With nurse practitioners, who needs house officers?
BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7000.309 (Published 29 July 1995) Cite this as: BMJ 1995;311:309
- Sue Dowling, consultant senior lecturera,
- Sue Barrett, reader in policy and organisation studiesb,
- Richard West, postgraduate deanc
- aDepartment of Social Medicine, University of Bristol, Bristol BS8 2PR
- bCentre for Social Management School for Advanced Urban Studies, University of Bristol
- cDepartment of Postgraduate Medical Education, University of Bristol, Frenchay Hospital, Bristol BS16 1LE
- Correspondence to: Dr Dowling.
- Accepted 9 May 1995
The boundaries between the work of doctors and that of nurses are changing, with nurses taking over important parts of junior hospital doctor's clinical work. In 1993 an exploratory study was carried out to identify the professional, educational, and management issues that such developments raise. Interviews were carried out with a range of stakeholders in three innovatory posts in which nurses were doing much of the clinical work of house officers. A complex picture of perceived benefits and problems for patients, junior doctors, and nurses emerged. These seemed to be associated with (a) the extent to which the contribution of professional nursing was valued in the new role and (b) the amount of clinical discretion which the postholder was allowed, this depending on the type of preparatory education provided and the management of the post. The study points to the need for strategic issues—such as the development of appropriate education and the professional recognition of these new clinical roles—to be addressed at a national and regional level.
The boundaries between the clinical work of doctors and that of nurses in the acute sector are being redrawn owing to a complex mixture of pressures coming from new technologies and treatments, changing patterns of health care delivery, and the processes by which services are purchased and provided. To doctors, perhaps the most obvious pressures are the requirements of the “new deal” to reduce junior's hours,*REF 1* and the Calman report's recommendations to shorten specialist training.*REF 2* Both will reduce the availability of juniors for service work, making nurse substitution an option to be considered. In July 1992 the United Kingdom Central Council for Nursing, Midwifery and Health Visiting published new statutory regulations*REF 3* intended to liberate professional nursing practice from previous rules that had limited the activities they could undertake outside basic nursing.*REF 4*
By mid-1992 anecdotal accounts of nurses taking over important parts of junior hospital doctor's clinical work were beginning to appear in the health service press. At the time there was little systematic research in Britain to indicate the prevalence and types of such developments or their implications for the professions concerned and for patients. We therefore carried out a six month exploratory project in 1993 (a) to map the way clinical work traditionally done by senior and preregistration house officers was being taken on by nurses, physiotherapists, and other staff groups; (b) to identify boundaries for classifying these types of new post; and (c) to identify and gain understanding of the professional, educational, and management issues that the posts raise. Here we address the last two of these aims, with reference only to the changing boundaries in clinical work between doctors and nurses.
Methods
Central to the research was a multiprofessional working group, which provided a powerful resource for identifying relevant information and interpreting results from different organisational perspectives. It included two chief executives (one purchaser, one provider), a senior nurse educator, a consultant surgeon, the junior doctor from the regional taskforce, a consultant occupational psychologist, a social scientist specialising in health care, the project's researcher, and the authors. Meetings were facilitated by one of the authors (SB), who had the least direct professional involvement in the issues being studied.
With so little known about the nature of the organisational changes being investigated, the structure of data collection and subsequent analyses were broad and relatively untied to predetermined theory. However, three key issues influenced the focus of the research.
* The design and management of new roles in ways likely to support good quality patient care
* Respect for professional's requirements for appropriate education, management, personal support, and career structures when required to take on new roles and drop old ones
* Respect for the role of innovators—recognising the risks they take and the consequent need for confidentiality.
COLLECTION OF DATA
We collected descriptive information to map the types of professional skill mix changes referred to above. This was done by literature searches and by contacts through networks of junior doctors, chief executives, clinical tutors, the regional taskforces, and senior nurses. From this information we chose three case studies as examples in which notable shifts in professional boundaries seemed to be occurring, with nurses taking over large parts of the clinical roles of senior house officers or preregistration house officers. The terms “nurse practitioner” and “nurse specialist” and other related titles may be used differently by hospitals for posts requiring varying levels of skill, roles, and responsibilities. We have therefore used the term “postholder” to refer to the nurses in the three posts discussed.
Information for the three case studies was obtained from job descriptions and other documents about the posts and from semistructured single interviews (by SD) with different stakeholders in the development, including the nurses in the new posts and the junior doctors, nurses, consultants, and other key staff with whom the postholder worked. We explored their experience of the new post and perceptions of its benefits and problems.
