Journal of Orthopaedic Nursing (2009) 13, 63–69

www.elsevier.com/joon

Journal ofOrthopaedic Nursing

The practical issues of establishing paediatricorthopaedic nurse led clinics and judging successthrough parent satisfaction

Julia Judd MSc, RSCN, RGN (Advanced Nurse Practitioner) *

Southampton General Hospital, Tremona Road, Southampton SO16 6YD, United Kingdom

Ed

Ad

ou

cl

sk

Pe

th

13do

KEYWORDSPaediatric;Nurse led clinics;Implementation;Parent satisfaction

itor’s comments

vancing nurse practitioner

tlines some of the pitfalls an

inic setting. It illustrates how

ills to improve their own per

rsonal experiences are very

e patient group.

61-3111/$ - see front mattei:10.1016/j.joon.2008.12.00

* Tel.: +44 23 8079 4991.E-mail address: julia.judd@

roles and

d proce

practit

formanc

helpful

r �c 2002

suht.sw

Summary This descriptive paper outlines the issues encountered when setting up anew nurse led clinic: identifying the driving forces behind the establishment of theclinic, personnel training needs, the requirement for robust protocols, supportmechanisms, practice pathway and problems encountered. The paper concludeswith results of a parent satisfaction survey.

�c 2008 Elsevier Ltd. All rights reserved.

clinic practice are two important and developing aspects of orthopaedic nursing. This paper

sses involved in challenging the boundaries of orthopaedic nursing in the paediatric orthopaedic

ioners are using enormous amounts of passion and enthusiasm as well extended knowledge and

e and the patient and family experience. In this respect this paper is useful to all practitioners.

to all who wish to make sure that their practice is relevant, current and meeting the needs of

JS

Introduction

In 1997 the nurse led clinic for the paediatric ortho-paedic service was established in Southampton, UK.This was at a time when nurse led clinics nationallywere fairly scarce in the UK. Changes in service deliv-ery were on the UK government agenda with recom-mendation that nurses could contribute to these

8 Elsevier Ltd. All rights rese

est.nhs.uk

changes through extension of practice (Departmentof Health (DoH), 1999), specifically through theintroduction of nurse led services (NHS Plan, 2000).A literature search offers a wealth of informationregarding individual condition specific nurse led clin-ics, highlighting their impact on service delivery andpatient satisfaction. Examples of these include astudy by Cox et al. (2006), which identified a poten-tial 20% clientele suitable for nurse led lung cancerfollow up, which was supported by patients, familiesand staff. Similarly Miles et al. (2003) found thatnurse led sexual health clinics were deemed to be

rved.

64 J. Judd

an ‘acceptable alternative to the existing doctor ledclinics’ through the results of a patient satisfactionsurvey. Likewise Hill (1997) found rheumatology pa-tients to be ‘highly satisfied with the care providedby the rheumatology nurse’. Of particular note wasthe perception that a longer consultation time affor-ded by the nurse may be an influence on the overallpatient satisfactionwith the nurse led service. Finan-cial benefits of nurse led clinics are reported: Uppalet al. in 2004 found that ENT nurse led services werenot only cost effective (a £75 saving per outpatientvisit compared to the patient being seen by amedicalpractitioner) but, also facilitated a reduction in out-patient waiting times, enabling the consultant to seemore complex patients. These papers represent justsome of the supportive literature demonstrating thesuccess of nurse led clinics. They were further pro-moted by the UK National Audit Office in 2001(DoH, 2001b), with recommendations for ways inwhich outpatient waiting times could be cut andthe ‘optimisation’ of outpatient department capac-ity could be achieved through their use,with an over-all improvement in health service delivery (Lipley,2001). Further investigation of the achievements ofnurses offering a nurse led clinic service, provideda discovery of personal experiences presented at lo-cal, national and international conferences. Theseaccounts coupled with the findings in the literaturegive guidance andmotivation for the advanced nursepractitioner (ANP) involved in delivering a new nurseled clinic service and reveal how success can be dem-onstrated through patient satisfaction surveys.

