Non-medical practitioners' roles in out-of-hours care

ABSTRACT: Davies, B. (2007) Non-medical practitioners' roles in out-of-hours care. www.nursingtimes.net

A retrospective review has been undertaken mapping patients' presenting complaints to the NHS Education for Scotland (NES) competency framework for out-of-hours (OOH) practitioners within the Clyde division of Greater Glasgow and Clyde Health Board. An initial pilot study carried out in January 2007 analysed 153 presentations. Mapping indicated that approximately 81% of patients presenting to the Clyde OOH service could have been managed by a non-medical practitioner (NMP). These findings were contrary to anecdotal evidence that hypothesised that only 40% of presentations could have been seen by non-medical practitioners. In order to validate the pilot results, a retrospective analysis of periods in 2006 was undertaken reviewing a total of 8,466 presentations. The results supported the findings from the pilot and provided statistical confidence that 88-93% of presentations could potentially be seen by NMPs.

Introduction

Unscheduled care is defined by the Scottish Executive Health Department, (2005) as care that cannot reasonably be foreseen or planned in advance, or is unavoidably outside core working hours. As such demand can occur at any time, services to meet that demand must be available 24 hours a day.

Unscheduled practice is a rapidly evolving concept in Scotland, fuelled by government policy and a need to advance nursing practice, which means the boundaries between medicine and nursing are being further eroded. In contemporary healthcare organisations, the dynamic nature of the boundary between the two professional groups is becoming more evident and appears to be intensifying as a result of patient expectations, developing medical technologies and value-for-money policies. These policy and economic drivers are leading to role diversification and changes in skill mix (Tye and Ross, 2000). However, nurses within the OOH service are not taking over or replacing doctors' roles, they are developing roles in line with training and acquired skills and defined competencies (NES, 2004).

New arrangements for the provision of unscheduled care, the demands on the service around compliance with the European Working Time Directive, and new training schemes for medical staff have provided opportunities to develop innovative approaches to care delivery. One of the most significant changes has been in the provision of OOH care, with the establishment of new models of unscheduled practice. The shift towards multidisciplinary and interagency working has involved practitioners including nurses, midwives, paramedics, pharmacists and allied health professionals (AHPs) in new and challenging roles, and has encouraged support staff to use the full range of their talents.

The new and developing role of the unscheduled care practitioner incorporates both clinical and organisational elements, with the specific mix varying depending on the individual practitioner's area of practice. There is substantial anecdotal evidence on this developing role, much of it undocumented. For example, it is assumed that approximately 40% of presentations in unscheduled care can be managed by non-medical practitioners, that is nurses and AHPs, but there is no documented evidence to support this hypothesis. The management team and clinical director of the local OOH service therefore undertook a pilot study with a view to developing the future service provision within Clyde Primary Care Emergency Service (PCES).

Literature review

Within the OOH service the question has been raised as to what presentations could be seen and managed by non-medical practitioners. To explore this question a literature search was undertaken primarily through CINAHL, British Nursing Index and EMBASE, using the keywords 'out-of-hours practitioners', 'unscheduled practice', 'nurse practitioners', 'out-of-hours presentations' and 'emergency care'. Very few relevant texts were identified despite a wealth of anecdotal remarks and evidence on unscheduled care. This relative lack of published evidence on the contribution of nurse and AHPs in OOH care and unscheduled practice is surprising.

The nurse practitioner role has emerged in the UK within the past two decades. Read et al (1992)stated that only 6% of A&E units within the UK used nurse practitioners. Since their emergence in the UK, nurse practitioners have formally managed patients with minor injuries across a wide and varied setting including small community minor injury units and casualty departments, as well as in larger A&E departments (Cooper et al, 2001; Tye at el, 1998).

More recently physiotherapists and paramedic practitioners have been managing patients with minor injuries and certain minor illnesses (Stark, 2004). In surveys undertaken in 1998 and 2001, the number of A&E departments and minor injury units using nurse practitioners was recorded (47% in 1998 and 63% in 2001). These surveys found considerable diversity in the educational preparation for the role and their clinical scope of practice. Currently in the UK, there are no nationally agreed educational or practice standards or even a firm definition for nurse practitioner practice, despite numerous requests (Walsh and Crumbie, 2003).

