Reduction In Junior Doctors Research Articles

Nurse practitioners: the role in A&E and primary care.

This article describes a recent evaluation of the work of nurse practitioners across a range of A&E departments and minor treatment centres in west London. Questionnaires, face-to-face interviews and focus groups were used to collect the data. The authors found that across the sites in the study, the provision of nurse practitioner services varied in scope but were well received by staff and patients. Issues surrounding training remained unresolved, but the role appeared to be developing in response to the reduction in junior doctors' hours and improved and extended opportunities in pre- and post-registration nurse education. The authors recommend that the cost effectiveness of nurse practitioners should be evaluated. The accompanying commentary suggests the nurse practitioner role should be explicitly defined.

Role definition: nurse practitioners or clinicians' assistants?

This article discusses two different types of nursing role currently being developed and highlights their impact on professional practice. One role type is concerned with meeting trusts' needs to reduce junior doctors' hours and costs, and includes specific aspects of medical practice. The second seeks to advance nursing practice and patient care. Both however, lack organization and clarity of definition. Developing the first type will not achieve the objectives of the second, even if the title of nurse practitioner is attached to the role. The nurse surgical assistant provides a lucid example of a role that is being medically defined, driven and supervised. Although individual nurses are clearly enjoying their new roles, the unique and valued characteristics of nursing are being threatened. This retrograde step should be viewed as unacceptable to the profession.

The scope of professional practice in specialist practice.

The Scope of Professional Practice (UKCC, 1994a) now offers nurses, midwives and health visitors new opportunities to develop their clinical role. Role expansion is at the centre of debate in the health service. In the spirit of Scope, trusts and regional health authorities have been experimenting with new roles that combine medical and nursing practice in order to promote a holistic approach to health care. Education, experience and the appropriate clinical competency are the foundations for role expansion and the development of professional practice. However, some of the new roles and innovative practices have also been targeted at reducing junior doctors' hours (Read and Graves, 1994). New roles must be evaluated before they are allowed to develop and there is an urgent need for national evaluation of the initiatives underpinning Scope. This article examines the changing role of practitioners in specialist practice. The ethical, professional and legal issues surrounding these changes will also be considered.

Using nursing theory to introduce change in practice.

This article outlines the theoretical basis of nursing using Carper's (1978) fundamental patterns of knowing and explains how this theory can be integrated with practice. The authors also describe how Carper's theory was used to introduce change related to the reduction in junior doctors' hours through the development, implementation and evaluation of nurse practitioners. Using a SWOT analysis exercise and various workshops, practitioners have been able to develop professionally and integrate the art and science of nursing.

Consultants launch blueprint for the future BMA wants higher loans for medical students NHS chief executives receive 7.6% average pay rise Osteopaths' statutory council GMSC reviews dispensing pay Talks held on confidentiality Correction

# Consultants launch blueprint for the future {#article-title-2} Leaders of Britain's consultants have launched their blueprint for the future role of consultants in the NHS. Towards Tomorrow, which was approved by the Central Consultants and Specialists Committee in December (6 January, p 59), sets out the unprecedented changes that have taken place in the past few years, proposals for the future, and the prerequisites that will be necessary for any changes. Increased management responsibilities, the internal market, increases in emergency admissions, and the reduction in junior doctors' hours were all cited last week by the CCSC chairman, Mr James Johnson, as adding to consultants' workload and making inroads into their quality of life. Consultants, he said, wanted to get back to their prime role of looking after patients and Towards Tomorrow makes several recommendations on how this can be achieved. Consultants should be allowed to delegate some of their duties to medically or non-medically qualified staff but there would need to be a national agreement on the principles under which tasks could be delegated. There was, for example, scope for nurses to play a greater role in preoperation screening and to act as first assistants in theatre. Consultants would have to explain to patients why other health care professionals were more suitable for such work. The CCSC wants a greater emphasis on team working. It believes that the consultant's role would be enhanced and workload lessened by the formal introduction of consultant only teams and the report sets out alternative models. There could be cross specialty cooperation in units between consultants not normally associated with one another in …

An action research investigation into the feasibility of experienced registered sick children's nurses (RSCNs) becoming children's emergency nurse practitioners (ENPs)

Emergency nurse practitioners (ENPs) formally developed in accident and emergency (A & E) departments as a direct response to waiting times for the walking wounded, the need to reduce junior doctor hours and changes in nursing practice. ENPs existed informally for many years in minor injuries units and specialist ophthalmic departments. This study aimed to examine whether or not the role of ENP could be applied to the specialist service of a paediatric casualty department. The results showed that 3% of patients could be seen and treated to conclusion by a children's ENP, and some patients could have their care accelerated by a children's ENP. The introduction of children's ENPs would have an impact on waiting times, junior doctors work-load and the quality of patient care.

Has The Scope of Professional Practice failed in its original aim?

