Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Nurse specialist care
- Gordon Smith, Gordon Smith (28 March 2005)
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What’s the difference between medical and nursing care? - 29 March 2005
- Phillip J. Colquitt (29 March 2005)
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Nurses are autonomous professionals delivering expert care
- Jonathan R Benger, Rebecca Hoskins, Nurse Consultant (30 March 2005)
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Re: Nurses are autonomous professionals delivering expert care
- Hamed Khan (31 March 2005)
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Defining roles!
- Nikhil C Kaushik (31 March 2005)
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Nurse led care- definitions
- J W Albarran (9 April 2005)
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Economic evaluation of nurse-led intermediate care: authors’ response
- Bronagh Walsh, Andrea Steiner, Ruth M. Pickering (3 May 2005)
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Re: Economic evaluation of nurse-led intermediate care: authors’ response
- Peter Griffiths (3 December 2005)
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Gordon Smith, Consultant Urologist Western General Hospital, Edinburgh EH4 2XU, Gordon Smith
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The title page for the issue on 26th March should have been 'Nurse led care is not necessarily true'. Good practice in health care currently demands a collaboration by a number of skilled workers. The process of establishing guidelines within which each member of the team can function, is no longer exclusively the province of senior medical staff. In organising new, more suitable pathways for the patient, clinical nurse specialists will have a major input over what they can and can not contribute. However this is quite different from the process being nurse 'led'. Similarly while working within any team delivering care, there will be patients outlying the normal boundaries or with complex issues. At present these patients will merit discussion or be directed for fuller evaluation by medical staff within the team. It would seem unnecessary to introduce the term 'led' into the title of any such article as it obscures the true nature of a modern team approach. Competing interests: None declared |
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Phillip J. Colquitt, RN Independent Comment
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....your headline link to this article asked. One is sexist, being the expression of a female dominated profession, and the other isn’t, being the expression of a more recently reformed, formerly sexist profession. Phil Colquitt – minority male member of the nursing “profession”. Competing interests: None declared |
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Jonathan R Benger, Consultant in Emergency Medicine Emergency Department, United Bristol Healthcare Trust, Bristol. BS2 8HW, Rebecca Hoskins, Nurse Consultant
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Editor, It is true that non-medical healthcare professionals, mainly nurses, have recently taken on a variety of roles that are traditionally viewed as the province of doctors. Clinical evaluations have generally been positive, suggesting that the skills of the healthcare team are being more effectively utilised, and that similar patient outcomes can be achieved by different approaches.[1,2] Unfortunately the thinking of some professionals has been slower to change, as exemplified by your editorial on nurse led care.[3] We object to the statement that doctors are “delegating” their work to nurses, and the subsequent implication that only simple activities will be appropriate for nurse led care. This statement reinforces the commonly held medical view that nurses are appropriate to fill in where junior doctors are in short supply and the required tasks menial, such as pre- assessment clinics and routine procedures, but not to act as autonomous professionals initiating and delivering high quality care. Such outmoded thinking returns nursing to the status of “handmaiden”, rather than accepting that nurses have a specific set of skills and their own professional accountability. Experienced nurses have been undertaking a variety of “medical” tasks for many years, though often in a covert fashion. We welcome the acknowledgement of the diverse skills that nursing staff can bring to healthcare, and the formal introduction of posts such as the nurse consultant, which is able to develop the nursing role whilst ensuring that the essence of nursing as profession is not lost. Inter-disciplinary teams, not doctors, deliver modern healthcare. Doctors bring their particular skills to the team, but no longer sit at the apex of a hierarchy, delegating to other professions. Whilst it may feel uncomfortable to relinquish the traditional notion of medical control, doctors must embrace and support the development of better healthcare, regardless of the professional training of those who deliver it. 1. Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie LD. Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomised controlled trial. BMJ 2005;330:707-10. 2. Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999;354:1321-26. 3. Cullum N, Spilsbury K, Richardson G. Nurse led care. BMJ 2005;330:682-3. Competing interests: None declared |
