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Trespassers on medical ground?

  • 29 Comments

With a government review, increased autonomy, advanced roles and working time laws contributing to nurses taking on junior doctors’ tasks, Clare Lomas looks at how the boundaries between the professions have become blurred.

When prime minister Gordon Brown launched his Commission on the Future of Nursing and Midwifery in March this year, it signalled the first full scale review of nursing care for nearly 40 years.

The primary aim of the commission is to help put nurses in control of services and policy direction, and not since the 1972 Briggs report, which had a significant impact on nurse education, has the spotlight been so firmly on the future of nursing.

However, we don’t need to go back 40 years to see how much the profession has changed. The last 10 years alone have seen significant changes in nursing, and nurses’ roles in patient care.

Since the first nurse-led NHS walk-in centre opened in January 2000, nurse-led services in both primary and acute care have developed all over the UK. Ten years ago, many specialist nursing roles were in their infancy, yet nurse specialists, nurse consultants and nurse practitioners now care for patients on a regular basis. 

The advancement in nurses’ skills and knowledge means that some of the more fundamental nursing tasks are now delegated to health care assistants, with senior nurses taking on roles more traditionally associated with junior doctors, such as assessment, diagnosis and prescribing medications for patients.

However, this “blurring of the boundaries” between doctors and nurses is nothing new to the professions, says Anne-Marie Rafferty, professor of nursing policy and dean of King College London’s Florence Nightingale School of Nursing & Midwifery.

 “The boundaries between medical and nursing care have always been fluid. Even 50 years ago it was not unusual for nurses to take a patient’s blood pressure, a task that was essentially considered a medical one back then,” she said.

“But we have made great strides in terms of developing the depth and scope of nurses’ capabilities and skills. It is not about nurses being mini-doctors, but about extending nursing practice to increase patient access to services and enhance care,” says Ms Rafferty, who is also a member of the prime minister’s commission.

Nurses working in advanced practitioner roles now take on the responsibility for assessing and diagnosing patients, including ordering diagnostic tests and interpreting results. Many nurses are able to prescribe medications for patients, either independently or in collaboration with a doctor using an agreed patient care plan.

Nurses also run clinics and services all over the UK, which have been well received by patients, other nurses and doctors.

The successes of advanced nursing roles, and nurse-led clinics and services, have been well documented. A 2007 study in the Journal of Emergency Medicine found that emergency nurse practitioners were just as good as doctors at managing patients with closed musculoskeletal injuries.

And a UK study of more than 1,000 patients with coronary heart disease and chronic heart failure, published in 2008, found a nurse-led disease management programme for the secondary prevention of cardiovascular events to be both clinically and cost effective.

The European working time directive, introduced in the UK in August this year, has further increased the autonomy of the nursing role.

Under the directive, junior doctors can work no more than 48 hours per week. This prompted the NHS to look at more creative ways of multidisciplinary team working, and many trusts now operate Hospital at Night schemes to provide safe and effective out-of-hours care.

The reduction in the number of junior doctors on wards at night has meant senior nurses stepping in to fill the gaps, often heading up multidisciplinary teams and managing patient care.

“The European working time directive has been the most influential policy lever for driving changes in nursing practice in this direction,” says Ms Rafferty. “But there has to be a clear division of labour and effective communication between nurses and doctors. Failure to care situations often occur where there is confusion about roles and a lack of communication,” she says.

Nurses’ input since the directive was introduced has also been welcomed by junior doctors, says the British Medical Association’s chair of the junior doctor’s committee, Dr Shree Datta.

However, she says there needs to be a “distinction between the roles” of doctors and nurses to ensure that “priorities are allocated correctly”.

“The lines of communication have to remain open or there is potential for conflict,” she says. “The RCN and the medical professional bodies have to be clear on the remit to ensure complementary working and mutual respect between the professions.”  

As well as responding to external policies, nurses have also been pivotal in leading on government initiatives, such as tackling healthcare associated infections.

Research has shown that nurses are significantly better than doctors at performing hand hygiene, and their drive in leading the infection control agenda has prompted the prime minister to look at other areas where nurses could take the leading role, such as discharging patients from hospital.

In March last year, Nursing Times reported how a nurse-led discharge scheme significantly improved patient care and reduced costs at a London hospital trust.

Working to strict criteria tailored to individual clinical areas, senior nurses at Barts and The London NHS Trust took full control of the discharge process for suitable patients, reducing length of patient stay and freeing up beds more quickly.

The policy – which sees nurses organise care packages, take-home medications and transport – also saved the trust around £2m in 2007.