The aim of this paper is to consider the key activ-ities in establishing a nurse led clinic, identifyingthe actual practicalities of setting up and runninga clinic and to discuss effectiveness in terms ofthe results of a parent satisfaction survey. This isdone through discussion about the problems theANP’s encountered and the adaptations requiredduring the past 10 years in providing and maintain-ing an effective service to meet the needs of the cli-ent group. The discussion of the initial clinic set upaims to highlight some of the issues encountered, sothat pitfalls might be avoided by practitioners whenembarking on establishing a new nurse led clinic.

Background to implementation of a newnurse led clinic

Behind the development of the paediatric ortho-paedic nurse led clinic there were two principledrivers: to reduce the patient numbers attendingthe consultant clinics and in turn to expand the roleof the nurse practitioner, thereby addressing thechallenges set by the government to meet targets

and respond to new initiatives. Health care needsare continually evolving and changing (Page,2002) and in response, the boundaries of medicaland nursing intervention expand (DoH, 1999b) andin some areas merge. New role development andthe extension of existing roles have been witnessedin nursing (Cameron, 2000), shaped to meet aneeds led service and supported by the UKCC’s doc-ument, ‘The Scope of Professional Practice’(1992). Individual hospital Trusts were set the chal-lenge of complying with the European WorkingTime Directive (DoH, 2003) and responding to theCalman report (Calman, 1993) in reducing to re-duce junior doctor hours, whilst also achieving areduction in outpatient appointment waiting times(NHS Executive, 1997). Locally there was a need toincrease the capacity for patient review in the con-sultant clinics and to respond to government rec-ommendations. This resulted in a medically ledimpetus (Dearmun and Gordon, 1999) to expandand extend our role as nurse practitioners in estab-lishing a nurse led clinic for paediatric orthopaedicpatients. The government and professional bodiessuggest that nurses should be skilled in their spe-cialist area of practice (DoH, 1999, 2000, 2001a;NHS Plan, 2000) and the Royal College of PaediatricSurgeons (2000), further endorsed our aim to pro-vide a skilled and expert service for children with‘benign musculoskeletal cases’ (Cameron, 2000)in a nurse led service that offered a ‘completepackage of care’ (Hicks and Hennessy, 1999). Par-allel personal aims were to offer a shorter appoint-ment wait, a longer consultation time, supplypertinent patient information and educationregarding patient diagnosis, provide consistencyof contact and ultimate parental satisfaction (Lu-cas, 2002).

In 1997 ANP roles were in their infancy. Therewere few nurse specialists or practitioners in postnationally and in reality those nurses carrying thetitle ‘practitioner’ or ‘specialist’ were in very di-verse roles. There was little guidance on the struc-ture of these posts from professional bodies andthe literature that was available was new andemerging. Before embarking on setting up thenew clinic all pertinent information identifying is-sues around advanced nurse practice, establishingnurse led clinics, managing an independent work-load and how to identify appropriate patients wasgleaned from the available resources.

Nurse led clinics are developed for a number ofreasons. Nurses are urged to identify ways inwhich patient care can be reshaped (NHS Plan,2000) and subsequently to expand their roles,blurring the professional boundaries betweenmedicine and nursing (DoH, 1999b). The 10 key

The practical issues of establishing paediatric orthopaedic nurse led clinics 65

skills for nurses (DOH, 2002) gave nurses whowished to expand their roles the motive, approvaland guidance to do so. Furthermore the NationalService Framework (NSF) for Children Standardfor Hospital Services (2003), challenges paediatricnurses to deliver skilled, co-ordinated, inte-grated, holistic evidenced-based care whilst, col-laboratively working with families, giving themempowerment and choice about their child’scare. Flynn and Whitehead (2006) suggest ele-ments influencing the success of nurse led clinicsare patient satisfaction, the caring role of thenurse and the nurse practitioner as an expertand patient educator. These requisites need sup-port mechanisms; the most relevant being train-ing and education of clinical skills andknowledge (NHS Plan, 2000) and subsequentsupervision, which ultimately provide the back-bone to any new development. Whilst nurses arekeen and able to respond to health care reformsand offer continuity of an expert and holistic ser-vice (Breslin and Dennison, 2002), meeting mana-gerial targets and responding to growing healthcare reform necessitates education, support anda strong personal aim to improve serviceprovision.