The U K C C published The Scope of Professional Practice in 1992. It originated from a desire to enable nurses and midwives to be more ‘responsive’ to change and to develop nursing and midwifery practice. It was not introduced as a means of reducing junior doctors' hours.

Junior doctors are still hard pressed BMA's concern over performance bill Junior doctors to retain employment rights GPs urged to take part in out of hours ballot

# Junior doctors are still hard pressed {#article-title-2} More than 96% of junior doctors now comply with the new deal targets for contracted hours, according to a parliamentary written reply. The number of hard pressed on call posts contracted for more than 72 hours a week—which should have been eliminated by the end of last year—was 771 in February. A year earlier it was 6524. The rate at which these posts are being eliminated more than doubled in the previous four months. Health minister Gerald Malone, who gave the figures, said that the regions were making good progress in reducing junior doctors' hours, but there was still more work to be done. He believed that a ceiling on contracted hours had been established, though there were still too many junior doctors under pressure to work too long. A total of 1776 doctors in non-onerous posts were still contracted for more than 72 hours a week. Mr Malone said that the priority was to ensure that no junior doctor worked on average for more than 56 hours a week. Regional figures for hard pressed posts contracted for more than 72 hours range from nil in the North West Regional Health Authority to 189 in Anglia and Oxford. The details are: Northern and Yorkshire 162; Trent 60; Anglia and Oxford 189; North Thames 178; South Thames 95; South and West 20; West Midlands 67; North West 0. Total: 771. Commenting on the figures the chairman of the BMA's Junior Doctors Committee, Dr Andrew Carney, said that while working conditions had improved the new deal as a whole has not been delivered on time with …

Consultants of the future

Few people disagree that the work of British consultants is changing rapidly. The questions revolve around how consultants should organise their work to meet a set of apparently conflicting demands on their time. Over the past four weeks we have invited contributors to discuss these issues,1 2 3 4 and last week the BMA's consultants' committee hosted a meeting at BMA House to think about the future role of consultants. Consultants clearly believe that they have been dancing to others' tunes for too long and that, in the words of Jim Johnson, the consultants' chairman, it's time to take charge of their own destiny. Change is needed because of reductions in junior doctors' hours; the proposed change to shorter, more structured training for juniors5; demands from purchasers that more work is done by fully trained specialists; and the requirements of the new NHS: audit, contracting, and managing. Scientific advances3 and changes in the pace and place of care4 also make change essential. The net effect is that heavier workloads leave consultants with little time to reflect on how they can best use their time. Teamwork is one solution. If fewer juniors are available for service work, more of that work will have to be done by consultants. Although consultants work more efficiently than juniors, the large amount of emergency and night work presently done by juniors remains a problem. Bigger teams make this more manageable. In the United States, for example, senior doctors in a …

Specialists in the United States: what lessons?

Several pressures are forcing a rethink of the way that consultants in Britain work. Perhaps the most acute pressures come from the current moves to reduce junior doctors' working hours and the Calman proposals for more structured and shorter specialty training programmes. Together these will mean fewer juniors available to do service work within the NHS and a greater load on the consultants who have to teach them. But patients and purchasers are also demanding that more clinical work should be done by fully trained doctors, not trainees, and the requirements of the new NHS require consultants to take part in auditing, contracting, and managing the service. Last week (11 March, p 673) the BMA council heard consultants' anxieties that the numbers of consultants were not growing in line with the demands of the Calman implementation plan. There is a feeling that something will have to give, and the BMA fears the proliferation of subconsultant grades (staff who are not trainees but do not have full clinical autonomy) to fill the growing gap between the work to be done and doctors available to do it. Also, on 6 April the Central Consultants and Specialists Committee of the BMA is holding a conference to discuss consultants' career development in the face of these changes. We have commissioned four articles to contribute to this debate about how consultants should organise themselves and their work in future. In the first of these our North American editor, John Roberts, outlines the effect of similar pressures on the way that specialists in the United States organise their work, and how their working practices are changing. The American specialist and the British consultant travel separate but often parallel roads. Both have recently been buffeted by the same storms: privatisation and competition; demands for account-ability; problems of …

Whose job is it anyway? The doctor/nurse debate.

The reduction in junior doctors' hours is a key objective for the NHS. Reports on the activities of junior doctors during randomly selected shifts over a four-month period, in general medicine and obstetrics and gynaecology in a district general hospital. Raises issues of job design, stress management, work organization and general issues of staff training and professional restrictions. Points to the need for management action with regard to the training of all staff, the way the service production is organized and the introduction of multidisciplinary team working.

HCA takeover will lower standards.

I agree with Linda Nazarko's view that the profession should debate issues surrounding the reduction in junior doctors' hours and the provision of direct patient care by health care assistants (HCAs) (System failure, November 9).

Clinical protocols are key to quality health care delivery.

