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"Warning: Nurses at work"

November 14, 2006 - Today The Daily Mail (UK) ran a very long piece about apparent problems in the National Health Service's expanding network of "high-tech health centres," which are reportedly "run by nurse practitioners" (NPs). Kathleen Kent's article raises troubling issues about the quality of care at one center in London. But the piece is very unbalanced, relying on anecdotes from two former clinic physicians for the great majority of its account, and consulting none of the nurses whose care is actually at issue. The piece includes a limited response from a Royal College of Nursing (RCN) spokesperson, who admits that the "national picture" for the scope of NP practice is "a bit of a mess," and that only about half of those who use the title "nurse practitioner" in the U.K. have actually met the RCN's training standards for that title. The NHS and the private company running the center in question offer short, limited statements that all is well. The piece fails to mention any research about the quality of NP care, so it does not inform readers that the care of qualified NPs has been found to be at least as good as that of physicians. The piece alerts readers to what may be some real problems in care--no one should practice beyond his or her competence, and the RCN's statements are troubling--but it also confirms the stereotype of NPs as incompetent, cut-rate physician substitutes.

The basic theme of "Warning: Nurses at work"--in case the anti-nurse headline didn't make it clear enough--is that the cost-cutting NHS has turned over control of the primary health centers, particularly their critical diagnostic functions, to nurses who are utterly unqualified. In pursuing that theme, the piece relies overwhelmingly on anecdotal comments by Anila Reddy, a physician who resigned from London's Canary Wharf walk-in center after working there for four months. At no time does the piece question these comments, or give any indication that it sought a response from the nurses the comments describe. On the contrary, the piece simply incorporates the comments into its reportage, clearly suggesting to readers that everything Reddy says is true, and giving them no reason to think there might be any more to the story. Similarly, the piece presents a number of critical comments from physician Nadeem Bhatti, but no response from nurses (unless you count Bhatti's assurance that most of the center's nurses agree with him). Some of the physician comments are difficult to believe, and appear to reflect at least some paternalism, but without any real nursing response or independent account, it's hard to assess.

The piece notes that the government has already set up about 80 of the NP-run health centers nationwide, with an apparently small number--including Canary Wharf--run by private companies. They promise "fast and convenient access to all NHS services." But the Daily Mail says its investigation can now "reveal" that there are "serious concerns about the working arrangements at some of these walk-in centres, with patients' lives being put at risk. Indeed, two doctors and a nurse recently left the Canary Wharf centre, concerned that patient safety was being compromised." We never do hear from this nurse.

The piece then turns the narrative over to Reddy for a very, very long time. He says that at first, the spiffy new Canary Wharf center seemed impressive, with a real focus on seeing patients quickly. But he soon discovered trouble in paradise:

The first thing I was told was that the unit was run by nurses. I would be one of two doctors and six nurses - we would all see patients but the nurses ran the actual centre. Nurses could not prescribe medicines for patients - they would have to write the prescriptions and I would just be expected to sign for them. ... I felt particularly unhappy that children and babies were being assessed by nurses who had never worked on children's wards, let alone been registered as specialist children's nurses. ... Next, I was told that I was not there to supervise the nurses but to be available for advice. But I was also told my clinical supervisor would be a nurse - that meant a nurse would take responsibility for the clinical management of patients. Even though I respect what nurses do, doctors have a longer training.

Despite the assurance of respect at the end, it certainly seems like someone can't quite conceive of a nurse as clinical leader. Some of the other assertions are hard to believe--were nurses really seeing children without any pediatric training or experience, as this suggests? And while physicians may generally have a longer period of formal education (though NPs in the U.S. typically have more years of formal education than U.K. physicians), that's not the only factor in assessing a given care environment. Qualified nurse practitioners are more than capable of operating as autonomous primary care providers. But without more specific information about the qualifications of these nurses and exactly what care is being provided, it's hard to assess.

Reddy next describes what sound like a series of reckless failures to diagnose:

Part of my job was to carry out an inspection of the work at the centre. ... I quickly began to pick up mistakes. A young woman came in with a lump in her armpit. Standard practice would be to examine her breasts for lumps because she could have early signs of breast cancer. Yet I discovered she had no breast examination and was sent home. I found out about it, phoned the patient who told me she had noticed some breast changes. I advised her to see her GP straight away. The audit also picked up a patient who had not been able to walk due to a glass injury but had been sent home without a foot X-ray. And another patient had his anti-depressant medication stopped suddenly, which is dangerous. ... In all these cases, doctors had to follow up the patients and deal with the mistakes - as far as possible. But it was worrying because the system only allowed checks on 17 in every 400 patients seen. I began to wonder what else was being missed.

Reddy goes on to say some nurses failed to follow the "correct protocols," which are apparently "step-by-step guides setting out how to manage patients with specific symptoms." Instead of using these standard NHS center materials, the piece reports, "nurses at the Canary Wharf centre were asked to use clinical guidelines - but these are written for doctors, so they assume much more knowledge and are not as detailed or prescriptive as the nurses' protocols. They do not point out danger signs and symptoms." This analysis suggests that nurse practitioners are essentially technicians who need exact step-by-step instructions, rather than autonomous professionals. Did the nurses at this center really need that? To find out, wouldn't it make sense to actually ask them, or find some independent evidence of their qualifications?