Training and development

As nurse practitioners we were fairly new in postand although we had a wealth of experience as se-nior paediatric and orthopaedic nurses, taking thestep into the medical domain was taken with sometrepidation. Preparation prior to setting up the newclinic was paramount and entailed a review of sup-porting literature and a period of in–house training(Lucas, 2002). The latter replaced the absence ofspecific courses relating to nurse led clinic prac-tice. Through a 3 month orientation programmeworking alongside consultants and registrars, weachieved confidence in our knowledge of specificpaediatric orthopaedic conditions that would comewithin our clinical caseload and learnt the art andscience of medical history taking and orthopaedicclinical examination. This experience was sup-ported by an immense amount of reading, whichdue to the breadth of our speciality and the furtherdevelopment of our role and expertise, continuestoday. The gradual process of observation of prac-tice in the consultant clinics, supervised practice,case presentation and finally fully independentpractice allowed us to develop our knowledge andcompetence, with the knowledge that professionalsupport was available as a safety net.

To manage a nurse led clinic in paediatric ortho-paedics, proven competence in the followingessential skills and knowledge is recommended:

� Advanced musculoskeletal assessment.� Academic and working knowledge in the paedi-atric orthopaedic conditions which will bereviewed in nurse led clinic.� Academic and working knowledge of childdevelopment.� Consultation and medical history taking.� Diagnostic tests relevant to the specialist area.� Complex decision-making skills.� Complex communication skills.� Formulating a working diagnosis and proposingmedical diagnosis.� Case management.

Our training was complemented with an under-graduate academic course in Physical Assessmentand History Taking (University of Southampton),which enhanced our skills in the systematic physi-cal assessment of patients and in the art of formu-lating appropriate questions to achieve a relevanthistory of the problem from the parent and child.The course also provided the opportunity to furtherdevelop our knowledge base and the skill of form-ing differential diagnoses. More recently achievinga Masters’ degree in Advanced Clinical Practice(University of Southampton) has academicallyunderpinned our knowledge and skills and enabledus further develop professionally.

Patient identification

Prior to embarking on any new development it isimportant to establish whether there is a need. InSouthampton rerouting patients that fitted intocertain diagnostic categories could dramaticallyreduce the sheer numbers of patients seen in theconsultant clinics. The exact classification of pa-tients was predetermined by the orthopaedic con-sultants and included children presenting with‘simple’ orthopaedic conditions and those who re-quired post ward discharge follow up appoint-ments. Whilst some of these ‘simple’ conditionsare very worrying for the parent, many are normalvariants requiring little or no intervention (see Ta-ble 1), or conditions that involve a diagnosis orexclusion from other more serious problems, fol-lowed with minimal health professional involve-ment or treatment. Our role was to correctlydiagnose the child’s problem, exclude the possibil-ity of a neuromuscular or developmental disorder,treat, refer or discharge appropriately and to ex-

Table 1 Examples of musculoskeletal conditionsreviewed in the paediatric orthopaedic nurse ledclinic.

Gait concernGenu varumGenu valgumPes planusIntoeing gait:

– Femoral anteversion– Tibial torsion– Metatarsus adductus

Other non-specific gait/development concernsOtherAsymmetric thigh/buttock creasesCurly/overriding toesSimple syndactylTip toe walkersIdiopathic pains of childhoodNon-specific hip pain

Ward patientsTransient synovitis of the hipWound reviews

66 J. Judd

plain the diagnosis and reassure the parents. Asummarised list of some of the conditions referredto the ANP clinic is included in Table 1.