“Nurses are adept at managing patient flow, and although it may be seen as controversial, I would like to see them performing more admission and discharge ‘gate keeping’ functions,” says Ms Rafferty.

“But innovations such as this cannot happen without medical support, and there has to be a symbiotic relationship between the two professions,” she says.

Nurse-led services and advanced nursing roles have also been instrumental in helping to deliver policies such as Lord Darzi’s NHS Next Stage Review.

Published last year, one of the core elements of the Next Stage Review was improving the care of patients with long term conditions, moving care out of the acute sector and into the community.

“Lord Darzi recognised that specialist nurses, with the appropriate support and training to deliver care, really add value to the patient journey,” says RCN policy advisor Tim Curry.

“Keeping patients [with long term conditions] out of hospital, and empowering them not to be too reliant on acute care, is something community nurses have been doing for years. But it is now being formally recognised,” he adds.

“Specialist nurses can also help to decrease patients’ dependency on prescribed drugs and reduce the number of [unnecessary] hospital admissions. This is a fantastic opportunity for nurses to show what they can do, but they need to gather data and share it with medical practitioners and commissioners to demonstrate the value of their services,” Mr Curry says.

The importance of sharing data and working in tandem with the medical profession is echoed by Queen’s Nursing Institute director Rosemary Cook.

“The evolvement of nursing roles is a clear sign that the nursing profession is maturing,” she says. “Nurses are no longer waiting to be told what to do but are taking control of service delivery and patients needs,” she says.

“However, we have to be aware of the danger of recreating the medical model in nursing by holding our cards to close to our chest and not involving doctors in patient care,” Ms Cook warns.

“Creativity, innovation and exploration are what help professions to grow, but this needs to be on a basis of principle, with patient need firmly at the centre,” she says.

As nursing roles are set to evolve further over the coming years, the future of the nursing profession sits firmly at the forefront of health policy for both the present government and the opposition.

The Conservative Party has pledged to “bring the best people into nursing” and attract a “broader range of people into the nursing profession”.

Shadow health minister Ann Milton tells Nursing Times she sees “a bright future for the nursing profession”.

“We will allow nurses to nurse by freeing them from government targets, trusting them with greater autonomy and professional control, and supporting them in their role by giving them better protection from abuse and management failure,” she says.

“We will also tackle problems in training and skills development, and ensure that nursing provides stable, continuing and supportive professional development.”

Health minister Ann Keen, who chairs the prime minister’s Commission on the Future of Nursing and Midwifery, pledges to put nurses “at the centre of the healthcare team”.

“We need to breakdown the traditional barriers and give nurses the confidence and freedom to practise to the best of their knowledge level, directing healthcare teams while staying in control of the quality and safety agendas that drive patient care,” she says.

“Healthcare is a complex area that requires joint learning and shared experiences, and the medical profession need to ensure they value nurses’ knowledge and expertise.”

 

Case Study – Laura Higgs, emergency nurse practitioner at King’s College Hospital in London

One of the most pivotal advanced nursing roles to emerge in acute care over the last decade is the role of the emergency nurse practitioner.

With a background in A&E nursing, emergency nurse practitioners work out of emergency departments at acute trusts and see patients with minor ailments and injuries, such as wounds and fractures.

They assess, diagnose and treat patients, including ordering diagnostic tests and prescribing medications, and can discharge patients without them having to see a doctor.

A qualified nurse for 12 years, Laura Higgs has been in her current role as an emergency nurse practitioner at King’s College Hospital in London for the past five years.

Miss Higgs is a qualified independent nurse practitioner and nurse prescriber, and has qualifications in minor injury and minor illness nursing for both adult and paediatric patients.

Additionally, she has an advanced assessment skills course which qualifies her to perform medical assessments and patient examinations, and she also orders and interprets diagnostic tests.

Since qualifying as an emergency nurse practioner, Miss Higgs says she has seen significant changes in the way the role is perceived by patients.

“Specialist nursing roles were less common several years ago, and many patients would rather see a doctor than a nurse,” she says. “However, the increase in the number of nurse-led services has raised patients’ awareness and they are now much more comfortable seeing nurse practitioners. I have only had one patient in the last eighteen months who wanted to be seen by a doctor.”

Patients benefit from seeing a nurse practitioner because they have more time to spend with the patient, meaning they get better “one-to-one care”, says Ms Higgs.

“Doctors will ask an emergency nurse practioner for advice”

The emergency nurse practioner role has also been well received by doctors. “We have an excellent consultant [at King’s] who encourages our clinical development, and junior doctors also find us a huge help. Junior doctors will sometimes ask an emergency nurse practioner for advice or a second opinion on an x-ray, or when to refer a patient to the plastics team,” she added.