The interviews were audiotaped and transcribed, and the key issues were identified. SB checked and clarified interpretations made by SD, referring to the audiotapes in a sample of interviews. Summaries of case material were then analysed by the multiprofessional group.
Finally, we gauged the validity and meaning of the study's findings at a national level by discussion at a closed seminar with a selected group of senior health service managers and professional leaders.
Description of case study material
The three case studies of new clinical posts (posts A, B, and C) were conducted in April and May 1993. The first nurses to hold posts A, B, and C had been in their post for nine, 18, and eight months respectively. Although posts A and B were developed independently in separate trusts, they had many similar organisational and clinical features, and we have therefore considered them together.
POSTS A AND B
In posts A and B experienced nurses who had worked in the employing hospital for several years partially substituted for preregistration house surgeons in work on surgical firms with no such doctors (gastroenterology in post A, urology and general surgery in post B). The postholders had no nursing duties and were clinically accountable to consultants. Both posts had been developed rapidly over a few months, each in response to a new consultant appointment without an associated preregistration house officer. The initiatives were consultant led, with minimal nursing involvement (although the director of nursing advised on the job specification and overall management of post A).
At the time of interview, postholders were paid the equivalent of nursing grades G and H and worked between 40 and 60 hours a week. Their work included the medical clerking of routine admissions; limited clinical examination; and specified clinical interventions, such as insertion of intravenous cannulas, urinary catheters, taking arterial and venous blood samples, and giving intravenous additives. The postholders also monitored the day to day condition of the consultant's ward patients.
To prepare for the job, the postholder in post A shadowed a house surgeon for one week; in post B the postholder underwent a two month training programme with several hospital departments and senior staff, as well as shadowing a house surgeon. Both postholders had supervision and teaching “on the job.”
Organisational features of development of posts A and B and of post C
POST C
Post C was part of a region wide development of a new clinical role for neonatal nurses, combining advanced nursing with the complete substitution, when required, for the clinical work of neonatal senior house officers (except for tasks legally limited to medical practitioners). These nurses, referred to as neonatal nurse practitioners, were clinically accountable to the consultant. An integral part of the initiative was the development of an advanced neonatal nurse practitioner's course validated by the English National Board for Nursing, Midwifery and Health Visiting. The initiative was supported financially by the regional health authority and had a lead time of several years for detailed planning and development. It arose from the shared desire among the region's neonatalogists, paediatricians, and neonatal nurses to improve the quality of patient care. The development was planned jointly by doctors and nurses and included a visit by a multidisciplinary team to the United States to learn from the experience there. Basic nursing standards were established in units as a first step to defining the advanced nursing role.
In the unit that we visited, the postholders worked for most of the time interchangeably with senior house officers, taking part in the house officer's rota. They took over the whole rota when new senior house officers were appointed. Posts were grade H and required a 37 1/2 hour week. Only nurses qualifying from the advanced neonatal nurse practitioner course were eligible for appointment. This course was aimed at experienced neonatal nurses with more than basic training in the specialty. A preliminary 10 week basic science programme was followed by a nine month full time course comprising six month's formal teaching and three month's clinical apprenticeship in the nurse's home units. The nurses were supported by personal mentors in the nursing and medical professions, including qualified postholders.
Analysis and interpretation of case study material
ORGANISATIONAL AND CLINICAL FEATURES OF POSTS A, B, AND C
The table and the box summarise the main organisational and clinical features of the three posts. These suggest two different types of development. Posts A and B were developed quickly by doctors and excluded nursing duties. Limited training allowed little clinical discretion in diagnosis or treatment. The postholders worked within the medical arena of control, organisation, and accountability. This type of job was described by one preregistration house officer as producing a “watered down doctor.”
In contrast, the development of post C was lengthy and built on the contributions of both the nursing and medical professions. Its important educational input was designed to give experienced nurses the same type of clinical discretion as senior house officers in investigating, diagnosing, and managing acutely ill neonates. The postholders were described by interviewees as “more than a doctor, more than a nurse.”
Features of clinical work and accountability in posts A and B and in Post C
SIMILARITIES IN PERCEPTIONS OF BENEFITS AND COSTS BETWEEN THE THREE POSTS
The postholders all reported that they enjoyed their jobs and had gained new skills and personal satisfaction from being trailblazers. Against this, however, a common concern emerged about the stress of moving from their previous nursing role to something new and largely unknown. Postholders spoke of the uncertainties surrounding their professional identities and how these could result in a feeling of isolation and “not belonging.”
