Personal paper: medicine in the 1990s needs a team approach

Introduction

The team approach to the delivery of health care has always been important and has become more so as the boundaries between professional groups have become blurred. Doctors and nurses are becoming managers; nurses are taking on jobs previously done by doctors; support workers are taking over jobs done by nurses; and, similarly, technicians, physiotherapists, and radiographers are all taking on tasks previously done by others. For the most part the NHS workforce is ready to adapt and update its skills as circumstances dictate. But unless there is dialogue and trust between the groups, one or more of them are likely to feel threatened as their roles are changed.

The changing role of nurses provides an example of the circumstances in which we need to alter our practice. If these changes are to be widely accepted there has to be a cooperative effort; and without the support of the medical profession these changes will not occur.

Extending the role of nurses

Some recent innovations in nursing practice have had a profound impact on both junior and senior doctors. Of these, three from Papworth were dependent on the close working relationships that developed between nursing and medical staff at the hospital during the 1970s and 1980s. This was largely a result of the transplant programme initiated during this time, to which the nurses made an important contribution.

The first example came about as a direct result of the transplant programme. A group of nurses who are now called clinician's assistants came into being in 1990. Apart from their role in clinical management, they give support and information to the patient and family throughout transplantation–providing continuity of care in the face of an ever changing junior medical team. They also coordinate the different hospital staff who contribute to the care of patients undergoing transplantation.

As this scheme developed a particular difficulty occurred–that of role identity–and this is now seen elsewhere. Despite their nursing background, clinician's assistants were initially seen neither as nurses nor as doctors. They were paid on a nursing scale, but they did not have the jurisdiction over nurses that a senior nurse at that grade would have. There was also no peer group within the hospital with which they could share concerns, and initially it was difficult to meet their training needs. However, with time clinician's assistants have acquired both experience and status and are now valued members of the transplant team, within which they fulfil many of the roles of a senior house officer.

The role of the clinician's assistant is still developing, and their clinical skills will soon include clerking patients undergoing transplantation, obtaining consent for a set number of procedures, and prescribing a limited number of drugs. These tasks will, however, be undertaken only after a further programme of training and supervision. They look forward to this greater degree of autonomy, but they are unsure how they will fare should they wish to reregister as nurses under the guidelines of the United Kingdom Central Council.1

Clinical nurse specialists

The title of clinical nurse specialist has probably been subject to as much misuse as that of nurse practitioner, and there remains a lack of agreement on their precise role. The key characteristics are that he or she is an expert in some clinical area, practises tasks often to a high level of technical expertise, and carries responsibilities commensurate with that role but not necessarily with the authority to go with it.

Fig 1

The extended role of the nurse: a sister giving chemotherapy

ULRIKE PREUSS/THAMPTON UNIVERSITY TRUST

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Against considerable criticism from within the medical profession, the Royal College of Surgeons and the Department of Health approved a scheme in Oxford in 1989 to evaluate the role of a non-medically qualified person working as a cardiac surgeon's assistant. The person appointed happened to be a nurse, and the main though not sole objective was to train her in the surgical skills needed to remove the saphenous vein from the leg for coronary artery bypass grafting. For this she attended the physician's assistants programme at the Cleveland Clinic in America, where up to 20 000 such people are now incorporated into the delivery of various aspects of health care, only a small proportion being in cardiac surgery. The principle, however, is the same for all. Such people, for whom there are formal training programmes with appropriate certification and career structures, enhance the way in which doctors function by relieving them of certain technical duties.

When the Royal College of Surgeons assessed the Oxford project in 1992 it concluded that there were sufficient advantages in the scheme to allow other surgical units to employ and train staff for a similar purpose but that such training needed to be carefully organised and monitored.

Papworth now has four cardiac surgeon's assistants at varying stages of being trained in an expanding repertoire of tasks within operating theatres. Surgeon's assistants are able to teach new junior staff the basic surgical techniques of dissection and wound closure.

Critical care practitioners

In 1995 Papworth began developing another category of clinical nurse specialist, this time in intensive care units–the so called critical care practitioner.

For the benefit of the 80% of patients who now have an uncomplicated recovery after routine cardiac surgery it was necessary to train enough senior nurses to ensure that there would always be one critical care practitioner available in each of the critical care areas to provide cover. Any patients who develop complications, or fall outside the clinical pathways defined in the protocols, receive the attention of surgical or anaesthetic staff as appropriate, but otherwise all decisions about routine management are made by the critical care practitioners.

The project was planned between the senior surgical registrar and the senior nursing staff in the intensive care unit. The senior surgical registrar took a large part in training the critical care practitioners and in making them aware of the sensitivities that could exist as a result of their new status in relation to the junior surgical staff, who might otherwise feel threatened and excluded from their role in intensive care.

After initial misgivings, the junior staff now believe that their training has been enhanced by the clear protocols that they have to understand and follow, and they welcome not being called for minor decisions about routine management. So long as clinical variables remain within the protocols that have been set, patients receive swifter attention, yet the junior doctor remains the first person to be informed if anything goes wrong. The scheme is still being formally evaluated, but it is likely to extend to other large cardiac surgical units, and accreditation for the training programme may be sought with the English National Board for Nursing.

There have also been comparable developments elsewhere. Resources for staffing paediatric intensive care units have been a continuing problem, and any scheme that helps to recruit and retain trained staff while also improving quality of care merits serious consideration. Such a scheme is now in operation at Great Ormond Street Hospital for Children, where neonates and infants with severe respiratory difficulties are treated by connecting them to what is in essence a miniature heart-lung machine providing extracorporeal membrane oxygenation.

