As doctors’ hours are reduced, will this mean greater career opportunities for nurses – or just more work being dumped on them? Steve Ford investigates how nurses think the European working time directive will affect their roles and standards of care.
Nearly two-thirds of nurses feel that the profession is not ready for the challenge posed by the European working time directive. That is the view of the profession according to an online survey of more than 500 nurses carried out by Nursing Times last week.
The directive, which limits the working week for all staff to a maximum of 48 hours, was first introduced in Europe in 1998 but the UK opted out until 2003. Work started in that year on introducing the reduction in hours in the NHS with a deadline set for full compliance by 1 August 2009.
There has been much talk over the years about the impact of the directive’s maximum 48-hour working week on junior doctors, which has gained fresh focus over recent weeks.
First, the government said that it would review the impact of reduced working hours on the quality of junior doctor training, following concerns raised by groups such as the British Medical Association.
Meanwhile, last week Health Service Journal revealed that one in 10 junior doctors whose hours were compliant on paper said they had been asked to lie.
Little attention has focused on the impact of the directive on the nursing profession which, as doctors are required to work less, has inevitably been required to take up the slack.
A range of measures have been tested to compensate for having fewer junior doctors around, especially during out-of-hours periods.
These have included, for example, employing more nurses in advanced roles, such as nurse practitioners, and introducing new models of multidisciplinary working such as Hospital at Night schemes, which also hand more responsibility and clinical decision-making to nurses.
‘As usual, we will take up the slack with no thanks and no recognition’
The Nursing Times survey suggested that around one-quarter of trusts have employed more nurse practitioners and 42% have introduced more multidisciplinary working such as Hospital at Night.
Yet nurses some serious concerns about the directive – as well as recognising the positive opportunities that it presents, the survey revealed.
While 81% of respondents thought the directive would result in there being more pressure on nurses to make clinical decisions, only 24% thought this was a good thing compared with 47% who thought it was a bad thing.
Additionally, 47% of respondents also thought the overall impact of the directive on nursing would be negative, while 53% thought it would reduce patient safety compared to only 17% who thought it would increase it.
Some said the theory behind the directive was sound but criticised the way it had been implemented, while others said they had not received enough information on the directive and what it would mean. Many views – both positive and negative – were expressed.
‘We can influence patient care positively if we plan and develop staff in the right way’
One respondent said: ‘Overall, nurses are stretched to the limit in most areas. Now they must undertake doctors’ work, so there are even fewer hours to carry out their own duties, so patient care will suffer.’
Another said: ‘As usual, we will take up the slack with no thanks and no recognition.’
However, another respondent said: ‘Nurses need to lead and own the change. We can influence patient care positively if we plan and develop staff in the right way.’
The key point that many respondents made was that training would be vital to back up any increase in the scope of nursing work. A large number of respondents also made the point that there had been little talk about increased remuneration for nurses, despite their having to take on more responsibility.
The Nursing Times survey has also attempted to gauge the impact the 48-hour working week has already had on nursing in trusts where compliance has been reached.
For example, it found that 52% of respondents at trusts that had introduced the 48-hour week said that nurses were now undertaking procedures that had previously been carried out by junior doctors, especially at night.
One respondent said: ‘The use of the extended role for nurses means that a lot of the junior doctors’ “routine” work, such as cannulation and venepuncture, is undertaken by the ward nurse in addition to more traditional nursing ward work – to the extent that the doctor simply refuses to do it if there is a nurse who is trained to undertake the task, regardless of the existing nursing workload on the ward at the time.’
Additionally, 45% said they had noticed serious gaps in medical cover for wards since its introduction, again, especially at night. One respondent said there was now ‘one junior doctor covering an area where once there two or more’.
Nursing unions have so far been cautiously positive about the opportunities that the directive may give nurses – in contrast to their medical colleagues – but with caveats.
For example, Gail Adams, Unison head of nursing, said ‘The directive will have different types of impact on nursing. Nurses are likely to be undertaking things that junior doctors were doing, especially at night.
While this could be viewed negatively, Ms Adams pointed out that greater decision-making powers for nurses could be a good thing in some situations. ‘There could be a positive impact on nursing because often specialist nurses are frustrated waiting for junior doctors to sign off on something that a nurse is equally competent to do,’ she said.
At an RCN council meeting in February, members said the directive should be seen ‘in terms of the benefits of the perspective of nursing development’.
At the time, Stacey Hunter, RCN council member for Yorkshire and Humber, said: ‘I work in an organisation that went working time directive compliant a year early. It gives a lot of opportunities for nurses. We want to be lobbying to maximise these opportunities.’
However, speaking last week, Alan Dobson, RCN nurse adviser for acute and emergency care, was more circumspect. ‘There is more pressure and expectation on nurses to make clinical decisions which is not necessarily a bad thing because they have the skills,’ he said.
‘But the biggest challenge is in out-of-hours where nurses are acting as the stopgap between junior doctors and senior doctors. Where it becomes contentious is where nurses are expected to fill the gaps between middle grade or locum doctors. With locums especially, nurses are constantly having to brief them on local policies and procedures and it takes its toll,’ he said.
A leading nursing academic has also warned that the recession and associated future cuts in public spending could could affect whether nurses would be able to acquire the skills needed in more advanced roles.
‘We are in a very different labour market situation from we were when we entered the process and a very different funding situation,’ said Professor James Buchan, from the faculty of social sciences and healthcare at Queen Margaret University College in Edinburgh.
‘There are certainly no shortages of nurses in numerical terms but there are skills shortages within nursing that need to be faced to cover for junior doctors.
‘Funding to support their redevelopment will be a bigger challenge than it was five years ago.
‘It could be funding for a short course for nurses to expand their role or full training for master’s preparation to be nurse practitioners. Funding for any type of training is tightening and it is going to be more difficult to cover the cost of doing that.’
The true effect of the directive, both positive or negative, on patients, nurses and junior doctors will no doubt quickly become apparent in the months after August – depending on when and if the NHS achieves full compliance.