Role Expansion of Support Staff in the NHS
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In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres.
We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve.
The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation.
The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research.
There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker.
In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996)
Evidence of change
In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity.
Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably “hard” statistics that give us much firmer evidence of change in the NHS.
Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff.
In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into
330,620 nursing, midwifery and health visiting staff (246,010 being qualified)
100,440 scientific, therapeutic and technical staff
17,940 healthcare assistants
21,430 were managers
the rest were estates, clerical and administrative staff
79% were women and
6% were from ethnic minorities
If we compare this with the situation in 2000 by looking at the same parameters we can see:
346,180 nursing, midwifery and health visitor staff (256,280 were qualified).
110,410 scientific, therapeutic and technical staff
62,870 support staff and
23,140 healthcare assistants.
68% were direct care staff and 32% were management and support staff.
79% were women and 7% from the ethnic minorities
And in 2001 we find a further difference, which is rather more dramatic:
458, 580 nursing, midwifery and health visitor staff (330,540 were qualified)
139,050 scientific, therapeutic and technical staff
23,140 healthcare assistants.
82% were women and 6% from the ethnic minorities
If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996)
If we consider the documented trends in support staff we can trace
Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years.
Reasons for change
In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999)
In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time.
One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994)
These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice.
Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators.
The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994)
It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate.
An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics.
Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001)
The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A & E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997)
The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres.
More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas.
A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an “ideal goal” but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals “in which financial control, service performance, and clinical quality are fully integrated at every level” are behind the major thrust of the piece.
Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005).
We also note that the “stage was being set” for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely:
Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance)
It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important
Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians
New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care
It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing & Midwifery Council about the expansion of professional roles.
Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world.
The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005)
Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:-
NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments.
Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation.
Tools of change
Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate.
One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise.
One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996)
One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000),
The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :-
These were a set of reforms that were designed to “streamline the administration “ of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988)
It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999)
The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005)
In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:-
Increase funding and reform
Aim to redress geographical inequalities,
Improve service standards,
Extend patient choice.
These aims have been, to some extent translated into reality. Let us examine each in detail.
The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a £500 million “performance fund” for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later.
The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004)
It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005)
We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003)
Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital.
None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001)
In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of:
a) making more money available
b) adopting progressive management strategies
c) increasing staffing levels and redefining some roles within the NHS
( after Dixon et al 2003)
It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally.
Reading of the provisions reveals that the general provision of £280 million over a three year period to “develop specific designated staff skills”. One of the proposed mechanisms is to set up individual learning accounts which will be worth £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms.
The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries.
The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002)
If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry
- a lack of national standards
- old-fashioned demarcations between staff and barriers between services
- a lack of clear incentives and levers to improve performance
- over-centralisation and disempowered patients. (Nickols 2004)
One observation that is also relevant to our considerations here is the phrase “seamless interface” appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003)
Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005).
The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative “sample” we will consider just one, the National Service Framework for the elderly.
In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004).
If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that:
Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries.
One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff.
The concept of “Person Centred Care” is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care.
The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998).
The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000).
The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005)
In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients.
We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the roles of just about all of the various sub-disciplines of support staff who have an input into patient care. Because of this we shall expand our consideration and highlight some of the differences in expectation between these concepts and working practices.
We can point to the fact that the prime difference between the concepts of multidisciplinary team working, the seamless interteam interface and the Single Assessment Process, is the fact that because of the mechanisms that have allowed the development of the first two concepts, together with the passage of time (and thereby bringing inherent acceptance), the various professional groupings in the healthcare continuum can both work and communicate together efficiently and well in the vast majority of cases
(Yura H et al 1998).
Each discipline will carry out the assessment of a patient needs in both their own discipline-specific way and in their own vocabulary-specific terms. For example, the patient may have difficulty in transferring from chair to bed. The nurse will assess this problem in terms of mechanical lifting assistance, the physiotherapist could assess the problem in terms of quadriceps weakness and the occupational therapist could assess the same problem in terms of chair adaptations and hand grips. All are clearly seeing the same problem, but in terms of their own training and discipline. It is the nature of this fundamental change of assessment process which is central to the role expansion of each of the support staff.
In the National Service Framework the purpose of the Single Assessment Process has been defined as:
Individuals are placed at the heart of assessment and care planning, and these processes are timely and in proportion to individuals' needs.
