For doctor, read nurse

When Nurse Tomlinson cut out a patient's appendix, she exposed for publ ic debate the yawning gap between what nurses are perceived to do, and the real ity. Liz Hunt reports

Valerie Tomlinson, who removed a patient's appendix and provoked a national furore, yesterday accepted that "her actions went beyond what would be normally be expected of a theatre nurse..."

They were not her words but those of a spokesman for the Royal Cornwall Hospital Trust, and disingenuous to say the least. The gap between what is expected of a nurse and what he or she does in practice, has been tacitly acknowledged by hospital managersand doctors for decades. What the Tomlinson case has done is to highlight the expanding role of the nurse in the health service, as no government report or PR offensive by the Royal College of Nursing has managed before. It may also have signalled the end of what is known in nursing circles as the "doctor/nurse game".

Laurence Stein, an American researcher, was the first to describe this theory of nursing in the Sixties. The game revolves around the nurse making the decision, in some cases taking action and then - with the collusion of the doctor - "pretending" that the doctor did it all to appease hospital authorities, professional guidelines, the law and the public.

"The Stein paper is one of the most famous in nurse training, according to Barbara Stilwell, principal lecturer in Primary Care and Nurse Development at the RCN. "A lot of what went on at Treliske Hospital [where Ms Tomlinson worked] and what goes on daily in wards and operating theatres all over the world is an example of the `doctor nurse' game.

"What the nurses are doing is often routine, they have done it hundreds of times before. The problem is that it is covert, it has not been formalised. We are now seeing that beginning to change. We are witnessing a rejigging of the demaraction lines between nurses and doctors."

Nurses are assuming greater responsibility not because doctors are "allowing" them to do so but because of the changing nature of health-care provision. There is a move away from secondary (hospital) care to cheaper primary provision in the community, and preventive care through education and screening, all of which nurses are ideally placed to provide.

Demographic and technological changes are the key to the quiet revolution. Elderly people who are chronically unwell rather than seriously ill can be maintained with nursing rather than medical care in their own homes. The young and middle-aged are in better health generally than they were 50 years ago, and make fewer demands on their doctors. Better drugs and improved surgical techniques, along with the advent of day surgery, have meant good after-care, rather than medical intervention, is wha t increasingly determines a full recovery.

And then there is the shortage of nurses, highlighted by a report from the RCN this week which showed that unemployment levels among nurses are the lowest they have been for a decade. Between 1983 and 1997 there will be have been a cutback of 55 per centin the number of student nurses being trained.

The turning point in extending the role of the nurse came with a document published in June 1992 by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, entitledThe Scope of Professional Practice. In essence, it permits a nurse,midwife or health visitor to care for his or her patient in whatever way they see fit as long as they are competent in the task they undertake and are fully accountable for it. Previously a nurse who took on additional tasks, such as intravenous injections or suturing, needed a proficiency certificate which was specific only for that task and valid only for the hospital where she worked.

The Department of Health was initially reluctant to accept the UKCC document and gave way only because it coincided with demands for the Government to reduce the hours worked by junior doctors. But the interface between nurses and junior doctors was, in any case, changing. Most consultants would expect a nurse to show a junior doctor how to set up a drip or give an injection.

In addition to the UKCC document, there has been the rise of the nurse practitioner, an American innovation which is redefining the traditional role of the doctor. There are more than 250 nurse practitioners in England and Wales, working on hospital wards and in health centres, able in certain circumstances to examine a patient, prescribe a drug, monitor a long-term treatment, order an X-ray, give an injection and stitch a wound.

Hospitals across the country are opening minor injury clinics staffed solely by these nurse practitioners to relieve the burden on their accident & emergency departments. At St Bartholomew's Hospital in London, such a clinic will replace the old A&E department which closes today. The patient will be seen only by a nurse who will make a clinical judgement on their condition, treat them, prescribe from a limited list of drugs, or refer the patient back to a GP or on to the casualty department.

In GP surgeries, the nurse practitioner is viewed as a partner in the practice, someone who can screen out a group known as the "regular attenders." These are people with minor ailments who do not need to see a doctor but want the reassurance of a professional health worker, leaving the GP free to see the more serious cases.