The process of referral is from the general prac-titioner (GP) to the consultant. These referral let-ters are triaged and dependent on whether theinformation provided meets the criteria for ANP re-view, the patient is allocated to the nurse ledclinic. Support mechanisms are invaluable to thenew ANP, to enable seeking of advice should a con-sultation with a child and parent prove to be be-yond the ANP’s scope of practice. Initially in theearly years, a consultant clinic ran nearby at thesame time as ours, although more recently, advicehad been available by phone.

Setting the standard

The NHS Plan (2004) set out the strategy for staff towork to agreed protocols for treating common con-ditions. Together with patient identification to fitthe criteria for ANP review, there was a need for ro-bust protocols to support us in our independentpractice. Protocols covering the expected patientpresentations and diagnoses were written as an Ex-tended Scope of Practice document and includedradiographic images, clinical investigations andorthotic prescriptions. These were agreed by theconsultants and validated by the hospital’s clinicalgovernance committee. Protocols are a means ofassisting and directing the nurse in clinical deci-sion-making. They can be valuable tools, forming

the basis of clinical governance for nurse led clinics,devolving the accountability for the safe delivery ofthe services to the practitioner, but giving protec-tion to the Trust hospital, the patient and practi-tioner (DoH, 1998). However, they involve a rigidpathway for assessment and patient management,and their inflexibility allows little or no change indirection (Plain Healthcare Clinical Decision sup-port, 2007). They can therefore be misleading andpotentially detrimental to the individual patientespecially if totally relied upon and if the child’spresenting problem does not completely fit the pro-tocol. Within our practice it was acknowledged thatcompetence in processing information, exercisingprofessional judgment and diagnostic skills were anecessary requirement, but also that we neededto possess the expertise to override these decisionsupport tools when appropriate. Deviation fromprotocols must be recorded and investigated appro-priately, as it may be that the protocol requiresreviewing. The ANP must be sure not to fall intothe trap of fitting the patient to the protocol. Forexample, children are referred by the general prac-titioner with a brief description of their problem.After recording a thorough history and undertakinga clinical examination, the ANP uses her knowledgeand skills combined with aides to clinical decision-making such as pattern recognition and hypotheti-co-deductive reasoning (Buckingham and Adams,2000) to determine a diagnosis. Sometimes how-ever, it is not possible to place the collective indi-cators into a protocol that states it is for themanagement of a certain condition. It is thereforedown to the expertise of the ANP to recognise andacknowledge this and to determine a plan of action.In these circumstances protocols can be unhelpfulespecially if the ANP fails to realise the problemand concede her limitations. Referral letters aretriaged by the ANP and patients are allocated tothe nurse led clinic based on the information pro-vided by the GP. Experience of this process hasdemonstrated that the consultation does not alwaysconcur with the information regarding the child’spresenting complaint. This can mean that a childwith a supposedly simple orthopaedic problem ful-filling the patient criteria for allocation to the nurseled clinic, on further investigation should have beenseen in the consultant clinic.

Implementation

The new nurse led clinic was implemented on anagreed day and time, following the completion ofour training programme. A clinic letter was devisedso that parents were made aware that they would

Table 2 Consultation pathway.