In all three sites the postholders, nurses, doctors, and managers identified gains from having front line clinical staff experienced in their hospital's organisation and ways of getting things done. They also suggested that the continuity of the postholder's appointments, which were for at least a year, was beneficial compared with the disruptive effects of frequently changing junior medical staff. They pointed out, however, that the salary costs of the postholders were greater for fewer hours worked that those of preregistration house officers (for posts A and B) and of senior house officers (for post C).
Main differences in perceived benefits and costs between posts A and B and post C
DIFFERENCES IN PERCEPTIONS OF BENEFITS AND COSTS BETWEEN POSTS A AND B AND POST C
The box shows the differences in perceptions of benefits and costs between posts A and B combined and post C.
For doctors
For posts A and B doctors of all grades reported that the posts probably reduced the workload of preregistration house officers but had minimal impact on their hours of work. Senior house officers and middle grade doctors, however, reported an increase in workload, apparently due to the limited training for new postholders and their resulting need for advice, teaching, and supervision. These senior house officers and middle grade doctors also had to take on work excluded from the new posts but normally done by preregistration house officers. In one site this excluded work was sufficient to cause the senior house officers to complain to the clinical director and the postgraduate dean.
For post C the doctors reported a reduction in senior house officer's hours when postholders were substituting for them and taking part in their rota. When new senior house officers started, the postholders took over the new doctor's service work, so freeing up a two week training period for them. The amount of work displaced to senior house officers and middle grade doctors was much less than for posts A and B. The doctors interviewed suggested that the advice and supervision needed by the postholders were similar to those given to most senior house officers.
In all three sites a few interviewees were concerned that the new posts might reduce training opportunities for junior doctors, although in practice this did not seem a problem.
For nurses
Although the nurses in posts A and B enjoyed the new work, few other benefits for these nurses were identified. Both postholders identified the absence of a recognised career path and a transferable, recognised professional nursing qualification as features requiring urgent remedy. Ward sisters were concerned that these very experienced nurses would become deskilled in these posts owing to the underuse of their nursing skills. They recognised that the postholders carried much responsibility for developing the posts and, being professionally isolated, could be vulnerable if problems arose from their clinical practice. They were also concerned that the absence of an easily accessible doctor for sick patients on their wards could increase the workload and stress of ward nurses.
Nurses were excited, however, that for post C a new career path was being created that could keep experienced nurses in clinical work with a recognised and transferable advanced qualification. They suggested that another benefit for nursing was the creation of additional trained clinical teachers who provided a model of how nursing can increase its clinical authority and professional autonomy. The professional and educational support for the postholders was such that the nurses did not identify any particular professional vulnerability, as they did for posts A and B. The main problems identified by the neonatal nurses were the personal risks of starting out on an extensive new training and role with uncertain employment opportunities when they had families and mortgages to support.
For management
Turning to broader organisational issues, differences in the perceived impact of the developments on patient care were reported, this being most favourable in C; also in the timing when benefits and costs occurred.
Discussion
The cases described have all evolved considerably since this study. They are now part of a growing number of innovations*REF 5* likely to increase further as the pressures to reduce junior doctor's hours continue and shortages of doctors in some specialties become more apparent. Alongside the more radical experiments in the redivision of medical and nursing clinical work, there is gradual change as doctors and nurses adjust to new working situations.*REF 6, 7* Since this study we have heard of other posts similar to posts A and B and developed mainly by doctors. In addition, new occupational groups, such as surgeon's assistants, are emerging,*REF 8* with recruitment largely (but not exclusively) from nursing, with the training and work defined and supervised by surgeons. New posts developing the careers of experienced nurses within nursing, such as in post C, are likely to increase. The recent specification by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting of standards of education and practice for the qualification of “specialist practitioner”*REF 9* (to be recorded on the professional register) will offer opportunities for new course developments in addition to existing validated postregistration nursing courses relevant to the acute sector—for example, in the specialties of accident and emergency; ear, nose, and throat surgery; gynaecology; and neonatology.