The programme now depends on the expertise of nurses who are specialists in this technique. They essentially take over the combined roles of anaesthetist, perfusionist, and intensivist while providing conventional nursing care. The consultant intensivist in charge of the intensive care unit points out that these nurses have largely replaced the need for junior doctors in the unit. Indeed, the intensivists would now prefer to work directly with these specialist nurses, rather than have inexperienced and transient junior doctors interposed between them in effect authorising what the highly specialised nurses are already doing.

If the current situation for such critical care practitioners is to be formalised, and if other units are to be encouraged to adopt the practice, several steps will be necessary.

Firstly, the nurses should be given a title appropriate to the specialist training that they have received.

Secondly, they should be given the necessary authority to act independently, commensurate with the responsibility that they already carry.

Thirdly, they should receive a salary which reflects the value of the work they do and which would help to retain their services. Trusts now have more freedom to set appropriate terms and conditions of service for staff, but support is also needed from the nursing authorities and the Department of Health.

Nurse practitioners and primary care

There have also been profound changes in the role of nurses in primary care. These changes started with the Cumberlege report in 1986, entitled Neighbourhood Nursing–A Focus for Care.2 This report recommended introducing the nurse practitioner into primary health care and said: “We are suggesting that patients who visit their general practitioners with conditions which are self limiting, or want to discuss other aspects of their health care, should have a choice of whom to see. Research has shown that nurses can be as effective as doctors, and as acceptable to patients, in securing compliance with therapy for chronic disease, making initial assessments of patients, diagnosing and treating certain minor acute illnesses and behavioural disorders, and rehabilitating elderly people after surgery.”

An extensive role was thus envisaged for this new category of nurse practitioner. The Department of Health and the Royal College of Nursing both responded favourably, as did general practitioners, who soon appreciated the potential value of having a new class of health professional working alongside them.

With the introduction of the scheme, however, came a profusion of new posts that were given the title of nurse practitioner but did not always meet the criteria outlined in the Cumberlege report and subsequently expanded by the Department of Health. There is a need to resolve this confusion not only to clarify relationships between general practitioners and nurses but also to dispel some of the uncertainty that exists in the minds of the public and consumer organisations about what the title and role of nurse practitioner really implies. The ethical and legal issues also need to be resolved if this innovation in the delivery of health care is to progress into areas such as management of specific diseases, in which even closer cooperation with general practitioners will be needed.

Nurse practitioners have not been confined to primary care. They also have a role within accident and emergency departments, where the recent shortage of junior doctors has lent further impetus to their training and employment. The Royal College of Nursing has decreed that the accident and emergency nurse practitioner should be “a key member of the health care team and directly available to members of the public. He or she must be an autonomous practitioner, able to assess, diagnose, treat and discharge patients without reference to a doctor, but within prearranged guidelines. And must also be able to make independent referral to other health care professionals.”3

The potential value of such a practitioner was recognised by recent reports from both the Clinical Standards Advisory Group and the Audit Commission.4 5 Nurse practitioners in accident and emergency departments can reduce waiting times, improve staff morale, and facilitate the more sensible use of resources. Designated nurse practitioner schemes are, however, still comparatively rare, although it is quite common to find unofficial schemes in specialist units such as ophthalmic accident and emergency departments.

Response of the professions

For the most part, the doctors and nurses participating in these developments have adjusted their professional relationships smoothly and without rancour. Such initiatives, however, whether they originate from local needs, such as the clinician's assistants in the transplant programme at Papworth, or whether they result from national planning, such as nurse practitioners in primary care, will also need to be supported by the professional organisations that represent nurses and doctors if they are to achieve their full potential. These organisations have the responsibility of entering discussions at an early stage of developments so that they can inform and educate their members of the benefits of closer cooperation and changing roles. It is better for them to lead the debate rather than to follow or react to events.

In the nursing profession there has been considerable talk during the past few years about the extended or expanded role of nurses, and in 1992 the United Kingdom Central Council responded to this by publishing The Scope of Professional Practice.6 This emphasised each person's need to acquire the extra skills and knowledge to adjust to his or her extended scope of practice rather than the acquisition of certificates for a string of tasks. There was, however, concern that nurses were tending to relinquish their caring role and concentrate too much on the acquisition of technical skills. And there were other more cynical views that The Scope of Professional Practice was promulgated to enable nurses to help implement the reduction in junior doctors' hours as outlined in the new deal agreement. These fears were not allayed by the Greenhalgh report in 1994, which was commissioned to study the interface between medical and nursing staff in hospitals “with a view to enhancing the role of nurses and reducing the inappropriate workload of junior doctors.” 7 This was not received favourably by nurses, probably because of its task oriented approach and lack of recognition of the danger of overloading nurses with new tasks when many were clearly already overworked. This issue should continue to be addressed. The recently published report from the Sheffield Centre for Health and Related Research advises trusts and purchasing authorities on how various aspects of patient care can be dealt with as effectively by specialist nurses as by junior doctors.8

Debate for doctors

This debate is of as much importance to doctors as it is to nurses. The recent report from the BMA's consultants committee entitled Towards Tomorrow–The Future Role of the Consultant recognises that some medical procedures currently undertaken by doctors may be dealt with as effectively by non-medically qualified staff, provided that they have received appropriate training.9 Consultants would also want such staff to take legal responsibility for the tasks they undertake. The report also emphasises that the debate on skill mix should not focus on consultants simply delegating unwanted tasks to junior doctors or non-medical professionals. The primary concern is to develop roles and skills that are appropriate to the level of training and qualifications needed by each team member.