Professionals are willing, able and confident to use their judgement.
Care plans or statements of service delivery are routinely produced and service users receive a copy.
Professionals contribute to assessments in the most effective way, and care co-ordinators are agreed in individual cases when necessary.
Information is collected, stored and shared as effectively as possible and subject to consent.
Professionals and agencies do not duplicate each other's assessments.
(NHS KSF 2004)
It is clearly a matter of semantics as to whether this is considered an expansion or a realignment of the roles of support staff, but it clearly represents a change in the older perceptions of staff-specific roles.
This type of intervention is seen frequently throughout the National Service Framework concept. The subtle role change of the staff is a result of the power shift that the National Service Frameworks promote, from the patient being at the periphery as simply a recipient of whatever healthcare is measured out, to the patient being considered at the centre as a discerning consumer or “customer/client”. (Baggott R 2004 A )
Any significant doubt as to the validity of that statement should be dispelled by the series of surveys that have been carried out at Trust level on patient satisfaction and patient requirements that have been reviewed by Baggott (R 2004 B). This type of qualitative survey is becoming more commonplace as the managers attempt to try to assess the impact of this type of role expansion of the staff.
Surveys have been promoted in respect of patient’s perceptions of respect, dignity and care of emotional needs as well as the more “usual “ type of survey relating to expediency of access, waiting list times and healthcare outcomes. The former are a way of providing feedback as to the success of the implementation of the various aims that have resulted in this expansion of role, at least in terms of patient perception. Parallel surveys have been carried out in respect of some of the other “extra-hospital” support staff in the social service sector of healthcare provision by looking at and assessing patient and carer’s views on subjects such as the increased services available for carers, day care, night respite and leisure provision for both carers and patients. (Ham C. 2004).
Another, and this time very specific, role expansion mainly for the nurse, but it could potentially be for any of the support staff, is the introduction of the concept of the “Patient’s Champion”. (Bartley M. 2004). This is a role expansion specifically created in response to the patient-centred concept of the National Service Frameworks. Those patients who may not be able to speak up for themselves effectively such as the elderly, the ethnic elderly and those who have learning difficulties, are specifically those who may well have need of a “Champion” to ensure that their needs and wishes are both met or respected.
One of the fundamental principles that the NHS Plan champions is that of team work. We have alluded to it in other segments of this assessment but it is of fundamental importance and it merits specific consideration in its own right. To a large extent it is a logical progression from, and related directly to the preceding principal of the seamless interface in a professional context. The NHS Plan is notable for its distinction between intra-team working and inter-team working. It clearly advocates and champions the change from the former to the latter.
The pre-2000 NHS was historically constructed on the concept of teams, medical, surgical, nursing, physiotherapy to name but a few. There would be considerable intra-team liaison and work load sharing but each team was very insular in construction, function and ideology. (Netten et al 1996)
Each professional speciality historically developed its own empire and professional “territory” and, within its own professional boundaries, was largely self regulating. (Lee et al 2004)
In specific terms relating to our topic, the surgical team, although clearly working with the support staff in the Operating Theatre, would be considered, and indeed consider themselves, a functionally separate unit. The recovery nurses would hand the patient over to other nurses who they would regard as professional colleagues, but on a completely different team. The theatre technicians would equally consider themselves as a separate entity from the theatre nurses. (see on).
This elemental and tribal mind set clearly had some advantages as it could be considered as fostering specific profession-specific skills and the acceptance that other professionals had other skills that could be called upon if the need arose. The NHS Plan’s call for the implementation of the inter-team approach had, to a fair degree, been based upon the fact that such an approach had already been established and appeared to be working well in the primary healthcare team setting. (Indredavik et al 2000)
It seems also fair to observe that such comments and observation relating to insular and isolationist practices are not minority views a number of papers refer to the concept and call for it to be changed, both in terms of changes in the working practices of professionals within the NHS (Donaghy et al 2000) and also in terms of an end to isolationism and a smoother integration of all aspects of healthcare between the various professionals involved in the care of the patient. (Lee et al 2004)
The whole issue of expansion of roles amongst support staff is far from straight forward. One issue that we have already touched on (and will discuss in detail later ) is the issue of assumption of responsibility. In the NHS of more than a few decades ago, (the traditional NHS), the roles of each professional were tightly defined and responsibility and liability was clearly understood by all concerned. (Walsh J 2000).