Pathway – the advanced nurse practitioner questionsthe parent and child on:� The history of the presenting problem� The child’s relevant past history and anyassociated conditions� Relevant family medical history and treatment outcomes

(Social and drug history are usually excluded from themedical history, unless perceived relevant to thepresentation)� Clinical examination of pertinent area of the bodyand associated areas (e.g. asymmetric thigh creases– the back as well as legs and hips are examined)� Observe walking if appropriate� Order investigations� Formulate diagnosis (interpret results of X-ray)� Discuss diagnosis and X-ray results with parents� Plan– Treatment e.g. physiotherapy– Either further ANP review, discharge, refer to consultant– Information leaflet

� Check investigation results at later date and actionaccordingly

The practical issues of establishing paediatric orthopaedic nurse led clinics 67

be seeing an ANP. The clinic template allocated15 min for each patient consultation, since themajority were new referrals. The total number ofpatients to be seen during a clinic session was 10.Support was sought from the radiology departmentin performing investigative radiographs and frommedical secretaries for the typing of the consulta-tion letters to the GP’s.

The GP letter is checked for reference for cor-rect referral and a routine medical format for his-tory taking and examination (see Table 2) isfollowed by the ANP. Medical support was accessi-ble during the time the clinic was running andalthough not always in the same vicinity, advicewas alternatively available by the telephone.

Problems encountered

All new projects experience teething problems.Inexperience led us to learn things through trialand error. Initially children reviewed by the ANPwere placed under the overall care of one of fourpaediatric orthopaedic consultants. This mademanagement of patient problems difficult whentrying to find time to meet with an individual con-sultant to discuss a concern. Today all GP lettersare generic and my colleague and I discuss our con-cerns with the designated lead paediatric ortho-paedic consultant during a convenient time. Oneof the main problems became a fairly major issuewith the allocation of a clinic room which lackedappropriate space to observe a child walking. As

the majority of patients presented with a gait con-cern, observation of walking was required as partof most of the clinical examinations and to do thiswhilst protecting the older child’s dignity proveddifficult. Resources were limited; the room lackedan X-ray viewer and even the relevant orthopaedicpaperwork such as referral forms to the orthotist orphysiotherapist. The paediatric orthopaedic nurseled clinic in Southampton was unique, in terms ofbeing both ‘nurse led’ and in the patient speciality.This led to an obvious and acute unawareness ofstaff in the outpatient department of the needsof such a service.

We were perhaps naı̈ve in our expectations,believing necessary resources would be arrangedand occur automatically as for any consultantclinic. Unfortunately we were proved wrong andexperienced difficulties such as staff support forthe running of our clinic and insufficient secretarialsupport for typing our consultation letters. Allinvestigations prescribed by us e.g. blood testsand X-rays were covered in an agreed protocol be-tween pathology, radiography and the consultants.As the prescribing practitioner it was our duty andresponsibility to follow up test results, althoughthis simple procedure proved difficult without ac-cess to a computer. This situation was remedied ur-gently and once acquired we undertook thenecessary information technology training to learnthe retrieval of results using various computer sys-tems. Today the nurse led clinic is smooth, fast,efficient and properly supported in terms of staffand resources. To achieve this we remained deter-mined in our efforts to prove that the clinic was asvaluable to the children and their families as to theTrust.

Evaluation

Evaluation of a new service is key to judging its suc-cess. Two years after the implementation of thenurse led clinic a retrospective audit was under-taken to measure parental satisfaction. Workingwith the clinical effectiveness team the ANP for-mulated the questions to identify best practicesand the deficiencies of the service from a parentalperspective. One hundred questionnaires were sentto the most recent attendees, with this data beingsourced from nurse practitioner records of patientsfor whom investigations had been prescribed. In2005 the audit was repeated to allow comparison.Both audits sought to retrieve informationspecifically about the parent’s experience andtheir satisfaction with a nurse led as opposed to amedically driven service. The administrative and

Table 3 Best aspects of nurse led service 2000 and2005.

� Friendly� Efficient, thorough, competent, professional and politeservice� Communicated well with children� Listened and gave understandable explanations� Not frightening� Unrushed and informal� Short appointment waiting time

Table 4 Worst aspects of nurse led service 2000 and2005.

� Waiting to be seen� Waiting in X-ray department� Didn’t know seeing an ANP – but didn’t mind!

68 J. Judd

environment problems such as secretarial supportand room size were addressed as they arose and re-solved promptly.

