Beyond junior doctors

How WTD will affect nurses, midwives and allied health professionals - Lynne Greenwood

The Working Time Directive - and the subsequent reduction of junior doctors’ hours - provides a unique opportunity for the development and expansion of the role of nurses, according to the Royal College of Nursing.

Already trusts have significantly developed the roles of nurse practitioners, offering beneficial career development at the same time as improving patient care and assisting WTD compliance.

In many cases, doctors, nurses and allied health professionals have come together to create new ways of ‘teamworking’, benefiting both patients and staff.

Bernie Cottam, former acute sector advisor for the Royal College of Nursing (RCN), says, “Since 2000 nurses have led and delivered in terms of NHS modernisation and we know that nurse led services bring many advantages.”

“The RCN is continuing its scoping and mapping of how the ‘nurse of the future’ will look. The involvement of the nursing family in assisting in reducing junior doctors’ hours will contribute to the evidence base and help to shape our concept of nurses’ future roles.”

The RCN work is in line with the comments of Lord Darzi, whose report on the year long review of the NHS is expected in June.

The second half of the Minister’s review included an examination of workforce planning which he said ‘needs an overhaul’ but must be linked with new models of care.

Lord Darzi, who liaised with professional bodies, trade unions, the voluntary sector and other organisations, said it was important to introduce different ways of working to make the most of the talents of staff.

The RCN agrees. Bernie Cottam says, “Yes, we should explore new roles, but this must be in conjunction with both the development and expansion of existing roles.”

“But I do not believe this is about nurses taking on the jobs of doctors - it is about using the right person with the right skills in the right place. Providing nurses have had the proper training and are competent and confident to undertake certain roles in the best interests of the patients, that is a good way forward.”

The RCN has already seen the expansion of the traditional nurse within hospital based settings, where their members have taken on new roles including night or site nurse practitioners, the first point of call for ward staff when a patient is in difficulty, clinical nurse specialists taking on case management, pre-operative assessment and post-operative follow-up roles.

At Guy’s and St Thomas’ NHS Foundation Trust, the role of nurse practitioner has developed to include surgical care practitioners - theatre nurses who have been trained to prepare patients for surgery and conduct follow-up procedures on the wards, work which was previously carried out by junior doctors.

Carolyn Norgate, transformation project lead for Taking Care 24:7 at the trust, says, “Cardiac surgeons reported in March (08) the progress of this new nurse role which we are now hoping to expand into other specialties.”

“The trust was quite clear that the way to achieve WTD compliance was not by throwing extra doctors at it, but about using doctors in the roles for which they were trained and other members of staff in the areas in which they are skilled and can be best used.”

“Since 2004, site nurse practitioners - senior nurses trained for the role - have been the first point of contact for ward staff out of hours. Working on a points system of response, they can either stabilise a patient themselves or escalate the response to call a registrar or consultant.”

“Now the trust is expanding the role to cover day time, first at Guy’s and with plans to introduce it at St Thomas’.”

“In the past, ward nurses would bleep a junior doctor for most issues - for example if a blood test or prescription was needed. If that doctor is in clinic or theatre, it is not always the best use of their time,” says Ms Norgate.

The benefits for ward nurses, she says, are that the nurse practitioners have time to work with the ward team, helping to develop their nursing practice by discussing how situations may be dealt with in the future.

At the Royal Liverpool and Broadgreen University Hospitals NHS Trust, one of the Hospital at Night (HaN) pilot sites, nurse practitioner roles have also been developed.

Trained nurses now head recently introduced acute response teams - who work as ‘virtual teams’ in addition to their normal roles - providing a first point of contact for ward staff with patients who become unwell.

Clare Pratt, project manager for WTD at the trust, explains, “Using a specific agreed form of communication from the ward staff, the nurse practitioner’s role is to triage the patient and then either attend themselves, call a doctor or other members of the team she feels are necessary.”

“Already many patients have been seen by nurses from the acute response team, which has become a very robust system,” she says. “I see it as maintaining the good care and safety of patients.”

There are now plans for the team, which currently operates from 2pm to 7am on weekdays, and round the clock at weekends and Bank Holidays, to extend its cover throughout the day.

“Looking long term the role of the nurse practitioner will evolve and develop still further as circumstances change.”

For midwives and other health professionals, WTD brings different concerns.

The Royal College of Midwives (RCM), whose latest figures show there are currently 25,093 midwives (19,298 full time equivalent), has been involved in discussions around the directive.

George Georgiou, employment relations adviser to the RCM, says that it is important for midwives to know that a consultant or junior doctor is attached to labour wards at all times, in case of emergencies.

“Our concern is that WTD may reduce the number of junior doctors available to midwives who need to call on them for advice or assistance when they encounter problems,” he says. “We are working to ensure this will not happen.”

Midwives’ working patterns will not be directly affected by WTD - their rotas, based on an average 17 week period, already comply.

But for radiographers, WTD will involve a change from a traditional on-call system to shift patterns. Diagnostic radiographers already provide essential out of hours cover, responding to the increasing expectation of a 24/7 service, according to Richard Evans, chief executive officer of the Society Radiographers (SOR) which represents over 90 percent of diagnostic and therapeutic radiographers.

“More and more trusts are asking their managers to look at shift systems for their radiographers,” he says. “But is it important that it is done for the right motives - to provide the proper service and comply with the legislation and not for cost saving purposes.”

A group of SOR members is currently drawing up advice on how shift patterns can be implemented.

WTD has created a number of outstanding issues, says Mr Evans, “Our members know there is not normally enough diagnostic x-ray work to keep them busy during an on-call period, but they need to know whether that will count as working time and, if so, when compensatory rest breaks must be taken.”

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