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Horses for courses: A nurse is not a replacement for a doctor

By Dermot - 10th May 2016 | 4 views

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n the news story ‘‘Medical model’ ethos is restricting advanced nurse role — INMO’, <strong><em>Medical Independent</em></strong>, 8 April, Mr Liam Doran, General Secretary of the Irish Nurses and Midwives Organisation, advocated a radical approach to the current crisis in the Irish health services. Some non-training NCHDs’ posts, he suggested, could be terminated and replaced with those of advanced nurse or midwife practitioners. Such a move would be justifiable, he opined, as St James’s Hospital’s emergency department (ED) employs six advanced nurse practitioners and it is, he claimed, the “best-performing” ED in the country. He does not think this to be a coincidence.

It is difficult to discern on what basis Mr Doran has determined this; for example, the HSE’s latest <em>Management Data Report</em>, for December 2015, shows patient wait times in the department to be comparatively long. But even if it can be demonstrated that, by some metrics, this department is indeed the country’s best performing, it is difficult to accept that this is so largely as a result of the performances, however stellar, of six advanced nurse practitioners.

Despite this, Mr Doran believes the health service should employ more advanced nurse practitioners, hired at the expense of existing doctors’ posts. The foundational flaw in such an argument is that international evidence shows that reducing the number of employed physicians frequently worsens patient outcomes. Inadequate physician staffing is a widely acknowledged factor in ED overcrowding, which in turn threatens patient welfare, and is associated with higher rates of premature mortality. By contrast, there is much research to suggest that an increased number of physicians employed in EDs can improve performance by reducing patient waiting times and delivering more timely and accurate care.

Comparatively, Ireland already possesses fewer doctors than most developed states. The OECD reports that this country has fewer professionally-active doctors per capita than any other in Western Europe. This figure sits at just three doctors per 1,000 population; one doctor less per 1,000 population than countries like Germany, Italy, and Spain. The same organisation, by contrast, notes that Ireland already has one of the highest numbers of professionally active nurses per capita in Europe, employing more than 12 per 1,000 population. It is true to say that hiring more doctors, in isolation, will not resolve the significant difficulties that Irish healthcare currently faces. However, under current physician staffing levels, patient outcomes are being endangered and doctors’ working conditions compromised.

Successive Ministers for Health have spoken of the need to develop a consultant-delivered health service. Increasing patient access to doctors, particularly specialists, should remain a central policy goal. This vision will not be realised, however, where a complete manpower plan, which methodologically assesses the number of doctors required to adequately provide each aspect of care in Ireland, remains absent. The IMO has repeatedly called for such an assessment to be conducted and its findings acted upon, but regrettably this vital component of health service management has been largely ignored by the HSE. Unless adequate numbers of doctors are recruited, and are provided with a structured career pathway towards consultant posts, Irish healthcare will fail to properly address patients’ needs.

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Admittedly, some tasks currently undertaken by doctors can be successfully transferred to nurses to enhance the care of patients and extend the nurse skillset 

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Admittedly, some tasks currently undertaken by doctors can be successfully transferred to nurses to enhance the care of patients and extend the nurse skillset. The current initiative across the hospital system providing for the transfer of four tasks of IV cannulation and drug administration, phlebotomy and nurse-led delegated discharge is a very welcome development. The swift implementation of this initiative will be a positive move in the enhanced delivery of patient care.

There is little benefit, however, in attempting to diminish the role of the doctor in hospital care. In general, doctors undergo four-to-five years of undergraduate medical education, and often close to a decade of further postgraduate training, all uniquely focused on enabling them to provide the correct diagnosis and appropriate treatment of the patient. The role of the doctor, by virtue of such training, cannot be replicated or substituted by others. A nurse is not a replacement for a doctor, any more than a doctor is a replacement for a nurse. They perform two crucial but distinct roles in the provision of healthcare. Patients’ best interests are served when health service management ensures adequate staffing across the health service. It is only when this is achieved that Irish patients, and healthcare professionals, can expect our hospitals to perform to their potential.

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