Although it can be a very pressurised job, Ms Higgs says she enjoys the autonomy of her role and the extension of her nursing skills.

“Discharging a patient without them having seen a doctor is a huge responsibility and requires an experienced and qualified practitioner. However, it is vital to know your boundaries, ensure you only work within your scope of practice, and to always ask for advice if you feel you need it.”

  • 29 Comments

Readers' comments (29)

  • All of the above may be true for a minority of senior nurses but unfortunately the vast majority of band 5/6 nurses seem to have lost the plot. They can no longer prioritise work effectively, they cannot safely administer medications, they cannot measure and record patient observations correctly or add up simple MEWS scores correctly and they cannot recognise the signs of a deteriorating patient. Lets get the basics right before we disappear up our own backsides.

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  • could not agree more!

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  • Martin Gray

    Whilst I agree that nursing has come on leaps and bounds I also agree a little with the anonymous comment made above. Nursing STILL has many problems at the basic levels that never seem to get addressed; in truth they are swept under the carpet and emphasis is placed on how much nursing has progressed rather than deteriorated.

    As an ANP in primary care my role does involve a great deal of tasks previously performed only by a GP. However, due to the ever increasing number of QoF targets and other money-making intiatives (such as swine flu vaccinations and CVD risk assessment) nurses are becoming more involved in administrative tasks so that income generation is accomplished. Is that what I became a nurse for? NO, but I have no choice in the matter if I value my job!

    And the EU directive is not just applicable to doctors, it applies to nurses as well. Yet many of both professions undertake 2 jobs, either with agencies or OOH providers, to make a decent living. Whereas a salaried GP may take home over £50K per year I know of not one single nurse that does the same yet may be doing a lot more hours!

    Nurses, historically, have been prepared to take on additional tasks without complaint, yet it is obvious that this 'goodwill' and a feeling of responsibility to provide exceptional patient care is not rewared in any other way than verbally. No matter what the commision board recommend there will be no measurable reward for the nursing profession. And how does the nursing profession decide on which people are the best suited? On academic qualifications in the main part. Academics are not the best suited to what is a practical profession of caring. Yes they can read and interpret research, but does it make them any better at bed bathing or feeding, or even simply talking to patients?

    My roles encompass all the tasks and responsibilities the ENP your article discusses; bear in mind that not all nurses work in hospitals and many are at the forefront of keeping patients out of hospital or of attending A&E departments inappropriately.

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  • Yet again the Nurse picks up the tab of the Department of Health's inability (due to underfunding from Central Government) to employ Doctors and instead provide a willing work-horse to subsidise on the cheap a fiscally failing Health Service being brought to it's knees by reduced investment. Don't talk to me about investment in 'real terms' being up. Clinical Practice in term of Nursing Standards is falling in 'very real terms' and it is because our most experienced and clinicly apt 'NURSES' are playing Doctor!!! And why, because they are being fed the line 'Nurse led practice and practice development roles!!' While the Nursing profession is jumping 'lemming-like' over a professional cliff. My call to nurses would be... don't be easilly led.... lead standards of Nursing Care for Nurses by Nurses not subsidise medical shortfall.

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  • While nurses continue to take on more responsibilities and roles who will be doing the work they were already doing? Yes, that's right, the nurses! The public still demands and expects nurses to be there for them doing the usual tasks while they also struggle to be doctor substitutes Do we want to be doing everything? When is the work going to be shared out fairly?

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  • i am an nurse practitioner in secondary care and whilst i agree with some of the thngs being debated i have to say every area of my advanced practice whether that is assessment, prescribing, or bedside communication is undertaken as a nurse not a substitute doctor. There is a difference and i think allowing nurses to expand their skills, helps more patients. i think that the anonymous 1st comment is asking that all nurses have an understanding of clinical situations to enabling them to better care for their patients. nurses should be able to understand basic physiology, be able to at least recognise abnormal blood results and record a temperature or the need to accurately record respirations. i feel that if nurses start to question the need to update themselves they would realise that patients actually want a safe knowledgeable nurse looking after them far more than one that bleets about other nurses doing what they see as traditionally doctors roles. Just imagine the benefit if we actually worked as a team and supported each other.

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  • Martin Gray

    I totally agree about the team work and suport ethic, however it rarely seems to happen apart from in certain areas. As for nurses 'bleating' about doing junior doctor tasks and 'playing' at being doctors I think is a little insulting to say the least! Many of us have had to work long and hard to be able to accept further clinical competencies and the responsibilties they entail. We have helped ensure patients DO receive a better level of care, and I hope that none of us fails to maintain our nursing ethic rather than a medical one in performing our roles.