The current trend that we are examining here of the expansion of roles inevitably will be seen as a blurring of the inter-profession dividing lines that were traditionally observed. With the blurring comes also a lack of clarity. If this is considered alongside the concepts of multidisciplinary working and inter-team co-operation then the role expansion is seen as being fraught with practical difficulty, not the least of which are ethical and practical considerations. We will consider these elements at some length.
We can observe that the Nursing & Midwifery Council have recognised this trend of change with the production of a set of Professional Standards which now cover the most important elements of practice and, of particular relevance to our considerations here, they specifically address the issues involved where hitherto, normally accepted role boundaries are crossed. Specifically it sets out in Paragraph 1.3
You are personally accountable for your practice. This means that you are answerable for your actions or omissions, regardless of advice or directions from another professional.
The implications of this may not be immediately obvious to the nurse, physiotherapist, doctor or occupational therapist working in their traditional roles, as, in those circumstances, it is simply stating what has been accepted practice for many years. For example, traditionally a nurse would carry out the doctor’s instructions and would not be held responsible if those instructions turned out to be wrong. The doctor, in those circumstances would assume a vicarious liability and responsibility to make certain that his instructions did not cause difficulties with another healthcare professional’s conduct. GMC (1995).
The case arises that, if in an expanded role, the nurse (or other healthcare professional) takes on additional responsibility, then it is expected that they will also assume a degree of the vicarious responsibility. The more modern interpretations of the situation suggest that, in the same circumstances as suggested above, the doctor would not be absolved of responsibility. He would still be criticised if his instructions were incomplete or incorrect, but the progressive rise of the support staff and nursing staff in particular in recent years, effectively means that more professionalism is expected and that translates into more responsibility being taken. (Walsh 2000)
Having considered this point there are several other sequelae that come from it. The N &MC directive also has a number of other clarifying paragraphs which, although helping with the interpretation of their guidance, strongly suggests that the situation is actually considerably more complex than our simplistic overview suggests.
Whilst stating that the healthcare professional must retain responsibility for their own actions, the instruction immediately before reminds them that they must “co-operate with other in the team, maintain their own levels of professional knowledge and competence and equally act to identify and minimise the risk to both patients and clients”. Clearly this leads us to an area of potential conflict. As Hunt (1994) points out :-
How is the nurse supposed to resolve a situation where, when working as part of a team, she sees something that is, in her opinion, not correct? On the one hand she has instructions to co-operate with others in the team and yet she must also maintain her own professional integrity.
In order to resolve the issue we can consider the second part of the guidance which suggests that a healthcare professional should always act to minimise the risk to both patients or clients. If the healthcare professional feels that something is not in the best interests of the patient then there is an implied obligation on them to speak out. (Holm S 1997).
In specific consideration of our topic here we should also note that as well as actually devolving the implied, and actual, responsibility for the doctor’s actions onto the healthcare professional, the directive also allows for further professional delegation from the nurse (in her expanded role) under exactly the same terms. Paragraph 4.6 states that :-
You may be expected to delegate care delivery to others who are not registered nurses or midwives. Such delegation must not compromise existing care, but must be directed to meeting the needs and serving the interests of the patients….you remain accountable for the appropriateness of the delegation, for ensuring that the person who does the work is able to do it and that adequate supervision or support is provided.
Further reading of the document tells us that personal and professional responsibility is extended to “ensuring the promotion and protection of the dignity and interests of patients irrespective of culture, race, gender, ability, sexuality, economic status, lifestyle, culture or religious or political beliefs” (Paragraph 2.2). The effect of this is to make for a wide and indeed onerous burden of professional responsibility. It is clear from reading this document that the implications are that, as the role of the healthcare professional expands, so do the burdens and expectations of responsibility. It is not just about assuming the mantle of an expanded work load or copying part of the actions of a skilled professional in some degree, it is actually the assumption of the whole package of professional responsibility that goes with the newly assumed role. (Sugarman J & Sulmasy 2001)
We shall consider the implications of role expansion in the context of multidisciplinary team work and the implications of the “seamless interface” later, but in the context of the guidance that we are considering here, we should also note that there are specific section of the directive that relate to these specific topics. The burden of professional responsibility in these circumstances includes a commitment to “communicate effectively and share your knowledge, skill and expertise with other members of the team, as required for the benefit of patients.” (Paragraph 4.3). Again, this is not simply an altruistic requirement to pass on the particular knowledge that you may have on a subject, but is actually an important practical safeguard that if you feel that a particular course of action is of benefit to the patient then you should share that opinion with the rest of the team so that they may all consider its implications. This, hopefully, will have the effect of reducing errors of judgement by bringing collective consideration to bear on the decision-making process.