Reddy thinks a big part of the problem is that the nurses are not well trained. The piece reports that nurses "study for three years to become registered, [but] there are no standards that spell out what training or qualifications they need before they can work at advanced levels where they will be examining patients, diagnosing problems and recommending treatments." Reddy notes that physicians study for five years, "work in hospitals for at least a year," then do "GP training for three more years." All this involves constant assessment by more experienced physicians, but

[t]he nurse clinicians I came across were a mixed bag and there was no way of checking formally who had sufficient skills to do the job. I felt their examination skills were not up to the standard of even a medical student. Two had done a 38-day course in which they learn about prescribing drugs and how to examine a patient's tummy or chest.

So the nurses Reddy worked with--as a class--lacked the assessment skills of a medical student? That is difficult to believe, and the piece's failure to get any response from a nurse is astonishing. We agree that a "38-day course" would not be adequate to train a registered nurse with no relevant experience to be a full-fledged nurse practitioner, but without any context as to the actual background and apparent scope of care, once again it's hard to assess. The great majority of the 140,000 NPs in the United States have a master's degree in nursing (6+ years of formal education), and the vast majority have many years of nursing experience before going to graduate school.

The piece includes some confirming remarks by the other physician, Nadeem Bhatti. Bhatti hammers away at some of Reddy's key points:

[Physicians] have to do yearly appraisals and agree a programme of study for the following year to show we are clinically up to date. Yet nurses are being allowed free rein - it's a huge blind spot. Of course, there are some very experienced nurses out there and I'm happy to work with them and I respect their opinions. But there is a real difference between that sort of shared working arrangement and nurses seeing all the patients and excluding doctors. In fact, most of the nurses working at the Canary Wharf centre agreed and did not feel happy with the level of responsibility they were being given. It is very difficult for a patient to tell whether a nurse is incompetent. You can examine a stomach and make the right noises and fool anyone. But as a doctor I could tell that some of the nurses were not competent to examine patients properly. Some had never examined any patients before! My feeling is the Government is encouraging this sort of set-up to save cash.

Do the nurses really have "free rein," with no continuing education requirements? Had some of the Canary Wharf nurses really "never examined any patients before?" Do those nurses really "agree" with this assessment? Why not ask them, or at least report that an effort was made?

Then the piece concludes with final hits from Reddy:

Patients walk in to these centres and think, like me, it looks impressive and it's all hunky dory - but they don't realise the standard of assessment is lower. I'm 100 per cent sure that some patients will come to grief. I think this is just the tip of the iceberg - and that within a year we will start hearing of cases of major tragedies.

Prior to the final section, the piece includes relatively limited reaction from the RCN. The RCN reportedly admits that the "national picture" for NPs is "a bit of a mess." It also says that about 4,000 NPs have met the standards it established in 1996 (which standards are not explained), and it estimates that "at least 4,000 work under the title but without the training." The piece includes the following from the RCN's "nurse practitioner advisor" Katrina Maclaine:

We want it to be made clear what these nurses can and cannot do and for all nurses to be assessed before they can call themselves a nurse practitioner. We get calls from nurses saying their employers want to call them nurse practitioners. They know they have to follow their code of conduct - which means they must work only within their level of competency - but employers are pushing them to work beyond that.

That sounds like a real problem, but is that really all the RCN had to say about NPs? Nothing about what trained NPs really are qualified to do? Nothing about all the research showing qualified NP care is as good as that provided by physicians?

The piece also includes reaction from other groups. Not surprisingly, British Medical Association General Practitioner Committee chair Hamish Meldrum says (correctly) that employers should not push nurses or other health workers to do things outside their competence. Joyce Robbins, director of advocacy group Patient Concern, says patients lack information about what the NPs can do: "You get the impression that anyone attending with anything other than a scraped knee is taking their life in their hands." Well, you certainly do from this piece. Atos Origin, the company that runs the Canary Wharf center for NHS, says that a full investigation has confirmed that practitioners are operating within their abilities, though the piece does not give any details. And a vague NHS statement informs readers that "NHS now has a track record of successfully planning these centres and certainly knows what it is doing." Very reassuring.

On the whole, the defenses offered are so weak and general that any rational reader would conclude that these health centers have serious problems (which may well be the case), and also that NPs generally are dangerously unqualified sub-physicians (which is not the case). This piece provides detail on one center, but how widespread are these apparent problems? Has there been any actual research--as opposed to anecdotes from two former clinic employees--to confirm the existence of these problems? If there really are thousands of nurses falsely presenting themselves as qualified practitioners, what might be done about that? Such a situation would endanger patients, and seriously undermine the demonstrated health benefits that NPs have been providing elsewhere for decades, in many case to underserved populations who desperately need their care. If the RCN shares the concerns presented by the physicians quoted here, we hope it is able to resolve the problems not only for the good of patients, but nurse practitioners themselves.

The Daily Mail was right to focus attention on such serious health care concerns. But its unbalanced piece is highly unfair to nurse practitioners and nurses generally.

See the article "Nurses at Work" by Kathleen Kent in the November 14, 2006 edition of The Daily Mail.

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