Health: Sisters are doing it for themselves: Why shouldn't a nurse tend a cut finger? Stephen Ward reports on a new unit where accident patients don't have to see a doctor
Tuesday 01 March 1994
But Daniel will not be seeing a doctor; not at first anyway. If the wound is not serious he won't see a doctor at all.
Instead, he will be treated by a specially trained nurse practitioner at St Albans City Hospital's Minor Injuries Unit, which opened last year.
Daniel's finger is inspected by Rita Dunkerley, a registered nurse with 20 years' service in the hospital's accident and emergency unit - before it closed in March last year. The departure of the A & E department to the nearby Hemel Hempstead Hospital has stunned local people. It has meant that St Albans has become a test bed for nurse practitioner units which could become increasingly common as market forces bite further into the NHS.
Mrs Dunkerley asks Daniel to bend and straighten the injured finger and decides the cut is not too deep. She cleans it and seals it with steristrip to keep the loose flap of flesh in place, so that the wound heals with the minimum of scarring and the least risk of infection.
Daniel's mother, Deborah, says: 'I didn't know what to do. The school secretary told me I could go to the hospital because they had a minor injuries unit.' After the treatment she adds: 'I am quite happy. I needed to get Daniel seen quickly and it has been done perfectly satisfactorily. I am not at all worried that we have not seen a doctor.'
Philip Nye, director of nursing at St Albans City Hospital and Hemel Hempstead Hospital, says that there continues to be resistance to the new unit at a local level. 'There is still ill feeling when you ask people what they think, because they see this as a city that has lost its accident department. We say: all right, but let us look at what is here and what is here is meeting the bulk of the need.'
The unit is one of a handful around the country and is open 24 hours a day. It is staffed by six nurse practitioners - qualified nurses who have received additional training in diagnosis. They each work a 12-hour shift rota and there are two on duty at any one time, aided by one health care assistant. The nurses have been regraded so that their salaries are higher than before.
The unit is housed in the old casualty department of the hospital where Anita Lees, who has 19 years' casualty experience, is sister-in- charge. 'We don't have a doctor here,' she says. 'We are trained to make a diagnosis and to carry out certain treatments. In an accident department every patient must see a doctor. Although initially a nurse may see a patient with a cut, she would have to say: 'I will just put a temporary dressing on you and then you can sit in the waiting room. When the doctor has seen the other patients he or she will see you'.
''A patient with a minor injury might have to wait several hours. But here we can deal with them straight away. It is much more efficient and you don't have all the distractions of serious cases that you would get in an A & E unit.
'We are allowed to deal with patients who have injured limbs, twisted ankles, injuries to hands and arms; we can take X-rays of patients from the elbow down and from the knee down; we undertake stitching of wounds providing nothing vital has been cut such as tendons or nerves, take pieces of floating debris out of eyes and a whole range of things that children put in their noses and ears.'
The nurse practitioners also deal with some acute infections, such as those in the nail. 'We are able to lance those,' Mrs Lees says. 'And during the summer we get a lot of insect bites and stings.'
In more serious cases, the nurses will arrange an immediate transfer to the casualty unit at Hemel Hempstead, although they are able to give life support and resuscitation if required. Any other case that needs a doctor is referred to the appropriate unit - a child with a very inflamed eardrum, for example, will be referred to a GP. 'There are protocols laid down for these cases, but the nurses are able to use their own judgement and work safely within their competence,' Mr Nye says .
Since April the number of cases seen by Mrs Lees and her team amount to a staggering 6,165, about a third of those seen by the old casualty department. In addition, the number of patients who have returned to have their treatment assessed has reached 2,306. Peak times are around 9am, between 11am and 12 noon, and 4pm, just after schools finish. Twenty-five per cent of patients seen are children.
In October, the unit was given authorisation to carry out X-rays; since then more than 100 people have been given X-rays, although these are usually done by radiographers. Nurse practitioners have to be trained before they are allowed to undertake these extra tasks.
The training for nurse practitioners lasts eight weeks and was set up locally with the University of Hertfordshire. 'We have two weeks in a classroom doing anatomy and physiology and then work alongside a senior accident and emergency doctor,' Mrs Lees says. 'We assess a patient in front of a doctor and are trained by that doctor in the technique of examining, which as ordinary nurses we were not taught to do. This involves looking at things in a systematic way so that we don't miss anything.'
The nurses, she says, find it satisfying to carry out tasks they have felt they could do for years. Their new role is raising self-confidence and self-esteem, which have diminished in the past few years.
'People always said we need a doctor to do this and even we nurses began to believe it,' Mrs Lees says.
Another patient, Andrew Wallace, has come in with an abscess on his finger, swollen with pus.
'My wife remembered that this unit existed, otherwise I would have had to wait another day to see my GP,' he says. 'It is very painful, I couldn't have waited any longer. I am grateful this unit is here.'
The St Albans unit has attracted attention from health authorities throughout the country, as nurse practitioner units are being considered as the next step forward in the NHS. The units would take the pressure off A & E departments, allowing more of them to amalgamate. This in turn would mean larger accident and emergency departments, able to attract more specialist doctors because of the higher throughput of patients.
Mr Nye says: 'Nurse practitioner units have grown out of meeting local community needs, and each one is different, with its own peculiarities. What makes this unit different is that it has replaced a major accident unit.'
He would like to see nurse practitioners taking on further responsibilities - such as being able to refer patients in need of follow-up treatment to outpatients' clinics at St Albans City Hospital rather than sending them to casualty at Hemel Hempstead first.
'We would also like to see the Department of Health giving nurses the power to prescribe drugs. We want to increase the range of duties undertaken by nurses. But we also have to ensure that the safety of the patient is not put at risk.
'There is always a tension when you are breaking new ground, but we must push forward.'
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