Mechanisms of change
If we now accept the basic premise that change is both required and beneficial, there remains the question, how best to instigate and implement it? There is no hard and fast rule, but we can examine several models of implementation of change which may help to evaluate the feasibility of the prospect. Dench (2005) produced an interesting and relevant paper on experiences gained in staff behavioural modification which outlines many relevant principles that are both relevant to, and could well be adopted by NHS support staff.
The author makes the point that although staff are the key agents in delivering support in the workplace, effective technologies for staff training are not well developed.
If we consider the historical evaluation of attempts to institute implementation of behavioural strategies for staff, although the expressed intention is often there, attempts at both achieving and maintaining these changes have proved difficult (Kazdin 1978)
A brief overview of the literature on the subject of managing change shows many references to the fact that change, once achieved if often difficult to maintain, particularly if specific behaviour enhancing strategies are not specifically implemented.
Emerson & Emerson (1987), admittedly in a different context, point to the fact that a lack of knowledge of behavioural principles was closely linked to a failure to either achieve or even implement effective and lasting interventions by professional staff. If this is also as a result of inadequate training or lack of support from specialists (see discussion relating to nurse-endoscopist ) then the results of an evolution of role definition is less likely to be achieved and maintained. Berryman (et al, 1994) also point to the inappropriate modelling of interventions or multidisciplinary team involvement (see on) as being some of the more potent reasons for failure.
Before any move to institute a role expansion of staff is implemented there appears to be a general agreement that effective training strategies to promote the development of appropriate competencies at the new level are developed prior to the instigation of any conversion package. (Girot EA 1995)
As we have implied earlier in this dissertation the actual management of change is one of the most critical elements in this discussion. It is of no value to decide that change needs to be made, or even, for that matter, making a judgement about an appropriate degree or direction of change, if one does not have either the will, the knowledge or the capability to implement it properly. There is no value in having either vision or ideas if they cannot be translated into reality. (Bennis et al 1999).
The science of the management of change is based, linked and integrated by a well established set of principles known as the General Systems theory (Newell et al 1992). This is a hugely complex area but can effectively be summed up in the phrase “Unfreezing, Changing and Refreezing” in other words, assessing a situation changing it, and then making the changes stick. (Thompson 1992). Consideration of the failure of the Griffiths Report (above) to deliver what it promised in terms of management reorganisation could, in essence, be ascribed to the fact that it was imposed rather than managed. (Davidmann 1988)
We can therefore take a similar view as Marinker (Marinker M.1997) and suggest that there is a subtle but fundamental difference between compliance and concordance. We can find resonance with his suggestion that human beings, in general terms, respond better to suggestion, reason and coercion rather than to direct imposition of an arbitrary change. If people know and accept the reasoning behind the thinking in a concept, they are far more likely to embrace and accept it.
Exploration of specific instances of change in working practices
Earlier on we considered the suggestion that the move towards day case surgery was, at least partially, a result of the introduction of performance indicators and we made the assertion that this led to a change in the role of support staff. It is therefore appropriate to consider the evidence base behind this statement. If we examine the paper by McLeod (H et al 2003) which considers the implications consequent on booking patients for day case procedures.
The importance of this paper, in respect of our considerations here, is not actually the change in working patterns, which obviously was needed to accommodate the switch to day case surgery but the way in which this change expanded the role of the supporting staff.
Firstly, it has to be observed that the trial itself was huge with 24 sites across the UK and it ran over an 18 month period. The issues relating to role expansion are actually a subsidiary issue as far as the study was concerned even though they are of importance to our considerations here. They record that the Department of Health allocated £9.9 million to fund the project and this was primarily spent on expanding the roles of the current support staff.
To quote the authors verbatim the money was used to:
employ project managers, purchase equipment, buy additional time from clinical and other staff, and invest in information and communications technology. The National Patients' Access Team organised monthly meetings for project managers and other staff to enable them to be trained in service redesign skills and to exchange experience with their peers.