The results shown in Fig. 1 of both audits arevery similar, indicating that in both audits parentsunderstood the diagnosis explained by the ANP,that they were given sufficient time and that theANP had explained the problem and plan in detail.In 2000, 78% of parents were unaware they wereattending a nurse led clinic with little improvementin this number in 2005 (68%). This is despite theclinic letter stating that the clinic is nurse led. Toaddress this, the clinic letter has been re-format-ted to highlight the words ‘nurse led’. Encourag-ingly, of all those unaware that they would beseeing an ANP few had concerns about the consul-tation being with a nurse (Fig. 2). Finally, the auditquestioned parents on what they felt were the bestand the worst aspects of the nurse led clinic (shownin Tables 3 and 4).

0%Understood Time Explanation

2005

Diagnosis Understood

Sufficient time

Explanation & Treatment

2000

2005

Figure 1 Parental response to understanding of diag-nosis, sufficient allocated time for appointment andsatisfaction of ANP’s detailed explanation.

2000

2005

Unaware seeing an ANP

No concerns

Figure 2 Parents unaware they were attending a nurseled clinic, but few had concerns when realised.

Flynn and Whitehead (2006) cited a number offactors as being probable influences on the successof nurse led clinics; shorter appointment wait alonger consultation time, the supply of pertinentinformation and consistency of contact. The auditsshowed that these contributing factors of successwhich were also personal aims had mostly beenmet:

The majority of children (72% in 2000 and 76% in2005) received an appointment within 6 weeks, asignificant reduction on the normal 13 week waitfor a consultant appointment. 100% in 2000 and95% in 2005 felt that an appropriate length of timehad been allowed for the consultation and in bothaudits 90% of parents stated they were given rele-vant information regarding their child’s condition.The target of ensuring consistency of contact how-ever, was not measured. This is partly due to thefact that many children are discharged after firstreview (48% in 2000 and 60% in 2005) by the ANPand therefore not requiring a second appointmentto demonstrate consistency of contact. Meanwhileothers may be referred to other health profession-als such as the physiotherapist or for a consultantopinion.

Conclusion

This paper has given an overview of the problemsencountered when endeavouring to establish anew service. In addition the ANP’s setting up thisinnovative clinic were fairly new in post themselvesand perhaps naı̈ve in their expectations. Generallymany of the problematic issues were trivial and eas-ily remedied; though at the time they gave an added

The practical issues of establishing paediatric orthopaedic nurse led clinics 69

stress factor to overcome. Whilst the two auditsidentified parental satisfaction with the nurse ledservice, the specific expertise of the ANP was notevaluated. A separate audit looking at the ANP’s re-sults of correct diagnosis and prescribed patientmanagement has since been completed.

Today the nurse led clinic for children with be-nign musculoskeletal problems continues to flour-ish and expansion of the service is expanding toinclude more diagnoses and review of ‘innocent’patient conditions. One of these is the diagnosisand management of paediatric anterior knee pain.In addition there are discussions surrounding thepossibility of taking the clinic to district generalhospitals within the Wessex region of the UK,establishing a ’Hub and Spoke’ service as outlinedin the recent ‘Blue Book’ for Children’s Orthopae-dics and Fracture Care (British Orthopaedic Associ-ation, 2006).

References

Breslin, E., Dennison, J., 2002. The development of telephonetriage: historical, professional and personal perspectives.Journal of Orthopaedic Nursing 6 (4), 191–197.

British Orthopaedic Association, 2006. Children’s Orthopaedicand Fracture Care. Online: 13th May 2007. <http://www.boa.ac.uk/site/showpublications>.

Buckingham, C.D., Adams, A., 2000. Classifying clinical decision-making: interpreting nursing intuition, heuristics and medicaldiagnosis. Journal of Advanced Nursing.

Calman, K., 1993. Hospital Doctors Training for the Future. TheReport of the Working Group on Specialist Medical Training,Department of Health, London.