Nurses could increasingly take on some clinical roles traditionally held by doctors
**FIGURE OMITTED**
REQUIREMENTS FOR PRELIMINARY STAGES OF EVALUATION
Just as new surgical techniques require careful evaluation and control,*REF 10* so too do these innovations in the divisions of labour delivering front line clinical care.*REF 11* The problems of studying such heterogeneous working practices are considerable*REF 12* and are beginning to be confronted at the boundaries between nursing and medical work.*REF 5, 13* Until there is identification and understanding of the essential and generalisable features of these new working practices (as opposed to features specific to the organisation studied), controlled trials will be of limited value.*REF 14, 15*
This type of small, exploratory study is not intended to provide conclusions. However, it illustrates how in a new field of study a rigorous qualitative approach,*REF 16, 17* combined with a collaborative process of working*REF 18* drawing on a range of service and professional experience, can quickly identify and frame important research and management issues requiring further investigation. Some of these issues are currently being investigated by members of the working group.
IMPLICATIONS OF MAXIMISING OR MINIMISING SCOPE OF NEW CLINICAL ROLES
Our research suggests that the substitution of nurses to undertake large parts of house officer's clinical work is neither a cheap nor easy solution to the longstanding problem of junior doctor's hours. The data from the three case studies imply that when the scope of these new clinical roles is maximised as an expansion of nursing, and considerable clinical discretion allowed (as in post C), long term benefits for trusts may result, such as improved quality of patient care, the potential for reduced junior's hours with almost all the work of senior house officers being done by nurses in the new roles, and the development of a new cadre of clinical teachers for doctors as well as for nurses. The short term costs, however, may be considerable for trusts if, independently of each other, they take on the detailed design of such posts with in house provision of carefully tailored education and training. There are fears too that if nurses take on increasing amounts of technical and medical work then characteristics highly valued in the profession may be threatened—for example, skills in caring and communicating and in providing a holistic approach to patient's treatment, and encouraging patient's active participation in it.*REF 19, 20*
When the scope of the clinical role is relatively minimal, as in posts A and B, with no nursing duties and little training and clinical autonomy, the evidence suggests that trusts may find short term benefits to immediate medical staffing problems. The overall impact on junior doctor's hours, however, will be slight, while the workload of junior doctors working alongside such posts may increase. The long term impact of such posts on the professions concerned and on patients—for example, the potential fragmentation of care—needs further study.
NEED FOR NATIONAL AND REGIONAL STRATEGIC PLANNING
If these and other types of new clinical roles are to be developed widely to benefit all the main stakeholders then certain strategic issues—particularly role specification and appropriate education and professional recognition—need addressing both nationally and regionally. As divisions of labour change, issues of professional power and control are likely to become increasingly important, centred on two interrelated themes: (a) the type of professionalism that will operate—old style, defensive and restrictive practices maintaining closed and carefully boundaried groups*REF 21* or a new type of professionalism reflecting the realities of changing clinical practices in many areas of nursing and medicine so long as they primarily benefit patients*REF 22, 23*; and (b) the extent of understanding and appreciation by both professional groups of medical and nursing work, the nature of the differences, and how they interrelate.*REF 23, 24* Our project suggests that nursing work may be undervalued because of a lack of knowledge among doctors about the scope and nature of nursing and because of the recognised difficulties of describing the caring aspects of nursing work in ways that will not be dismissed as trivial.*REF 23*
CONCLUSION
We have described some radical changes in ideas about who does what at the front line of clinical care. Such ideas are valuable and may have a greater potential for achieving efficient production in health services than new techniques and equipment.*REF 25* Mechanisms are needed, however, to share and link local learning with the development of national and regional policies, with cooperation between the main professional and educational bodies as well as senior NHS managers. The new framework for planning and commissioning education and training in the NHS*REF 26* may provide such a mechanism. It will be important, however, for the NHS Executive, regional education and development groups, and local health consortiums to ensure that the development of education to support these types of clinical innovation is not swamped by the main activity of purchasing more traditional education for the rest of the NHS workforce. In addition, the NHS Executive and regions should ensure that support for the training of newly created specialist staff groups requiring relatively small numbers in any one region is not overlooked.
Members of the project working group who contributed to this work were Sally Burrell, researcher, School for Advanced Urban Studies, University of Bristol; Peter Colclough, chief executive, Gloucestershire Health Authority; Lesley Doyal, professor of health studies, University of West of England; Jonathan Fielden, senior registrar in anaesthetics, Bristol Royal Infirmary; Philip Jardine, research fellow, department of child health, University of Bristol, and junior doctor representative, South Western RHA Task Force; Richard Kinder, consultant urological surgeon, Cheltenham General Hospital; Ann Lloyd, chief executive, Frenchay Health Care Trust; Sharon Lloyd, lecturer in organisational psychology, University of Bristol; and Margaret Williams, vice principal for preregistration nursing studies, Avon and Gloucestershire College of Health.