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Hamed Khan, SpR Surgery Barnsley DGH
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Interesting comment on doctors no longer sitting at the apex of decision making but unfortunately does not bear any resemblence in truth. I am yet to sit on a meeting of any MDT or other type (out of hundreds that I have joined in) that has been led, organised and dominated by any other professionals other than doctors. This may be peculiar to surgery but I dont think so!! Competing interests: None declared |
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Nikhil C Kaushik, Consultant Ophthalmic Surgeon North East Wales NHS Trust, Croesnewydd Road, Wrexham LL13 7TD
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The healthcare requires a multidisciplinary approach. Doctors and nurses work together and are parts of a total package. The issue is what their respective roles are. It must be appreciated that everyone who qualifies as a Doctor will not finish up as the top notch surgeon, some of us will always perform and make a living by undertaking the less glamourous roles during operations. Many of roles that are being proposed for nurses are considered to be the mundane or boring jobs. But this does not mean that anyone can do these. Every nurse will not be equal to the task of an assistant surgoen. It is that some of the brightest of the nurses will be cherry picked by surgical teams for carrying out such jobs. The net result will be that their talent will be lost to the nursing profession. This is a kind of brain drain where the best nurses leave nursing to do the unpopular jobs that are presently carried out by those holding medical qualification...the present day NCCG doctors and even some DGH based Consultants. Societies must address this aspect of professionalism, and not just look for quick fixes to deliver some ill thought out political agenda. Competing interests: None declared |
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J W Albarran, Principal Lecturer Faculty of Health and Social Care, University of the West of England, BS16 1DD
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Dear Editor, In recent weeks there has been a range of divided opinions in relation to nurse led initiatives [1, 2]. But, such roles prefixed with "nurse led" [3-6] or involving specialist nurse-led home based interventions have become established in certain areas of clinical practice. These have been about improving service delivery and patient experience. It is perhaps useful to define the terms 'Nurse-led,' which is principally about task or role substitution, in which well defined protocols drive the delivery of high quality patient care. For example, we have nurse-led extubation and nurse-led weaning practices, which are about the substitution of former medical tasks to nurses. Nurse-led cardioversion and thrombolysis may be regarded as an intermediate level of medical substitution. The work of nurses is still driven by protocols but the concept of "nurse led" is not exclusive of medical staff being present or participating as appropriate. In this model, a nurse is responsible for the overall co-ordination, management and continuity of care for a specific episode of treatment or intervention. By contrast, in 'nurse- initiated' roles, the nurse will perform clinical assessments, review other data and is authorised to prescribe thrombolytic therapy according to defined protocols or standing order without referring to medical staff. It may be viewed as higher level of substitution but, the role still operates within medical parameters and guidelines. History teaches us a lot. There was a time when junior doctors were required to remain in a coronary care unit and observe cardiac monitors in case a patient suffered from lethal arrhythmias. In due course they were removed because this was ineffective use of their skills and presumably once you saw a few patients in ventricular fibrillation you knew what to look for. Being involved in regular weekly sessions of elective cardioversions may amount to the same feeling for junior doctors. References: 1. Currie MP, Karwatowski SP, Perera J, Langford EJ. Introduction of nurse led DC cardioversion service in a day surgery: prospective study. BMJ 2004;329: 892-894 2. Cullum N, Spilsbury K, Richardson G. Nurse led care. BMJ 2005;330: 682-683 3. Somauroo JD, McCarten P, Appleton B, Amandi A, Rodrigues E. Effectiveness of a ‘thrombolysis nurse’ in shortening delay to thrombolysis in acute myocardial infarction. Journal of the Royal College of Physicians of London 1999; 33(1): 46-50 4.Hughes C, Scott K, Saltissi S, Mullins P. The effects of an acute chest pain nurse (ACPN) on door to needle times at an inner city teaching hospital. Heart (Suppl 1) 1997; 77: 49 5. Stewart M, Vandenbroek AJ, Pearson S, Horowitz JD. Prolonged beneficial effects of a home-base intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med 1998;159:257-61 6.Quinn T, Early experience of nurse-led elective DC Cardioversion. Nursing in Critical Care 1998; 3 (2):59-62 Competing interests: None declared |
