Introduction

This paper is based on a qualitative study of the lecturer-practitioner (LP) role in Nuffield Hospitals, a large inde-pendent provider of health care. The company owns over30 hospitals, mainly in England, and each one functions ina semi-autonomous manner with its own matron and hos-pital manager. The LP role was seen as that of a seniornurse who had both a teaching and a practice role, and who

was credible in both fields. The company appointed fourLPs in 1995 as part of a strategy for the development ofnursing practice. Each was based in a separate hospital andit was envisaged that they would spend 80% of eachworking week in the practice setting and 20% in educa-tional activities. The company has its own nurse educationcentre which services all hospitals in the group and whichhas links with higher education. The LPs linked with thecompany’s nurse education centre with regard to educa-

Journal of Clinical Nursing 1998; 7: 251–256

© 1998 Blackwell Science Ltd 251

An evaluation of the lecturer-practitioner role inthe independent health care sector

PAULA McGEE BA, MA, Cert Ed, RGN, RNTNursing Research Fellow, Nursing Research Unit, University of Central England, RavensburyHouse, Westbourne Road, Edgbaston, Birmingham B15 3TP

Accepted for publication 29 January 1997

Summary

• This study examined the impact of the introduction of lecturer-practitioner(LP) roles in four Nuffield Hospitals over a period of two years. A series of inter-views was conducted with the practitioners themselves, the staff and the man-agers. LPs also maintained structured diaries.

• Nursing practice in the independent sector is influenced by a number of factors,including caring for patients in individual rooms and working directly with con-sultants because there are no junior medical staff. Nurses encountered patientswith very diverse problems, and accordingly needed help to maintain a wide pro-fessional knowledge base.

• Nursing staff benefited from the presence of an LP in terms of linking theory topractice, role modelling, obtaining career advice and introducing change. Non-nursing staff also benefited from the LPs’ adoption of an interdisciplinaryapproach to certain care situations.

• LPs were valued as a resource for staff and seen as important in enabling thecompany to maintain its image as a provider of high-quality care. The LP was alsowell placed to raise the profile of nursing in the independent sector throughresearch activities.

• LPs themselves benefited from their experiences and were able to develop theirown skills.

Keywords: lecturer-practitioners, nursing in the independent sector, professionaldevelopment.

tional activities. This paper focuses on the LPs’ impact onthe practice setting.

Literature review

The introduction of LPs has coincided with the recogni-tion of a gap between what is taught and what is practisedin nursing. This gap, it can be argued, has been increasedby the introduction of radical changes in both nurse educa-tion and nursing roles (McGee, in press). The complexityof the ward manager’s job and the isolation of nurse tutorsfrom clinical areas make it impossible for these nurses tobridge the divide between education and practice(Vaughan, 1989). The LP therefore has a vital role to playin maintaining standards of practice in a specific clinicalarea whilst at the same time contributing to the educationalexperiences of students (Vaughan, 1987). The LP is alsoideally placed to support staff through the different stagesof their careers and to help them meet the demands ofPREP (Woodrow, 1994a; UKCC, 1994).

Fulfilment of this role is dependent first of all on clinicalcredibility (Childs, 1995, Lloyd-Jones, 1993). A high level of clinical skill and a broad range of experience areessential if the LP is to provide leadership and enhance thevalue assigned to practice (Woodrow, 1994b). Academicqualifications are also necessary if the LP is to have status inthe educational arena. Facilitation of staff and education ofstudents require an understanding of teaching and learningprocesses and a high level of interpersonal skills (Jones,1994; Lathlean, 1995).

