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Role of Nurse Practitioners in Ambulatory Urogynaecological Care

Angie Rantell

Introduction

Ambulatory care is defined as ‘a personal healthcare consultation including diagnosis, observation, treatment, intervention, and rehabilitation services using advanced medical technology or procedures delivered on an outpatient basis (i.e. where the patient’s stay at the hospital or clinic, from the time of registration to discharge, occurs on a single calendar day).’ Many different specialties across healthcare settings provide ambulatory care services, and they represent the most significant contributors to increasing hospital expenditures to set‐up services whilst improving the performance of the healthcare system in most countries, including most developing countries. Ambulatory gynaecology services were first reported in the literature in 2005, and many healthcare organisations around the world are actively moving towards an ambulatory model of care because it has been found to be associated with reduced morbidity and cost savings.

In some health systems, urinary incontinence has traditionally been seen solely as a nursing problem. The evolution of the nursing role and the provision of ambulatory care has significantly improved care and available treatment options. The role of the nurse practitioner (NP) was first developed in the United Kingdom (UK) in the 1980s and they now play a fundamental clinical role in many specialties, especially continence.

This chapter aims to describe the role of the NP within an ambulatory urogynaecology setting. It will discuss the different facets of the NP role prior to suggesting examples of diagnostics and treatments that can be provided by an NP as well as reviewing the additional risk and governance structures that need to be in place for safe working.

Who is a Nurse Practitioner (NP)?

The traditional nursing role is similar throughout the world and generally involves patient observations, toileting, personal hygiene assistance, medication administration, wound care, post‐operative care, and specific tasks assigned to them by the doctors in charge of the patient’s care. In many countries, however, this role has evolved not only as a result of reduced working hours for doctors and increasing demands for health services, but also due to enhanced education for nurses. NPs not only provide advanced clinical care but are also involved in research, audit, education‐and‐policy development, and they have an organisational role, as part of management teams; they may also be responsible for budgets, purchasing, and finding suppliers.

From a clinical perspective NPs work autonomously, providing general and specialist health assessment, diagnostic investigations and treatment planning, as well as performing certain treatments. Many will be independent nurse prescribers. Ultimately, NPs in specialist practice are exercising higher levels of judgement, discretion, and decision‐making in clinical care. A significant part of the role is also in the education and counselling of patients regarding their condition, prognosis, and available treatments, in addition to being a patient advocate.

One of the expanding roles of all NPs has been in the performance of minor surgery. It was reported by Dunlop in 2010 that in several specialties, nurses have started to undertake minor surgical procedures to ease waiting‐list pressures and to increase capacity to enable training of more junior doctors in complex cases. This has included performing procedures such as flexible cystoscopy hysteroscopy, insertion of supra‐pubic catheters and intra‐detrusor injections of botulinum toxin A under local anaesthetic or mild sedation. With the advent of more surgical devices for incontinence that can be inserted under local anaesthetic this role may soon expand further. NPs have been shown to be as effective as junior doctors at many of these procedures. A Cochrane Review also explored the substitution of doctors with NPs and found similar patient health outcomes, at least in the short‐term, over the range of care investigated. Within a continence/urogynaecology setting, the role of the NP has been reported as essential for service development, to ensure integrated care and optimal continence care packages.

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