Cameron, A., 2000. New role developments in context. In:Humphris, D., Masterson, A. (Eds.), Developing New ClinicalRoles. A Guide for Health Professionals. Churchill Living-stone, London.

Cox, K., Wilson, E., Heath, L., Collier, J., Jones, L., Johnston,I., 2006. Preferences for follow-up after treatment for lungcancer: assessing the nurse-led option. Cancer Nursing 29 (3),176–187.

Dearmun, A.K., Gordon, K., 1999. The nurse practitioner inchildren’s ambulatory care. Paediatric Nursing. 11 (1), 18–21.

Department of Health, 1998. A First Class Service: Quality in theNew NHS. Department of Health, London.

Department of Health, 1999a. Making a Difference-Strengthen-ing Education and Training. HMSO, London.

Department of Health, 1999b. Modernising Health and SocialServices. Department of Health, London.

Department of Health, 2001a. The Report of the Public Inquiryinto Children’s Heart Surgery at the Bristol Royal Infirmary.The Stationary Office, London.

Department of Health, 2001b. Inpatient and Outpatient Waitingin the NHS. The Stationary Office, London.

Department of Health, 2002. Chief Nursing Officer. PL CNO:Implementing the NHS Plan – Ten key roles nurses. TheStationary office. London.

Department of Health, 2003a. European Working Time Directive.Department of Health, London.

Department of Health, 2003b. National Service Framework forChildren, Standard for Hospital Services. Department ofHealth, London.

Department of Health, 2004. The NHS Plan: A Plan for Invest-ment a Plan for Reform. Department of Health, London.

Flynn, S., Whitehead, E., 2006. An exploration of issues relatedto nurse led clinics. Journal of Orthopaedic Nursing 10 (2),86–94.

Hicks, C., Hennessy, D., 1999. A task-based approach to definingthe role of the nurse practitioner: the views of UK acute andprimary sector nurses. Journal of Advanced Nursing 29 (3),666–673.

Hill, J., 1997. Patient satisfaction in a nurse-led rheumatologyclinic. Journal of Advanced Nursing 25 (2), 347–354.

Lipley, N., 2001. NAO backs nurse led clinics to ease outpatientwaiting. Nursing Standard 15 (46), 6–7.

Lucas, B., 2002. Developing the role of the nurse in theorthopaedic outpatient and preadmission assessment setting.JON 6, 153–160.

Miles, K., Penny, N., Power, R., Mercey, D., 2003. Comparingdoctor- and nurse-led care in a sexual health clinic: patientsatisfaction questionnaire. Journal of Advanced Nursing 42(1), 64–72.

NHS Executive, 1997. (BN NO:29/97) Improving NHS waiting listsand waiting times.

NHS Plan, 2000. A Plan for Investment, A Plan for Reform, TheStationery Office, London.

Page, S., 2002. The role of development in modernising the NHS.Nursing Times 98 (11), 34–36.

Plain Healthcare Clinical Decision support, 2007. Online 5th May2007. <http://www.plain.co.uk/index2.php?page=algovsgls.htm>.

Royal College of Surgeons, 2000. Children’s Surgery – A FirstClass Service. Report of the Paediatric Forum of the RoyalCollege of Surgeons of England.

United Kingdom Central Council for Nursing, Midwifery andHealth Visiting, 1992. Scope of Professional Practice. UKCC,London.

University of Southampton, 2008a. School of Health Sciences.History taking and physical assessment. Introduction to/foundations in. Available Online 10th November, 2008.<www.southampton.ac.uk/healthsciences/study/modules/level2and3>.

University of Southampton, 2008b. School of Health Sciences.MSc Advanced Clinical Practice Level 4 masters. AvailableOnline 10th November, 2008. <www.southampton.ac.uk/healthsciences/study/postgraduate/adv_clin_prac/>.

Available online at www.sciencedirect.com