Each pilot site set up project management arrangements involving a project manager or project team under the direction of a steering group. In some sites there was a strong commitment to the project through the close involvement of chief executives of hospital trusts and clinical leaders. These sites gave priority to staff training to support the programme and used the extra funds they were allocated in the ways indicated above.
We would suggest that the key to the importance of the consideration here is the commitment to staff training which clearly suggests that the staff were expanding into new and unaccustomed roles.
The authors did draw the conclusion that, despite these measures, the overall project was not a sustainable success as the initial improvements made were soon nullified by the increased demand consequent on the initial success of reducing the waiting times.
Role expansion in specific relation to the nursing profession.
Another major role expansion that we can cite is that of the progressive trend to technicalisation of the nursing profession. The role of the nurse has been progressively diversifying over the recent past. Nurses, like many others in different branches of the healthcare professional spectrum, are moving away from their hitherto traditional caring role and assuming the mantle of specialists in their own right. Roles that, only a decade ago were considered to be the unassailable province of the medically qualified practitioner, are being taken over by the nurse specialist.
In this respect we shall consider two different examples. The nurse as endoscopist and the nurse as a prescriber. It is fair to comment that there are clearly many other examples of this type of role expansion, but we shall examine these two in considerable detail as being , to a degree, representative of the general trend.
Endoscopy had hitherto be virtually totally the province of the surgeon or occasionally the gastroenterologist. (Di Sario et al 1993). The technological, expectational and professional changes that have accompanied the evolution of the NHS that we have been examining here, have allowed a role expansion of the nurse in directions undreamt of previously. (Raskin et al. 1999)
The nurse endoscopist.
Endoscopy became a commonly used procedure with the development of the modern flexible endoscope in the 1980s. The instrument has now developed to the extent that it allows unparalleled views of many of the hollow viscera that have a communication to the outside. It is, from a technological point of view a far cry from the rigid gastroscope and sigmoidoscope of the pre-flexible era. These advances have been accompanied by a comparative explosion in their uses and application which have increased almost exponentially over the last two decades with its demand outstripping the availability of trained endoscopists to provide sessions. (Waye JD: 1999).
We will discuss this situation in the context of the training of the nurse as endoscopy specialist in order, not only to fill in the short fall, but also in the context as a professional role expansion which is consistent with the professional standing of the nurse in the modern NHS. This can be considered as an not only an expansion of the role as support staff but in some respects as a transition from support staff to “supported “ specialist staff.
The professional status of the nurse-endoscopist was formalised in the early 1990s with the convening of a working party of the British Society of Gastroentorologists to explore and regulate the emergence of the phenomenon. This culminated in a report in 1994, the basis of which is still valid today (BSG 1994).
In essence, the first report can be summarised as follows:-
1. There is increasing interest and demand from within both the medical and nursing professions for nurses to perform endoscopy.
2. Studies have shown that nurses can develop the necessary skills. In addition they have the support of the United Kingdom Central Council for Nursing.
3. Medico-legally a nurse may perform an endoscopy provided he/she has received the appropriate training, has the support of the Health Authority/Trust and is adequately supervised by the responsible consultant.
4. Nurse Endoscopy should be restricted to diagnostic oesophago-gastro-duodenoscopy and sigmoidoscopy with or without biopsy on non-sedated patients at the present time, carried out in a recognised hospital Endoscopy Department.
5. Careful patient selection is essential to exclude high risk patients, those likely to need therapeutic procedures or requiring sedation.
6. Nurse Endoscopist training should follow the same schedule recommended for medical endoscopy by the British Society of Gastroenterology (BSG) and should include attendance at a recognised teaching course in endoscopy. The training should include anatomy and physiology relevant to the type of endoscopy being performed.
7. A designated medical Endoscopist should be immediately available within the Hospital during Nurse Endoscopy sessions.
8. The nurse should be responsible for obtaining consent from the patient prior to endoscopy and for discussing the findings with the patient after the procedure.
9. The nurse should be responsible for preparing the endoscopy report which he/she should sign. However further patient management should remain the responsibility of the supervising doctor.
10. Regular records and audit of the Nurse Endoscopist's work should take place.
11. Continuing education is essential with regular opportunities to attend Endoscopy courses and meetings.
The literature reveals only a very few good quality papers on the experience of transition between qualified nurse and specialist nurse-endoscopist. One of the best has to be the paper by Vance (Vance 2002), herself a Consultant nurse-endoscopist, who considers the aspects from both a theoretical and a practical aspect in a remarkable tour de force on the subject. The paper itself is structured with a “retrospective qualitative research design, using an exploratory descriptive methodology”.