    Which body came up with the title of 'Nurse Consultant', which, by its very nature, implies a very high status normally only awarded to very specialised doctors. And these 'consultants' only seem to be in hospitals, where the medical consultants are based, not in primary care I can assure you!

    The nursing profession needs to be re-vamped altogether if we are going to get ourselves back on the right, and appropriate track and regain our kudos with both the public and our respective professions. I'm not advocating a return to the 'doctors handmaiden' in ANY way whatsoever either.

    That will entail looking very carefully at what nursing duties are, what practical aspects rather than academic ones need to be addressed, and re-structuring. AfG has not helped the vast majority of nurses, indeed some have faired badly from this so-called moderisation to ensure a fair wage scale, particularly those working in the community and private practice (including care homes).

    Lastly I always wonder why peoplle prefer to stay anonymous when they post comments; if you have an opinion and express it why not let us know who you are?

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  • I strongly believe that ultimately, the patient gains when the nurse developes his/her practice. Nursing is not only about 'bed-bathing' and bed-making, and should not be. The more the nurse understands the underlying causes of dis-ease, the better placed he/she is able to nurse.

    The aim of developing the roles of the ANP and Nurse Consultant is to deliver patient care with a combination of the doctor's knowledge, and the nurse's knowledge and skills, and most importantly approach. The nurse's approach cannot be over-emphasized. It is an affront to label these professionals 'doctor's substitutes' or imply that they are 'playing doctors'. These individuals are well rounded and if anyone has worked with any one of them, he/she will attest to this. I know of one and I know how advanced he is. In the light of this, I think it is self-defeating to deride the government's initiative in increasing nurses' clinical roles. However, I must add that some of them are under-utilised. This is in the sense that some of them are bugged-down by administrative duties as Martin mentioned earlier. Our focus as nurses should be on accessing the expertise of these highly skilled nurses rather than viewing them as renegades. We should encourage the government to create more of these roles to make them more accessible. They should also be remunerated accordingly. These roles motivate staff nurses to develope their clinical and academic skills. This is pertinent to those who do not feel inclined to terminate their nursing careers at charge nurse or ward manager level, or do not wish to go into management. The position of Nurse Consultant or ANP theoritically demands high academic and clinical skills. You make the effort, you reap the reward. And I reiterate, ultimately the patient gains. In addition,this would attract individuals into nursing who would ordinarily go to medical school because they could not visualise themselves advancing further than a charge nurse, or visualise themselves in a position where they would have equal 'say' with a medical consultant in the care of a patient.

    If a nurse cannot make beds and bed-bath appropriately, or cannot correctly and safely administer medication, the senior nurses need to re-evaluate their in-ward training procedures. If a nurse wishes to develope professionally and take on more responsibility, he/she should be supported fully and not held back. The purpose of preceptorship for newly qualified nurses is to address the issue of these 'basic skills'. If they cannot do the 'basic' things, then teach them.

    Yes there is the risk of consolidating the medical model in the quest for professional development. However, this is unlikely when the nurses are adequately mentored in the staff nursing grade.

    I also need to mention that the more educated you are, the more confident you will be, and the more likely you will be listened to. If you are not motivated enough to develop yourself and your career, do not discourage others. And I think we should all be courageous enough not to remain anonymous.

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  • Whilst I agree that advances in training and responsibillity for senior nurses is a good thing in general - I think we should be careful. While many of the traditional 'Doctors' roles are being taken on by nurses, who is left to do the nursing? Health care Support Workers are. And the reward for taking this extra responsibility? - certainly not financial. We should take heed - "todays favour becomes tomorrows duty" and nursing as a professional may become unrecognisable.
    Charlotte

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  • I want to increase my knowledge/skills but I am finding that I am being discouraged, not actively but subtly; I have a diploma in nursing and an honours degree in a non-nursing subject (from my life before nursing) and would dearly love to undertake some courses at Masters level, but as a band 5 I am not encouraged/allowed to, as this is restricted to Band 7.
    I know I am capable of assessing a patient, yet this is to be taken from us and left solely to the medical staff; there is a serious danger that we will become subservient to the doctors; reverting back to the situation 100 years ago as depicted in BBC's Casualty 1909!
    There is a real possibility of a department being run using minimal registered nurses and depending on unregistered staff, as the only aspects that are unique to registered staff members that will be utilised will be administering medication and undertaking neuro observations, which could require at most two RNs; all of the other nursing tasks can be undertaken by unregistered staff at less cost.

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