Across the UK nurses have 'unofficially' treated patients in many smaller A&E departments for many years, using their clinical judgment about whether to consult a doctor, send the patient to a major A&E department or treat the patient (within locally agreed guidelines). Therefore, in essence, they are functioning as nurse practitioners (Read and George, 1994; Jones et al, 1986). In 1986, the first officially recognised nurse-led minor injuries service was introduced at OldchurchHospital, Essex (Morris et al, 1989). Three different formal nurse practitioner schemes in emergency care began in Scotland eight years later, with one of the first being a nurse-led minor injuries clinic at the Western General in Edinburgh (Stark, 2004).

Development of OOH practitioner services has been largely influenced by the changes in the provision of primary medical services, unscheduled practice and OOH arrangements (SEHD, 2005). A document on mapping and supporting new roles for practitioners in unscheduled care (NES, 2004) has identified the importance of educational provision for these emerging practitioners. Higher education institutions across Scotland have developed and validated academic modules to meet the core skills required for the new breed of practitioner. To this end NES has developed an educational framework for higher education institutions, outlining the standards for curricula, student assessment and accreditation. Presently a national pilot is in place, auditing the mentorship and assessment processes that exist for student practitioners, in addition to an educational audit mapping practice placements in unscheduled care to previously defined standard statements.

In 2003, NES published a competency framework for nurse practitioners working in unscheduled care (NES, 2003). This suggested there were two distinct levels of practice, which it termed 'option 1' and 'option 2'.At an NES-sponsored event it was identified and accepted that practitioners working within unscheduled practice will work across a specific range of developmental stages that are different to those listed in the original document in 2003. Subsequently, a competency framework has been developed based on a three-tier system, facilitating a clinical and educational progression through the levels of practice:

• Level 1 - practitioner working under supervision;
• Level 2 - practitioner working with decision-making support (local or telemedicine);
• Level 3 - practitioner working autonomously (NES, 2005; 2004).

The competency framework developed for use within Clyde has been based primarily on the clinical competencies of the academic modules within the University of Paisley. It is generally accepted that patients within unscheduled practice commonly complain of symptoms that can be categorised into one of seven presentations. These are chest pain, abdominal pain, shortness of breath, minor illness, minor injury, skin and rashes and mental health. The competency document is currently being ratified by both NHS Greater Glasgow and Clyde (Clyde Division) and NHS Highland.

Aims

Table 2. Presentation results by week

The results from the main study initially showed a mean average of 72.7% of presentations could potentially be wholly managed by non-medical practitioners; this is markedly less than the anticipated 81% suggested by the pilot study. However, following statistical analysis of the results by QIS, the point estimate of how many presentations could potentially be managed by non-medical practitioners was calculated as 90.5%, when calculated by cluster sample ratio or by unweighted average of cluster means.

Using a standard error based on the unweighted average, a 95% confidence interval is given that 88-93% of calls can be potentially managed by non-medical practitioners. This proves the hypothesis created by the pilot study. The pilot and the main study show similarity in results. The implications of this may have a potential impact on service design, development, workforce planning and budget allocation.

Discussion

It must be stressed that the mapping process and allocation of competency categories was undertaken by an experienced clinical practitioner. The primary researcher and collator is a specialist practitioner with over five years' clinical practice experience as a nurse practitioner, practice educator and lecturer practitioner, whereas the nursing staff within the service are presently student practitioners at the university. Allowance must therefore be made for practitioners working across the full range of practice, building confidence, exposure, competence and experience of the different presentations seen in unscheduled care. The findings must, therefore, be read as potential figures based on the continued and evolving experience and competence of practitioners within the OOH service.

Mapping presentations against the levels of practice and competency framework is presently ongoing but difficult to differentiate. As identified within the literature, practitioners themselves decide which presentations they are competent to manage, to which level they will practise and may, therefore, work across the various levels of practice for a number of presentations. However, it is proposed that over time and as competence and confidence improve, practitioners will practise at level 3 for the majority of presentations. Presently, the nursing staff within the OOH service are student practitioners, so it would appear prudent to suggest that they continue to work as level 2 practitioners until they reach a level of confidence and competence in which they start to evolve their own practice and service design.

