully funded apprenticeship model, which is increasingly attractive to employers and employees and includes prescribing and assessment modules. The downside is the lack of highly specialist pain content and a dilution of the clinical nurse specialist role with advanced knowledge and skills for a generic post holder. 

The RCN’s current work to develop and publish the nursing Professional Framework is needed now more than ever. The revised definition of nursing and the clarification of enhanced, advanced and consultant-level practice will support nursing. Because nurses, we have a problem. It’s not uncommon to see roles that historically have been nursing roles being advertised for non-nurses. When even the Chief Nursing Officer for England identified that non-nurses may hold a matron’s role in the Matron’s handbook, published in 2021, we know something is awry!

‘The handbook should be used by those working within the scope of the matron’s role. This includes nurses, midwives and allied health professionals.’ (The Matron’s Handbook p.5)

It’s up to each of us to champion nurses and nursing. We’re at constant threat of dilution of our safety critical role – maintaining patient safety through education, assessment and diagnosis, recognising early deterioration, assessing and treating adverse events and escalating if necessary. Don’t sit back and watch the value of the nurse specialist role diminish. This needs to be a collective movement.