The literature suggests that the LP role can develop inseveral different ways. For example, the LP could be anexpert in management and practice but have responsibilityfor some aspects of education. Alternatively s/he could bean expert in education and practice whilst delegating man-agement tasks to someone else (Lathlean, 1995). No singlemodel of LP practice predominates, which in some ways isa strength in that each post holder is free to develop in away that both suits them and meets local needs (Fairbrother& Ford, 1996; Woodrow, 1994a). The main satisfactions ofthe role seem to lie in having the flexibility to set one’s ownpriorities, develop practice and foster development inothers: seeing them grow (Lathlean, 1995). However, thisfreedom can be too open-ended, creating confusion in linesof accountability (Woodrow, 1994b). In surveying 30 posts,Fairbrother & Ford (1996) found a lack of commonalitybetween them and also that, whilst there was talk about thebenefits of LP roles, ‘there is little evidence of firm criteriafor the success of the role’ (Fairbrother & Ford, 1996, p. 42). Without clear parameters, the size and demands ofthe job can be enormous, with the resulting stress affecting

personal life and well-being (Lathlean, 1995). Colleagues inthe practice setting may have little idea of what the LP doesin the education arena and vice versa, and consequently indi-viduals can end up feeling that they hold two separate posts(Fairbrother & Ford, 1996; Crane, 1989). Managers have anessential role to play in preventing these problems throughcarefully planning LP posts, acknowledging the differentcultures in which the LP is required to function and providing support (Fairbrother & Ford, 1996; Woodrow,1994b).

Lecturer-practitioner roles in the independentsector

Independent health care providers recognize the impor-tance of educating and developing their staff to meet thechanging needs of customers. A few have addressed this byappointing LPs. Fairbrother & Ford (1996), for example,identified LPs employed in many different settings includ-ing the independent sector. However, there does not appearto have been any systematic evaluation of LP roles in theindependent sector within the UK and this study may bethe first to attempt this.

Research methods

The aim of this research was to provide an evaluation of theLP role as it developed in Nuffield Hospitals over a periodof two years. Conducting such an evaluation was a complextask requiring more than one method of data collection andmore than one source of information (Denzin, 1989).

Every week, each LP completed a semistructured diaryand a record of her work activities. A series of in-depth,semistructured interviews was conducted with each of theLPs on a regular basis throughout the two years to recordtheir experiences of the role and plans for future activities.In addition, the LPs met as a group every six months todiscuss their work with each other and the researcher.

A series of semistructured interviews was conductedwith staff in each hospital. These included nursing staffworking alongside each LP as well as the hospital managerand matron. Nurses were asked for their views on the con-tribution of the LP role both to their hospital and to theirindividual practice. Hospital managers and matrons werealso asked about this but their interviews also focused onmanagement issues and cost.

THE LECTURER PRACTITIONERS

Each LP was appointed from a clinical post within the hos-pital and therefore had a strong background of involvement

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in direct care in that setting. She knew the staff, the rou-tines and the organizational culture. Two LPs were seniorsisters. This meant that, in addition to direct care, theywere also required to deputize for the matron. The thirdwas an experienced theatre sister who was also required todeputize for the theatre manager. The fourth LP was asister, working in a ward area.

All LPs had completed the ENB course in teaching andassessing in clinical practice, and two were graduates. Thetheatre sister was studying for a Master’s degree and theremaining LP was registered for a Bachelor’s degree at thestart of the project. However, she had to withdraw from thecourse because of pressure of work in the hospital.

WORKING IN THE INDEPENDENT SECTOR: THE

BACKGROUND

Early in the study, LPs and other participants expressedthe view that assessment of the impact of the role had to beseen within the context of nursing in a private hospital andthe ways in which this differed from working in the NHS.First of all, the work setting differed in that patients werenursed in individual rooms. This required the adaptation ofcertain nursing skills, such as observation, in order toensure that patients were monitored adequately. Also,patients’ expectations differed. For example, it was assertedthat they valued, and therefore expected, identifiable lead-ership as personified by the matron (Higgins & Wiles,1992).

In the independent sector, medical staff were consultantswho were senior and experienced practitioners. This alteredthe nature of the nurse-doctor relationship. Doctors weredescribed as having a rather protective attitude towardstheir private patients but also as being, especially in the caseof surgeons, rather remote from them. Anaesthetists werethought to be in the hospital more often and to have a differ-ent rapport with staff and patients.