Meanwhile, district and community nurses are taking on more and more of the hi-tech skills once the preserve of specialist nurses, such as intensive care nurses. Some coma patients on life support machines are being looked after at home. There is also a growth in the number of "hospital at home" schemes, where patients are discharged within days of the operation to receive post- operative care from a nurse who is on call for 24 hours.

As Ms Tomlinson's intervention in the appendectomy at Treliske suggests, the boundaries between nursing and surgery are becoming increasingly blurred. The Royal College of Surgeons is developing a programme to train nurses as surgeon's assistants so theycan perform low-level work in theatre. Already Suzanne Holmes, a nurse at the John Radcliffe Hospital in Oxford, works alongside cardiac surgeons, stripping out leg veins to be used in heart bypass operations.

There has been some opposition from doctors to the empowering of nurses, but the limited research to date shows that once they have worked with a nurse practitioner or a nurse qualified to carry out extra tasks, the hostility diminishes.

In fact most opposition has come from nurse mangers who see their influence weakened as nurses at the sharp end take on more responsibility for patient care. "Obviously, some people feel threatened," says Ms Stilwell. "But it is a natural progression. When I started out as a nurse in the 1960s I cleaned lockers and made beds. Now that is the duty of health-care assistants; in the same way that doctors are being liberated to concentrate on more sophisticated clinical and medical matters, nurses, too, hav e greater freedom to contribute to patient care."

Nurses, who for so long have been the poor relations of the clinical team, are well placed and well equipped to take full advantage of the changes in health-care provision. The nurse of the future has the opportunity to become an "entrepreneur", a highlyqualified, multi-skilled professional., operating as a freelance, contracting out her expertise to whichever health centre, trust hospital or other business is prepared to pay for her services.

The doctor Dr David Colin-Thome, is a GP at the Castlefield health centre in Runcorn, Cheshire

Once we were given budgets we began to question the centre's efficiency, and introducing a nurse-practitioner (NP) seemed a good way of reducing the hours of working GPs.

In fact we've found that employing an NP is only marginally cost-effective; but it has been a tremendous success and brought great benefits to patients. The nursing profession uses the term "skill mix", and I think it ought to apply to doctors too. The NP brings fresh skills and talent to the primary care team, and we offer a better service as a result.

People attending the centre may choose whom they wish to be seen by first: a GP or the NP. Habit still leads most people to ask for the GP, but people are increasingly willing to see the nurse first.

There are six GPs working at Castlefield. The introduction of an NP relieved the workload, and I do now see fewer run-of-the-mill illnesses. I now lecture for part of the week. When I went part time I recommended that I did not need to be replaced, and Ihave not been - I regard that as a measure of the NP scheme's success.

It's an excellent system, popular both with the 12,000 people attended to by the centre, and with the GPs who practice there. I see Castlefield as a model for the country - we have been doing it here for two years, and partly pioneered it in Britain. I'dcertainly like to see it spread.

The nurse practitioner Lance Gardner, 34, is a part-time nurse practitioner at the Castlefield centre.

I did a diploma at the Institute of Advanced Nursing Education in London, commuting from near Leeds once a week for two years; I qualified as a nurse practitioner last September.

I'm unusual, being a male nurse: 99 per cent of qualified NPs are female. Some people see nurse practitioning as the natural thing to progress to from traditional nursing, but I don't agree: it's completely different - different requirements, different skills. I'm sometimes called a mini-doctor but that's not right either.

People communicate with NPs in a special way. We are easier to talk to: expectations of doctors and nurses are historically different. Nursing is still associated with Florence Nightingale and with hospitals, where nurses spend eight to ten hours with a patient. Doctors, on the other hand, are associated with the 10-minute consultation in the surgery. We have time to talk: if a client is worried about their pet dog, we'll worry along with them. I'll even drive a patient to hospital if need be.

A third of the cases I see are respiratory, a third ear nose and throat; the other third can be anything. I can fill out prescriptions although I must get someone else to sign them. But I can refer patients direct to consultants, or for laboratory investigations.

I'm very proud to be a nurse, and I'm glad to see that from this year, the NP qualification will be an MA or a BA rather than a diploma: that's a sign of progress.

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