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Bronagh Walsh, Lecturer School of Nursing & Midwifery, University of Southampton, Highfield, Southampton. SO17 1BJ., Andrea Steiner, Ruth M. Pickering
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Editor Cullum et al1 contrast the clear benefit demonstrated by Raftery2, with our non-significant trend in improved physical functioning3. A reader of this editorial might conclude that the failure to demonstrate benefit reflected trial size rather than true absence of benefit. We do not believe this to be the case. Cullum et al. postulate a continuum of nurse-led care, from highly protocol driven to more complex, reflected in the two evaluations. Our trial examined the impact of substitution of the professionals leading care, with no other organised difference in content of care4. Raftery’s trial examined a substantial increase in organised care. Results from such differing situations would not be expected to be similar. Our observed difference in physical functioning was small, and smaller still after controlling for confounding variables. Nor was the trend convincingly supported by other outcomes; rates of transfer to institutional care were worse for the nurse led group. The Cochrane meta-analyses4 cited included 5-7 (not 10) stronger and weaker studies; effect sizes for stronger studies alone were smaller in all cases. The review authors state that apparent benefit in discharge to institutional care “is sensitive to the quality of included studies and is clearly not supported by the higher quality research”. The review supports our findings in relation to length of stay and increased resource use. We believe therefore that our trial permits a rational decision as to the value of nurse led intermediate care in acute settings. We maintain that nurse led intermediate care in these settings is convincingly demonstrated to be more expensive than standard care and, whilst some benefits cannot be ruled out, these are unlikely to outweigh the increase in costs. We agree with Griffiths et al.4 that comparison with alternative forms of intermediate care, for which evidence is currently scarce or lacking, is vital. References: 1. Cullum N, Spilsbury K, Richardson G. Nurse led care. BMJ 2005; 330: 682-683. 2. Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie LD. The cost- effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomised trial. BMJ 2005; 330: 707-710. 3. Walsh B, Steiner A, Pickering RM, Ward-Basu J. Economic evaluation of nurse led intermediate care versus standard care for post-acute medical patients: cost minimisation analysis of data from a randomised controlled trial. BMJ 2005; 330: 699-702. 4. Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie G. Effectiveness of intermediate care in nursing led in-patient units. Cochrane Database of Systematic Reviews 2004 Issue 4 Art. No. CD002214. pub 2. 5. Walsh B, Steiner A, Warr J, Sheron L, Pickering RM. Nurse-led inpatient care: opening the ‘black box’. International Journal of Nursing Studies 40: 307-19, 2003. Competing interests: The authors carried out one of the trials which was the subject of this editorial and have published other work on nurse led intermediate care. |
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Peter Griffiths, Senior Lecturer King's College London, SE1 8WA
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As the author of both the review (1)which is cited by both Cullum et al (2)and Walsh et al (3)in addition to a 'complaining' letter about the editorial coverage on this paper (4)I feel I must point out an error in Walsh's response to Cullum. Although I am broadly sympathetic to the argument offered, our review did not state that apparent benefit in discharge to institutional care “is sensitive to the quality of included studies and is CLEARLY NOT supported by the higher quality research”. Rather we said that "This conclusion is sensitive to the quality of included studies and is NOT CLEARLY supported by the higher quality research...". An important difference in emphasis. Further the sentence concluded "...although the trend across all studies is consistent". Although the validity of a cost effectiveness analsyis based upon the evidence of their study alone is clearly arguable the impression given of the overall evidence base is a little misleading. 1. Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie G. Effectiveness of intermediate care in nursing led in-patient units. Cochrane Database of Systematic Reviews 2004 Issue 4 Art. No. CD002214. pub 2. 2. Cullum N, Spilsbury K, Richardson G. Nurse led care. BMJ 2005; 330: 682-683. 3. Walsh B, Steiner A, Pickering RM, Ward-Basu J. Economic evaluation of nurse led intermediate care versus standard care for post-acute medical patients: cost minimisation analysis of data from a randomised controlled trial. BMJ 2005; 330: 699-702. 4. Griffiths P. Nurse led care: Comment in This week in the BMJ is misleading. BMJ 2005;330(7499):1084-. Competing interests: I wrote the article which is quoted |
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