In the NHS patients could be grouped together accord-ing to their diagnosis. Thus there would be a urology wardor a cardiology unit. In independent hospitals this did nothappen. Each patient was completely different. One roommight contain a patient undergoing eye surgery; in the nextmight be someone who required a hysterectomy. Thus thenurse had to become familiar with a range of specialities atthe same time, whereas in the NHS this would not be thecase. This variety was one of the factors that attracted staffto work in the private sector. These nurses resisted thenarrow idea of specialization that the NHS would imposeon them. However, four of the nurses argued that thevariety of the work did create an image problem for them as‘jacks of all trades’ who had very little expertise. The public

and the profession needed to be educated about the truenature of nursing in the private sector: ‘we’ve movedforward so quickly in quite a short number of years’(nurse).

The number of nursing staff in each hospital was quitesmall. In one, for example, there were 54.8 staff for theentire hospital of 46 beds, theatres and out-patients depart-ment. Each nurse tried to keep up to date but, because ofthe nature of the workload, staff needed regular updating ina range of different specialities. In addition, there was theneed to learn the treatment regimes of the many consul-tants who used the hospital. It took quite a long time tomaster all this diversity.

There was a flat management structure that offered littleopportunity for promotion. Ambitious staff were said tomove on fairly quickly, but it was not unusual to find peoplewho stayed for a very long time because they liked theworking conditions and the family atmosphere: ‘it’s morelike living in a village rather than living in a big town.You’ve got a good supportive team around you’ (nurse).These long-stayers, however, could make it difficult toimplement change because, according to matrons and man-agers, they became set in their ways.

CONDUCT OF THE PROJECT

The work was undertaken by the author who, althoughbased in a higher education setting, had worked closelywith staff in the company’s nurse education centre for anumber of years. The author therefore had some insightinto the nature of nursing in the independent health caresector but had remained, at the same time, an outsider. Theauthor made a series of visits to each hospital over a periodof two years and it was during these visits that interviewstook place. The interviews were tape recorded, transcribedand coded as a basis for the identification of themes (Cohen& Manion, 1995).

FINDINGS

Two themes are discussed here. The first is central to anyevaluation and raises the issue of who benefits from theinnovation being studied. Consequently, nurses were askedto identify ways in which they personally had benefitedfrom the LP role. All participants were asked what, in theiropinion, the hospital and the company gained. In addition,LPs identified ways in which they themselves benefitedfrom the LP role. In the second theme, each LP identifiedthe promotion of research-based practice as a key elementin her role and so data included examples of the ways inwhich this was addressed. This theme was considered to be

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of particular importance as very little is known aboutnursing research activities in the independent health caresector of the UK.

Theme 1: Benefits of the LP role

(a) Nurses

Three examples are presented here. Each helps to identifyand illustrate a particular aspect of the LP role in facilitat-ing the development of staff and demonstrating clinicalcredibility (Lloyd-Jones, 1993; Woodrow, 1994a).

Example 1. A staff nurse explained that the LP’s knowl-edge of theatre work had helped her to gain a better under-standing of the patient’s needs. The LP had helped her tounderstand not only the procedure of the operation butother factors, such as the position of the patient’s bodyduring surgery or the equipment used, which might have abearing on the post-operative period. Thus the LP wasinstrumental in bridging the theory-practice gap for thisnurse.

Example 2. A staff nurse had learned from observing theLP giving direct care. In her opinion, the LP always foundtime for patients who needed some extra attention or teach-ing and the nurse felt that she had ‘learned a lot from whatshe’s been telling them’. In this example the LP was actingas a role model.

Example 3. An enrolled nurse felt that the LP hadhelped her to explore the ways in which her career coulddevelop and the information she needed to pursue the paththat she found most interesting. The information itself wasalready easily available. It was the personalized element thatmattered. She felt as if she had been treated as an individ-ual and that her personal needs were attended to. As aresult of this intervention by the LP the enrolled nurse hadembarked on a course at the local university and she wasenjoying this. Thus the LP acted as advisor and demonstratedgood interpersonal skills in helping the nurse to feel valued.