It has been demonstrated from both the pilot and main study that non-medical practitioners working within unscheduled care, and the OOH service specifically, have the potential to manage the majority of presenting complaints. This is disputed by some senior medical staff, who continue to reaffirm the anecdotal 40% hypothesis, contrary to the QIS validated 88-93% findings. An SEHD working party has now been commissioned, exploring 'doctor-light' services in unscheduled practice, using these findings as a catalyst for further research.

As the role of the non-medical practitioner develops, an audit of patient outcomes, referral pathways and patient confidence may be a more beneficial measure of their effectiveness, along with a qualitative assessment of patients' experiences following their consultation. Following a review of this study, NES has suggested a mapping exercise, both locally and nationally, to identify current levels of competence in practice measured against the defined levels of competence as defined by the NES framework document. Additional issues include the examination of roles and responsibilities for OOH practitioners and the variation of presentations based on duty station (centre or home visit) and the resulting outcomes for those presentations.

Examining roles and responsibilities

Across Scotland the individual health boards are reacting differently to the provision of services by non-medical or unscheduled care practitioners. NHS Lanarkshire, for example, is presently carrying out a trial in the rural setting of a combined community paramedic role, responding not only to 999 emergency calls but also to OOH home visits allocated by the PCES hub. This is in addition to the continued use of MINTS (major, minor illness and injury nurse treatment service) within the A&E departments. NHS Lothian continues to use pathfinder paramedics (with extended training) in the assessment and management of pre-prescribed presentations, for example, non life-threatening asthma and epistaxis, to prevent non-essential admission to hospital. NHS Grampian presently staffs the OOH mobile units for home visits with unscheduled care practitioners (nurse or paramedic) responding to OOH calls. NHS Ayrshire and Arran currently employs unscheduled care practitioners and community paramedics within the PCES treatment centres and continually develops practitioner-led community casualty departments, supported by the recent appointment of a consultant nurse for unscheduled practice.

The continued development of guidelines and practice protocols for unscheduled practice is now highlighted as a priority and work is now indicated locally in order to draw these together.

Nationally, NES (2007) has published Emergency Care in Scotland: A Framework for Practice, designed to benchmark roles and competencies for nurses working within A&E departments, community casualty departments and minor injury services. This document, although designed for emergency care, impacts directly on unscheduled care practitioners. In fact, many of the competencies for unscheduled practice defined by the different higher education institutions map the competencies laid out in this document. Local competencies need to be developed for practitioners in unscheduled practice and subsequent consideration should be made for future service redesign.

Implications for practice

Emergency care and unscheduled care in Scotland continues to be predominantly medically led. As competence and confidence in a practitioner's own skills and abilities grow, so will the developing role. In A&E departments, emergency nurse practitioners are now the norm, concentrating on the assessment and management of minor injury and illness presentations. However, educational support and competency frameworks now exist to allow practitioners to develop a more patient-centred approach to acute care. A feature of practice reform has been the continued move towards a competency-based work system to drive service and role redesign.

Through Agenda for Change and the Knowledge and Skills Framework we now have a national NHScareers framework that provides the opportunity to break down traditional occupational boundaries, enable greater movement and transferability of skills and provide better career opportunities for all staff. Nursing has been supported in this by radical workforce reforms that have increased capacity, capability and flexibility, and introduced new roles and freedoms. For example, patients presenting with chest pain are presently primarily assessed by nurses working in the emergency department; risk-stratified and triaged appropriately; intravenous access is obtained, an ECG is completed and life-threatening rhythms excluded; oxygen, sublingual nitrates and aspirin are administered and then medical assistance is sought. With the skills and competencies that now exist it would seem reasonable that a practitioner could complete the patient's assessment, prescribe adequate opiate analgesia, initiate further diagnostic investigations as indicated and arrange appropriate admission for further management. This truly meets the ideal of appropriate patient management at first point of contact. These roles are attainable and already in practice within hospital-at-night teams throughout the UK.