The use of clinical protocols allows health care providers to offer appropriate diagnostic treatment and care services to patients, variance reports to purchasers and quality training to clinical staff. Such protocols provide a locally agreed standard to which clinicians and the organization can work and against which they can be audited. By embedding protocols into patients' records and reporting by exception, the use of protocols may help to tackle a raft of other issues successfully such as the reduction in junior doctors' hours, and the facilitation of shared care. It may also bolster the medico-legal robustness of the health care delivered. If the protocols are sufficiently detailed, costing, coding and other resource usage information can flow directly from the clinical records. Such benefits may be maximized by using protocols within the framework of an electronic patient record system.

Nurse practitioners in acute care units.

The launch of the UKCC's The Scope of Professional Practice and measures to reduce junior doctors' working hours have once again raised debate on what roles are appropriate for nurses. For many, the development of the nurse practitioner role, with its advanced skills and increased levels of autonomy, offers a very desirable template. Much can be learned from the experience of US nurses, and this article describes a relatively recent innovation--the development of the nurse practitioner role in the acute hospital setting. The role is not a physician substitute; rather, it strengthens and promotes a multidisciplinary approach to patient care and presents the nurse with an opportunity to improve the delivery of care provided in the inpatient environment. Most significantly, it remains a nursing role.

Back to basics: medical staffing in general hospitals

There is a major crisis in medical staffing in hospitals in Britain and this is influencing other aspects of health care delivery. Before the new deal on junior doctors' hours the conventional pattern of staffing was the firm, usually of two consultants, a senior registrar or a registrar, a senior house officer, and one or two preregistration house officers. A one in two rota was often expected for resident junior staff. It was not unusual for registrars to be non-resident when on call, and even in major teaching hospitals the on call resident staff were sometimes surprisingly junior. Cross cover between firms was often unacceptable or discouraged. * “Overriding service needs have, therefore been met by the proliferation of unusual non-consultant posts.” The 1960s and early 1970s were characterised by this basic pattern of staffing spreading to all specialties with an enormous rise in senior house officer numbers but with a continued resistance to cross cover. As most of the senior house officers were destined for a career in general practice this did not always result in a high level of specialist junior skills. While junior doctors could be exploited by the service demands of a one in two rota, this was an effective way of providing 24 hour medical care and did result in continuity. It was, however, clearly socially and morally unacceptable and put service needs before training requirements. The statutory reduction in junior doctors' hours is a cogent factor in implementing profound change in the pattern of delivery of health care. Central and regional manpower committees tried to limit the uncontrolled growth of doctors in non-consultant grades but were faced with lack of funds and the expansion of senior house officers to meet service needs or …

Emergency transport for neonates after home deliveries: Expectations of flying squads are too high

EDITOR, - Northern region has had a centralised neonatal flying squad for many years, but we agree with Carol Sullivan and colleagues that the title is misleading.1 It causes confusion and results in an instant response being expected. Such a response has become impossible with the reduction in junior doctors' hours and has always been problematic if the squad is already attending a call. Community midwives may well have the expectations outlined by the authors,1 and these should be dispelled. A neonatal flying squad could never, however, react sufficiently quickly to fulfil a primary role in neonatal resuscitation. Northumbria ambulance authority has one of the best response times but would not be able to move a squad from hospital to a patient at home in less than 15 minutes from receipt of a call. In the few cases in which …

Health care delivery systems: effects on surgical education.

In the United Kingdom recent changes in government health policy and a reduction in junior doctors' hours are likely to have an effect on surgical training. These changes are occurring at a time when there is increasing specialization in surgical care, which necessitates careful organization of surgical training programs. This paper reviews the interaction of these factors in influencing our attitudes toward surgical training.

No to junior doctors’ second-hand roles

The ‘new deal’ to reduce junior doctors' hours is not an excuse for medics to dump unwanted tasks on nurses, a senior department official said last week.

A ‘New Deal’ for nurses too?

The reduction in junior doctors’ hours presents challenges - but also offers tremendous opportunities for nurses, Frances Pickersgill believes

Junior doctors' work at night: what is done and how much is appropriate?

Regional task forces have given some public health physicians a central role in attempts to reduce junior doctors' hours. This topic is the subject of many diverse opinions and little research. A key issue that has received little attention is the appropriateness of the work undertaken by junior doctors at night. This paper determines whether this work can either be postponed to the following morning or done by someone else. It was undertaken in two phases: a descriptive study using diaries, interviews and collection of data from registers; and identification of consensus on appropriateness of activities by a nominal group technique. The first phase took place in hospitals in the South East of England. The nominal groups consisted of six panels comprising medical, nursing and laboratory scientific staff. The panels identified activities done at night that can either be postponed to the following day or done by someone else and activities where there is disagreement, requiring further research. A third of general surgical and orthopaedic operations could safely be postponed until the following day. Up to a third of the tasks of house officers could be performed by nursing or clerical staff. Many laboratory investigations at night could be postponed until the following day. In conclusion, the work of junior doctors at night could be reduced by producing guidelines on the need to operate at night, by transferring tasks to other professionals, and by reducing the number of sites at which services are provided.