(b) The hospitals

Two examples are presented here that demonstrate ways inwhich the influence of the LP pervaded the hospital as awhole.

Example 4. As the project unfolded it became apparentthat it was not only nursing staff who benefited from theLP’s presence. For example, one LP initiated an interdisci-plinary approach to improving the management of cardiacarrest using a series of simulations and debriefings. Thishad a significant and positive effect on response times in allaspects of the cardiac arrest procedure. The interdiscipli-

nary approach fostered relationships between staff in manydifferent parts of the hospital where previously contactbetween them had been minimal. It also enabled this par-ticular LP to explore the needs of different staff groupssuch as theatre nurses, out-patient staff and care assistants.As a result she began to initiate educational activities tar-geting these groups of staff. She introduced a NationalVocational Qualification level 2 programme for care assis-tants in order to provide some basic training. This waswarmly welcomed by the assistants, who saw it as an oppor-tunity to develop a better understanding of their jobs andbecome more aware of their limitations. One of these assis-tants had gone on to take an access course for entry tonursing. Thus the LP role need not be confined to nursing.The LP can provide leadership in a way that enables all staffto improve patient services.

Example 5. The hospital gained from the provision ofin-house education on several different levels. Two LPswere involved in formal classroom work teaching on thecompany’s Enrolled Nurse Conversion Course. These LPswere thus well placed to advise and tutor nurses undertak-ing the course both in their own hospitals and in others.These two LPs and a third provided teaching activities intheir own hospitals through a mixture of formal study daysand informal, one-to-one sessions. Topics ranged frominfection control, care planning and sociology to demon-strations of new equipment. The informality of much ofthis teaching meant that it took place during the 80% of thetime that was devoted to clinical practice and highlights thedifficulty in trying to separate clinical and teaching activi-ties. Over and over again, nurses stressed that it was theaccessibility of LPs in the workplace that enabled them toimprove their knowledge and skill in relation to whateverwas relevant at that time. Teaching was valued because itwas immediately related to patient care that the LP per-formed alongside the other staff.

The LPs were valuable to the staff and the hospitals asproviders of easily accessible, expert clinical advice and guid-ance, particularly with regard to the care of patients withcomplex/unusual needs. The LPs recognized and actedupon a range of educational opportunities, providing tutor-ial support and encouragement for staff including thoseundertaking courses both within and outside the company.Overall the LPs were a resource. They provided a focal pointfor nurses and nursing that would otherwise have beenmissing.

(c) The company

Identifying the benefits of the LP role to the company as awhole was more difficult, but one example is presented here.

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Example 6. The most obvious benefit of in-house educa-tion was that of cost reduction. According to managers, in-house education was cheaper than sending staff elsewhere.In fact, when one LP left, the cost of education immedi-ately rose. However, cost was not the only issue. Working inan independent hospital, staff had to continually adapttheir skills, develop a broad knowledge base and function ina different way with medical staff. LPs played a pivotal rolein facilitating the development of staff, enabling them toadapt and apply their knowledge and skill to the demandsof working in an independent hospital. Managers saw thisas an advantage to the hospital and the company in recruit-ing and retaining highly motivated nurses who would be ableto continue their professional development in the company.In addition the LP role itself could be a way of providingpromotion for suitable nurses.

(d) The LPs

The LPs themselves gained through the opportunities pre-sented within their individual hospitals. Each LP role wasdynamic and changing, and it evolved over time. The indi-vidual began, as a novice LP, in much the same way asBenner’s (1984) nurses, knowing the rules and the parame-ters within which she could function. Each was already anexperienced and proficient practitioner but the LP rolechallenged that security. Those who were able to acceptthat challenge developed both their own skills and those oftheir colleagues. By the end of the project these LPs werefunctioning in a manner similar to the specialist practition-ers described by McGee et al. (1996).