Although the study can be considered both thorough and indeed complex, in the light of consideration of our subject here, arguably the most relevant finding can be summarised as discovering that the main problem experienced by the trainee endoscopists was a serious underestimation of amount of both practical and theoretical knowledge that was required to effect the transition and training programme. (Sivak 2000).
Other papers in the area concur that the actual skill acquisition was universally the least challenging part of the subject to master. (Teague 2000)
In consideration of the expansion of roles generally amongst support staff, one theme constantly recurs in analytical papers, and that is that, where the role expansion culminates in the acquisition of new practical (or theoretical) skills, in order for there to be a continued confidence in technical competence, continued training and support (perhaps in the form of mentorship) is vital. This is clearly recognised in this particular instance with the inclusion of the recommendation for protected time for this purpose in the BSG’s guidelines. This is generally acknowledged as being vital not only for the acquisition of new skills but also for the maintenance of existing skill levels. Clearly there is no value for either the endoscopist or the patient, if newly acquired skills are not maintained.
Practical implications of the expanded role
In this examination of the expanding role of the support staff in the NHS it is important not only to evaluate the actual role that they are expanding into but also the implications of this expansion. In this respect we shall continue our examination of the evolution of the nurse-endoscopist and consider some of the major implications of this new role.
Two particular issues which arise as a direct response to the expanding role of the nurse in this context are those of consent and professional indemnity. Consent is not only a legal and ethical prerequisite of good clinical practice, it is the single most important shield against the possibility of legal action. (MPS 2005).
The important issue here is that of informed consent. It is not sufficient for the patient to simply say “yes” to the procedure. Informed consent is the gold standard and it is vital that the patient understands and fully appreciates the expected nature of the procedure together with the possibility of what could potentially happen if the unexpected occurs. (ASGE 1988). One of the arguments that has been advanced against the expansion of the nursing role in this direction is that it follows that the operator must be fully conversant with all of these eventualities in order that they can be confident that they, themselves have appropriately explained all of the relevant facts to the patient.
The fact of the matter is that the nursing training is structurally, factually and functionally different from a doctor’s training and the nurse may be perfectly competent to technically perform the procedure, but may have to accomplish a great deal of associated learning in order to feel confident to address any question that the patient may put to them during the process of obtaining consent. (Baillie J 1997).
The operator must strike a professional balance between satisfying themselves that the patient is in possession of all of the relevant facts (as the operator sees them in any particular case), to enable them to make a reasoned and rational decision regarding consent, and not bombarding them with an information overload that may either be beyond the patient’s ability to assimilate, or “scraping the barrel” with potential complications which will have little practical effect other than to unrealistically scare the patient before the procedure begins.
The professional concept of empowerment and education must be paramount in the mind of the operator. The patient needs to be sufficiently educated in a field with which they are unlikely to be particularly familiar and to feel empowered to make a completely informed decision (Gilbert T 1995)
The majority of practical problems that are encountered after an endoscopy procedure occur because of a basic failure of communication between operator and patient, either before or sometimes during the procedure, and this is true whether the operator is a nurse-endoscopist of medically qualified.
We note that some centres have evolved a policy whereby the patient is mailed at sometime before their procedure with an explanatory leaflet which is designed to meet this balance between too much and too little information. It has been designed with help and approval of the British Society of Gastroenterologists (BSG 2005) It also has the advantage that the patient can sit and consider it at leisure in their own home and then formulate any questions that they might have that have not been addressed in the leaflet. (Thompson et al.2003),This is generally considered a better option than the normal practicality of getting them to sign the consent form in a hurried fashion just before the procedure. (Higgins et al. 1996)
Another issue that has been highlighted is the issue of communication with the patient . A nurse has traditionally been able to talk to a patient as part of their caring role. All healthcare professionals need to depend, to a greater or lesser extent, on their ability to communicate. Partly this is an innate skill but, as with most skills, it is one that is capable of being both refined, taught and improved. (ASGE 1999)
Although we conceed that it is a great generalisation, a patient will typically communicate with a nurse on the level of a knowledgeable friend and with a doctor on the level of an experienced professional whose authority they are less likely to challenge or question. (The A-M et al 2000). The significance of this observation (if it is accepted to be true) is that the nurse, in expanding their role, crosses a
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