Nurses are vital in achieving a healthcare reform programme. We need to make sure that practitioners have a career structure that enables them to work in different care settings, to take on changed roles and responsibilities, develop a varied mix of skills, to pursue education and training when they need it, and to develop both generalist and specialist skills as required.

Conclusion

The results of this study suggest that, once a competent and confident NMP workforce has been developed, OOH services can be safely developed with far less reliance on medical input. This offers healthcare providers the opportunity to develop more cost-effective services, while giving nurses and other NMPs new career options.

References

Cooper M.A. et al (2001) The extent and nature of emergency nurse practitioner services in Scotland. Accident and Emergency Nursing;9: 2, 123-129.

Jones N.P. et al (1986) Function of an ophthalmic accident and emergency department: results of a six-month survey. British Medical Journal; 292: 188-190.

Morris, F. et al (1989) The nurse practitioner: help in clarifying health and educational activities in accident and emergency departments. Health Trends; 21: 124-126.

NHS Education forScotland(2007) Emergency Care in Scotland: A Framework for Practice.Edinburgh: NES.

NHS Education forScotland (2004) Out of Hours: Mapping and Supporting New Roles for Practitioners in Unscheduled Care.Edinburgh: NES.

NHS Education forScotland (2005) Emergency Care in Scotland. A Framework for Practice. NHS Education for Scotland: Edinburgh.

NHS Education forScotland(2003) A Route to Enhanced Competence for Nurse Practitioners Working in Minor Injury Units, A&E and Community Hospital Casualty Departments.Edinburgh: NES.

Purcell, D. (2003) Minor Injuries: A Clinical Guide. London: Churchill Livingstone.

Read, S.M., George S. (1994) Nurse practitioners in accident and emergency departments: reflections on a pilot study. Journal of Advanced Nursing; 19: 4,705-716.

Scottish Executive Health Department (2005) Delivering for Health. Edinburgh: SEHD.

Stark, L. (2004) A minor injuries clinic: a year of change, innovation and integrated working. Emergency Nurse; 12: 6, 14-16.

Tye, C.C. et al (1998) Emergency nurse practitioner services in major accident and emergency departments: a United Kingdom postal survey. Journal of Accident and Emergency Medicine; 15: 1, 31-34.

Tye, C.C., Ross, F.M.(2000)Blurring boundaries: professional perspectives of the emergency nurse practitioner role in a major accident and emergency department. Journal of Advanced Nursing;31: 5, 1089-1096.

Walsh, M., Crumbie, A. (2003) Nurse practitioner education: what level? Nursing Standard; 18: 4, 33-36.

Further reading

Carnwell, R., Daly, W. (2003) Advanced nursing practitioners in primary care settings: an exploration of the developing roles. Journal of Clinical Nursing; 12: 5, 630-642.

Carr, J. et al (2005) Perceptions of the nurse practitioner role. Practice Nursing; 16: 7, 350-355.

Chang, E. et al (1999) An evaluation of the nurse practitioner role in a major rural emergency department. Journal of Advanced Nursing; 30: 1, 260-268.

Cooper, R.A. et al (1998) Roles of non-physician clinicians as autonomous providers of patient care. Journal of the American Medical Association; 280: 9, 795-802.

Farmer, J. et al (2006) Rural/urban differences in accounts of patients' initial decisions to consult primary care. Health and Place; 12: 2, 210-221.

Horrocks, S. et al (2002) Systematic review on whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal; 324: 7341, 819-823.

Kaufman, G. (1996) Nurse practitioners in general practice: an expanding role. Nursing Standard; 11: 8, 44-47.

Kihlgren, A.L. et al (2003) Referrals from home care to emergency hospital care: basis for decisions. Journal of Clinical Nursing; 12: 1, 28-36.

NHS Modernisation Agency (2004) Right Skill, Right Time, Right Place. The ECP Report. London: Department of Health.

Perry, C. et al (2005) The nurse practitioner in primary care: alleviating problems of access? British Journal of Nursing; 14: 5, 255-259.

Scottish Executive Health Department (2005) Framework for Developing Nursing Roles.Edinburgh: SEHD.

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