Theme 2: The promotion of research-based practice

All the LPs regarded research-based practice as an impor-tant element of their role and throughout the data collec-tion phase a number of different activities were identified.These were grouped and examined using the three levels ofresearch activity proposed by McGuire & Harwood (1989)for nurses who wish to be involved in research.

Level 1. This involves interpreting research findings,communicating them to others and making decisions aboutapplicability of the findings in practice. As an example ofthis level, all the LPs regularly read nursing journals andpassed information on to the staff. This included providinghard copies of articles that staff might otherwise find itdifficult to obtain.

Level 2. Involves applying research findings in practice,testing them out and noting the results. One LP usedresearch skills and data to initiate an interdisciplinaryapproach to improving the management of cardiac arrestresponse times through a series of simulations and

debriefings. This had a significant and positive effect on allaspects of the cardiac arrest procedure. The interdiscipli-nary approach fostered relationships between staff in manydifferent parts of the hospital where contact had previouslybeen minimal. It also enabled this LP to explore the needsof these different groups and to develop educational initia-tives that served their needs. Two other LPs demonstrateda similar ability to function at this level.

Level 3. Involves undertaking research projects eitheralone or as a member of a research team. One LP under-took a study to explore the introduction of clinical supervi-sion in her hospital. She used a single case study with onesupervisor and one supervisee. Results demonstrated thatclinical supervision was beneficial to both parties and indi-cated ways in which it could be applied on a wider scale.

Another LP explored theatre nursing in relation to theperioperative role and the opportunities this might createin the hospital. This work began as course work for ahigher degree programme but in time this factor becamealmost incidental, as the initial research raised unexpectedand positive possibilities. From this base the LP was able todevelop the pre-admission clinic, which became mandatoryfor patients undergoing fixed price surgery. A paper aboutthis work was presented by the LP at an international con-ference in Finland.

Discussion

Theme 1. It seems from this data that everyone involved,including the post holders themselves, benefited from theLP role. Four LPs involved themselves in practice in a waythat enabled them to facilitate staff development throughthe use of multiple strategies, such as role modelling andone-to-one teaching, in addition to more formal educa-tional work. There is evidence that this approach is used byother LPs (Guilfoyle, 1990), who regard themselves asresponsible for the clinical learning environment in whichthey work (McNally, 1994). Benefits to employing organi-zations do not appear to have been formally researched,although there is some support for the idea of LPs enhanc-ing staff retention (Fairbrother & Ford (1996). Jones (1994)also found that managers valued LPs because they stimu-lated the practice environment, improved the standard ofeducation and demonstrated links between theory andpractice. However, the benefits to organizations of employ-ing LPs require further investigation.

Theme 2. The research activities identified here are ofparticular significance, first of all because nursing in inde-pendent hospitals in the UK has a very poor record as far asresearch is concerned. Extensive literature searching forthis project provided a limited range of literature about this

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field of nursing and none of it was research-based. Nursesworking in this field have a responsibility to engage in pro-fessional discourse with their peers regarding the nature ofthose differences and to provide systematically collectedevidence to support their arguments.

Secondly, the company was changing to become amanaged care organization. Managed care is defined as apatient-focused, needs-driven, outcomes-based approachto care (Benton, 1995). It challenges professionals in everydiscipline to produce high-quality research and to supportthe development of packages of care (Guanowsky, 1995).Thus every aspect of clinical decision-making is placedunder scrutiny, with the intention of clarifying the effec-tiveness of specific interventions (Benton, 1995) and reduc-ing unnecessary variations in treatment and care (Hampton,1993). Professionals are required to justify their actions andsupport them with relevant research or face the increasedpossibility of litigation because a package of care has notbeen delivered as promised (Guanowsky, 1995). Researchactivities are therefore an integral part of a managed careorganization.

Conclusion

This study examined the development of LP roles in fourNuffield hospitals over a period of two years. During thattime each role developed in a unique way. Contributions tothe development of staff and of practice could be clearlytraced as the roles unfolded. It is anticipated that such roleswill definitely have a future in a managed care organizationwith a strong commitment to high-quality nursing care.

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