Are we giving away nursing?

Abstract

Manuscript accepted 27 February I996 Accident and Emergency (A & E) is now a specialist service, and no longer the ‘Jackof-al-trades, master of none’. With increases in technology and expansion of roles, however, tasks are being taken over by unqualified staff the Health Care Support Workers (HCSWs). Are A & E nurses giving away nursing? A & E departments face increasing pressures in relation to staffing and health care demands. The proportion of unqualified staff has increased to replace the now supernumerary students, whilst the qualified nurse’s role is expanding to decrease doctors’ working hours, and cope with the shortage of A & E doctors. But, who is left to ‘nurse’ the patient? In addition, health care demands increase as medical technology advances, and as ‘consumer’ awareness, the elderly population and A & E attendance grow. Managers are more aware of costs, following the National Health Service (NHS) reforms regarding purchasers/providers. On examination of nursing roles, employment of ‘cheaper’ unqualified staff appears to offer greater cost effectiveness. Many hospitals are therefore downgrading qualified nurses or replacing them with unqualified HCSWs. Since qualified nurses are expensive, why do we need them in A & E? Why not have one qualified nurse and a team of HCSWs? I believe qualified nurses are essential for several reasons. First, the Government gave patients the expectation of various rights and standards through the Patient’s Charter. For example, patients must be Triaged immediately on arrival and have a named qtrul$ed nurse responsible for their care. To fulfil other standards, staff need knowledge and experience to handle questions from relatives, and assess patients’ health and social needs. Second, unlike unqualified staff, nurses have a professional responsibility through their ‘Code of Conduct’. This entails directing and supervising support staff, and remaining accountable for the assessment, planning, standards and documentation of care. and time wastes their qualification. Many studies have found that inadequate support (clerical, domestic and paramedical) is ‘expensive’ because it deflects nurses from direct patient care (DHSS NHS Management Board 1986; Jones 1986; Ball et al 1989; Robinson & Stilwell 1990; Audit Commission 1991; Crouch 1992; Blee 1993). It is not a simple matter however, of trading nurses for housekeeping and clerical hours and the practitioner’s role should not be simply administration and supervision of support workers. In practice, deciding which tasks are suitable for delegation to unqualified staff causes considerable debate. MacLeod (1994) suggested that often tasks termed ‘basic’ were complex and their importance was frequently overlooked. The ‘little things’ made a difference to patients because they were steeped in nursing knowledge and skill. Many examples cited by the Royal College of Nursing (1992) demonstrate the invaluable ‘art of nursing’. In fact, benefits of higher proportions of trained staff or higher grades have been suggested by some studies (Helt & Jelinek 1988; Carr-Hill et al 1992). However, it is difficult to provide tangible, comparable evidence regarding the costs and benefits of qualified nurses (Buchan & Ball 1991). The Audit Commission (1991) found a lack of reliable, measurable nursing (health) outcomes and it was virtually impossible to separate the contributions different professions made to the individual patient’s care. Determining the ideal skill mix within A & E departments is difficult due to fluctuating patient numbers and dependencies. The Royal College of Nursing (RCN) offers some guidance on skill mix, but there is no ‘ideal’ formula. For ‘relatively stable’ patients the Department of Health Nursing Division (1989) proposed that appropriately trained and supervised support workers could undertake a wide range of care and treatments, but it is debatable whether A & E patients come into this category. How are differences in skill mix perceived in practice? Dewar (1992) found that nurses are poor at differentiating between qualified and unqualified staff roles verbally, or when the amount of direct care is compared. In addition, lack of consensus on patient care roles for unqualified staff was found by the Audit Commission (1991). HCSWs were expected to provide the bulk of care for their allocated patients regardless of their nursing needs (Rhodes 1994; Ahmed & Kitson 1993). This is despite evidence from Gibson & McMillan (1992) that nursing auxiliaries were deficient in