Nursing—the wave of the future
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2355 (Published 31 May 2018) Cite this as: BMJ 2018;361:k2355
All rapid responses
Dr Nick Mann (rapid response) is in error. Dentists registered with the GDC are also now doctors. And qualified veterinary surgeons too are doctors.
Once upon a time, only medical students and junior doctors used to strut with the stethoscope slung round the neck. Then, in the seventies, intensive care nurses and nurses in family planning clinics started to sport stethoscopes.
As for making “nurse” a protected designation - problems.
Not unless you define and legislate thus:
BE IT HEREBY ENACTED That -
There shall be
matrons (subsuming patrons)
assistant matrons
sisters
charge nurses
staff grade nurses
enrolled nurses
nursing assistants
health care assistants
employed in all registered nursing homes, hospitals, private and state-run
employed by local authorities
employed by registered nursing agencies.
It is further ENACTED that any transgression of this Act shall be punishable by imprisonment for seven days and fine ranging from £1 to Pounds 999.
Competing interests: No competing interests
Nurses have contributed a lot to the health care system in India. Under the National Health Mission initiative of the Government of India, there is a strong felt need for providing newer roles for nurses in far flung areas where doctors are not available. The presently existing sub-centres catering for a population of 5000 in the plain, valley areas and 3000 population in hilly, tribal areas are being renamed "Health and Wellness centres". Earlier, a male and female health worker were posted to such centres and they were implementing the national health programmes.
Taking cognisance of non-availability of trained manpower and doctors even in the primary health centre, a level above the erstwhile sub-centre, the Government of India has initiated a bridge course to update the knowledge and skills of working nurses (having a qualification of General Nurse Midwifery ). The course is being developed in collaboration with officials of the Ministry of Health and Family Welfare, Government of India (MOHFW) and Indira Gandhi National Open University, New Delhi (India) and titled as BPCCHN programme (Certificate in Community Health). The course is being funded by MOHFW, India and the desiring nurses are selected based on selection test, aptitude for working in rural area. The course is run for 6 months with skill development at the district hospital level. They are taught clinical skills, basic epidemiology of communicable, non communicable diseases, identification, basic management of common health problems (all body systems) and provide referral in case of serious illnesses to higher health facility besides health promotion activities. Once the course is completed after passing a final examination, they are proposed to be placed in the health and wellness centres. During the course work, they are given stipend in addition to their salary and once they are posted in the health and wellness centres incentives in the form of higher pay scale are incorporated so that they stay in the rural areas. Their position is now being referred to as "Community Health Officer". The present initiative is supposed to provide a greater role to the nursing profession and boost the health care delivery in the rural and far flung areas of India.
Competing interests: No competing interests
I appreciate the idea of nurses taking on wider roles to enhance medicine.<1> I notice that other healthcare professionals, such as pharmacists and physician associates, are also trying to expand their scopes of practice.<2><3><4> Nevertheless, should we rather spend more effort to ensure all professions have the fundamental skills for their jobs?
As suggested in a BMA publication, doctors are more likely to perform a procedure than nurses.<5> In many NHS hospital wards, doctors cannot easily find other professionals to perform minor procedures, such as venepuncture, intravenous cannulation, and urinary catherization. This creates huge workload for on-call doctors, and distract them away from their intellectual input to patient care. My nursing colleagues in Canada are often shocked to hear doctors are required to perform these procedures in the UK.
My British medical colleagues have offered to teach other professionals on these procedures, but tend to receive lukewarm responses. Some of these professionals suddenly said they knew everything about the procedures and did not need us to teach them. Some learnt the procedures, but somehow forgot what they learnt as soon as the next group of junior doctors rotated to the placement.
As an analogy, it would be embarrassing if pharmacists said they could not do dispensary work, but would only take on wider roles in consultation. When I worked as a pharmacist in the past, my supervisor reminded me to take responsibility on drug-related issues in both the wards and dispensary. He added, “If another profession can do all your jobs, then you're just replaceable."
I am worried who would provide the essential services, such as minor procedures, to patients when everyone else wants to take on a bigger leadership role. Would “I don’t know how to do it” become a trump card to deny a task?
References:
1. Crisp N. Nursing—the wave of the future. BMJ. 2018;361:k2355.
2. Yeung EYH. Explaining the role of pharmacists in multidisciplinary care. Br J Gen Pract. 2017;67(663):447-448.
3. Yeung EYH. Pharmacists are not physician assistants. Br J Gen Pract. 2017;67(665):548-548.
4. Jackson B, Marshall M, Schofield S. Barriers and facilitators to integration of physician associates into the general practice workforce: a grounded theory approach. Br J Gen Pract. 2017;67(664):e785-e791.
5. Are doctors more willing to 'have a go' than nurses? London, UK: British Medical Association; 2015 Mar 25; cited [2018 Jun 3]. Available from: https://www.bma.org.uk/connecting-doctors/b/the-secret-doctor/posts/are-....
Competing interests: I have been paid for working as a pharmacist and medical doctor, but not writing this letter.
Yes, important point: we need more Nurses, appropriately upskilled.
I suggest a key measure for Nursing Now to raise the profile and status of Nurses would be to lobby Parliament to mandate that 'Nurse' - like 'Doctor' - becomes a legally protected title.
Competing interests: No competing interests
Re: Nursing—the wave of the future
Crisp highlights the need for healthcare to look beyond the medical profession in finding solutions to deal with an expanding and ageing population with multiple non communicable diseases. Ever increasing costs of delivering care within conventional models and hospital based systems can no longer be considered sustainable or affordable in a global sense. New diagnostics and expensive treatments pose real threats to crippling already fragile health systems, particularly in the developed world.
Reverse innovation allows us to tap into the strengths of the developing world to maximise capabilities and responsibilities of our nursing staff, many of whom wish to do much more from a patient care perspective. These opportunities are however often limited for nurses due to a lack of funding, restricted through regulation or by lack of acceptance and support from senior medical staff. The rampant increase in technology with its capabilities and affordability provides unprecedented opportunities to connect with and effect care delivery into remote and isolated areas; regions where there is chronic and severe shortage of healthcare workers. Not only is it the sheer size of the nursing workforce globally, but their sensitivity, knowledge, skills and unflinching commitment to holistic patient care that is universally accepted.
We agree that it is time to break the shackles of rigid and limited roles for nurses and open the gates to opportunity through workforce upskilling in order to realise better access and quality of care for all patients.
Competing interests: No competing interests