Advanced nurse practitioners should have an equal role in giving basic medical care as junior doctors, according to safe staffing guidance from the professional standards body for hospital doctors.
The Royal College of Physicians has estimated the number of hours that clinicians need to be present in a particular situation and set out examples of the staff needed to work these hours.
“Now we are all clinicians who work in teams and are co-dependent”
It said its new report – titled Guidance on safe medical staffing: report of a working party – was the first attempt to enumerate safe medical staffing limits anywhere in the world.
Launching the report, RCP president Professor Dame Jane Dacre said that at a time of workforce shortages there needed to be an end to “cultural stereotypes” about what work doctors and nurses can do.
The document said it was “no longer appropriate to refer to work being done only by specific grades of doctors”.
Instead, the report suggested dividing clinical staff into three tiers. Tier 1 clinicians, which would include advanced nurse practitioners, were defined as being “capable of making an initial assessment of a patient”.
Tier 2 would include medical registrars and tier 3 would be expert clinicians who have overall responsibility for patient care.
“The document recognises the importance of continuing professional development”
The RCP report described how the tier model might be various hospital care settings. These included the medical assessment and admission team, the medical ward team, the weekend medical ward team, and the on-call team providing out-of-hours cover for inpatients with medical problems.
The RCP said using the guidance within the report would enable trusts to map their current staffing against recommended levels to ensure they were able to provide safe care.
Tier 1 staff in the medical assessment and admission team require 15 hours per 10 patients who present acutely to hospital is 15 hours per 10 patients, the guidance said.
This would apply whether or not the care is partly-delivered by a consultant or there is no immediate consultant presence, it said.
For example, to cover a 30-bed medical ward by day, Monday to Friday requires tier 1 staff to be present for 71 hours each, said the RCP working group behind the guidance.
It stated that two tier 1 clinicians were needed for most of the day on the ward irrespective of whether or not a formal ward round took place. A workforce of 2.2 tier 1 posts per ward was needed to provide this staffing.
During weekends and public holidays, a tier 1 clinician needed to be present on every ward for 8 hours each day. A workforce of 0.5 of a tier 1 post per ward was needed to provide this staffing.
“This report is a useful addition to the ongoing research into how the NHS can achieve safe and sustainable staffing2
The report also suggested that 10 minutes of tier 1 time per patient was required for the routine tasks that arose when a patient was transferred to a new ward. In regard to the daily ward round, it was suggested that tier 1 staff allowed seven minutes per patient.
Discharging a patient was likely to be predominantly tier 1 time, the report stated. It recommended 20 minutes per patient is allowed for this task.
For emergency care, the medical team needed one tier 1 clinician available throughout each 16-hour on-call period for every 100–120 beds covered by the on-call team. Meanwhile, a workforce of three tier 1 posts was needed to provide this staffing.
The document sets out detailed arrangements for how staff in the medical assessment and admission team would see patients when all three tiers of clinicians are present.
For a cohort of 10 patients the report recommends:
- Four patients to be initially assessed by tier 1 and reported directly to tier 2
- Four patients to be initially assessed by tier 1 and reported directly to tier 3
- One patient to be initially assessed by tier 2 and reported to tier 3
- One patient to be initially assessed by tier 3
The workforce numbers take account of periods of leave and thus avoid “predictable rota gaps”, and absences from the ward or admission teams.
“Our recommended staffing numbers are intended to be indicative rather than definitive, and they should always be validated or modified by the results of appropriate audit,” the report authors said.
They argued that it was “essential” that as much patient care as possible is delivered during the normal working day, rather than out of hours.
“We think that this is a key issue for patient safety, and the daytime staffing of wards should be such as to minimise ‘legacy’ work,” they stated.
In the interests of safety, staffing calculations should be based on 80% of maximum activity, the report stated.
From 30-70% of medical staff time was estimated to be spent on indirect patient care, including activities such as coordination, leadership and management of care.
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Hospitals needed effective mechanisms in place to continuously monitor for surges in activity that compromise safe patient care, it recommended. And all hospitals should have agreed, effective escalation protocols for responding to such surges in activity.
Routine staffing requirements should be reviewed if escalation protocols are activated more than once a week on average, the report says.
In 2013 the RCP identified a need to work with the NHS to provide guidance on acceptable staffing levels for a given workload.
The working group behind the new report, which included the Royal College of Nursing as one of its members, represented an attempt to deliver clear benchmarks for staffing.
The RCP said it will now work with hospitals to pilot the recommendations in real-life situations.
Dame Jane said that in recent years other clinical staff had started to perform tasks traditionally done by doctors. This had been “born out of necessity” and there now needed to proper rules established, she said.
At the same time, preconceptions among patients might need to be challenged, she said.
“There is a cultural stereotype about doctors and nurse, but actually now we are all clinicians who work in teams and are co-dependent, because medicine is more complicated and more sophisticated,” she said.
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Janet Davies, chief executive and general secretary of the RCN, welcomed the report. It would put the issue of patient safety straight into the new health secretary’s in-tray, she said.
“The issue will intensify as growing numbers of frontline professionals call for guarantees to enable them to deliver world-class patient safety,” she said.
“Despite demands for action, five years after the Francis Report we are no closer to staffing for safe and effective care in England,” said Ms Davies
The report also showed that nurses and physicians were working together on solutions, she said.
“Advanced Nurse Practitioners are included in the RCP’s new guidance for calculating safe medical staffing levels in acute settings, recognising the contribution made by nurses of all levels,” noted Ms Davies.
“The document recognises the importance of continuing professional development in enabling ANPs to deliver effective multi-professional working to determine the best outcomes for patients,” she added.
Dr Kathy Mclean, executive medical director at NHS Improvement, said: “Having the right medical staff with the right skills in the right place and at the right time is vital for providing patients with high quality, responsive care.
“This report is a useful addition to the ongoing research into how the NHS can achieve safe and sustainable staffing across all its health settings,” she said.