Published: 30/09/2004, Volume II4, No. 5925 Page 34 35

Training nurses to take on aspects of a doctor's job is not new in theory, but how much is it happening in practice? Claire Laurent reports on a lack of progress

Extending the role of nurses is not new - the original Wanless report suggested that nurse practitioners could take on about a fifth of doctors' jobs if they were supplemented with a large increase in the number of healthcare assistants.

The reduction in junior doctors' hours as a result of full implementation of the European working-time directive in August has added to the momentum.

And yet the reality is that the extended role has been slow to develop. Queen Margaret's University, Edinburgh, professor of health and social care James Buchan says: 'One of the problem areas is a kind of bottleneck that relates to training provision. In England there are just three or four training courses for nurse practitioners. Advanced practice and nurse practitioners are just not on the radar screen in the way they should be.'

Leicester Hospitals trust critical care nurse consultant Pauleen Pratt says: 'There is potential for the nurse practitioner to be able to fill some of these gaps that would benefit patients. Critical care outreach nurses are competent in many of the skills and have the experience of house officer-level doctor and probably senior house officer.'

Ms Pratt welcomes a recent move by the Nursing and Midwifery Council to acknowledge the specialist practitioner on the nursing register and to set some guidance for what the term 'nurse practitioner' encompasses. 'The problem has been that the roles have developed willy nilly, ' she says. 'National guidance from the NMC will help by saying, 'to have this title you are going to have these particular skills and competences'.'

BMA junior doctors committee deputy chair Dr David Macklin says: 'The extended role for the nurse is long overdue. It is certainly a key factor in being able to reduce junior doctors' hours but It is not just for nurses.

There are opportunities for other professionals to extend their roles.'

He continues: 'It is enabling a greater proportion of staff members to have the skills they need to look after the patients. If that happens to be one of the ward nurses or a healthcare assistant, That is got to be better for the patient.'

Although not universal, support for the idea of more generically trained staff is taking hold.Ms Pratt says: 'What is needed is generic people, whatever we end up calling them, who have a level of skills they are competent in and do enough of to remain competent in, and are able to move from one ward to another to assess a patient, put in a cannula and to escalate treatment to someone senior if necessary.Hopefully, the issues of Agenda for Change will recognise the skills and experience of the practitioner.'

Proposals in the NHS plan to introduce new ways of working in the service and to break down professional barriers have been taken up by the Modernisation Agency, which is leading on work to identify best practice. The Hospital at Night project was set up to redefine how medical cover is provided in hospitals during out of hours. A survey of 20,000 clinical episodes in 11 trusts gathered evidence about what happens in the hospital during out of hours.

Pressures of elective surgery were absent, accident and emergency attendances and emergency admissions fell off rapidly and ward work also lessened. At 5am, for example, the number of calls to doctors is a quarter of the number at 5pm.

This evidence gave strong support to the development of a competency-based multidisciplinary approach to staffing at night. The model required cover defined by competency rather than professional demarcation and pilot projects were launched in four trusts - they are due for final evaluation in November.

Ann Buchanan, director of nursing and midwifery at Westmoreland Hospitals trust, one of the pilot sites, says the model works but there were 'teething problems'. She welcomes the concept of the model, which is 'about putting patients in the middle and asking what skills are needed', and she is pleased that nurses' skills and experience were at last being recognised.

But she adds that there is a need for people to truly understand the nature of team working. 'Far from people being reluctant for nurses to take up an expanded role, there is more an expectation of: 'I do not have to do that because someone else can'.We have to say to people that we are a team. Until we have the first cohort of doctors who have come through the system and worked in places where there is this model, we will have to challenge their expectations.'

Dr Macklin agrees: 'There has to be a combination. It is not to say this task is no longer to be done by a junior doctor. There will be situations where It is inappropriate for junior doctors to do things out of hours but There is also a situation where they need to maintain their skills for emergencies.'

RCN adviser Bernie Cottam says: 'You can't ask a nurse to undertake an extended role or a role that may previously have been undertaken by a junior doctor and do her own job as well. It is instead of, not as well as.

It is about nurses working differently but equally and what has to be recognised is that nurses have to be remunerated for it.'

Further information

Nursing and Midwifery Council, www. nmc-uk. org

Hospital at Night project, www. modern. nhs. uk (look under 'workforce'and then 'workingtime directive')