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Abstract
The last decade has seen dramatic changes in the working arrangements and training requirements of junior medical staff employed in neonatal units. As a result, there is a need for the professional roles in service provision to be reappraised.
In many neonatal services, advanced neonatal nurse practitioners (ANNPs) have been introduced and have been shown to be effective in providing an alternative option for the provision of neonatal care at both junior and middle-grade medical staffing level. One of the key factors of the success of this role is the underpinning years spent in clinical practice, a foundation that provides a valuable and unique perspective for professional functioning at a senior level. For this potential to be fully exploited, a more integrated approach to the development of career pathways for ANNPs is needed. However, there are challenges related to recruitment, and the relatively small numbers of ANNPs available means that they are unlikely to provide an immediate solution for many units.
The introduction of physicians' assistants (PAs) would seem to be worthy of consideration as part of the neonatal workforce, but it is likely that their functioning will be best integrated with that of ANNPs.
In the longer term, economic factors will be a powerful determinant of the relative proportion of consultants, trainee doctors, ANNPs and PAs in the workforce.
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Over the last decade, the medical workforce in the UK has been subject to a number of fundamental structural changes resulting from both political and educational drivers. The requirements of the European Working Time Directive,1 Modernising Medical Careers (MMC)2 and, more recently, the Tooke Report3 have all impacted on the way the workforce is educated and trained, the way service provision is organised and, last but not least, the expectations of the individual professionals. The structured formal training requirements imposed by MMC2 have, according to the Tooke report, raised concerns about the significant reduction in the “service element of junior doctor jobs” that has, in turn, had an impact on clinical service provision.
The challenges of the EWTD for training and experience have been recognised by the Postgraduate Medical Education and Training Board, which reports that the reduction in the number of hours worked by doctors in training has resulted in an inevitable decrease in “overall clinical exposure, which is crucial for developing experience and confidence”.4 This potential lack of exposure to clinical learning opportunities and the effect this could have on the training of junior doctors is at odds with the underpinning aim of the EWTD to improve or enhance the quality of life and training of doctors. According to a recent survey of junior doctors, neither clinical care provision nor quality of life has improved,5 and other reports also suggest that job satisfaction for junior doctors has been adversely affected by the recent regulations.3 4
Current challenges for the neonatal workforce
In the neonatal context, these regulations, requirements and working patterns are, according to the Royal College of Paediatrics and Child Health (RCPCH), imposing “some of the most difficult challenges ever faced by paediatricians trying to deliver a service”.6 Furthermore, it has been suggested that, owing to the current workforce configurations, it is unlikely that the 25 level 3 units in the UK will be EWTD compliant by August 2009.7 The predicted shortage of middle-grade staff is not new, having first been highlighted as a concern nearly 40 years ago8; with the increasing political pressures, the concern has recently re-emerged.9 A recent survey undertaken by the Royal College of Obstetricians and Gynaecologists and the RCPCH, working in partnership with National Workforce Projects, has concluded that for neonatal services, “there will be insufficient middle grade (tier 2) doctors to fill the number of posts needed for EWTD compliance” and that for the postgraduate training of junior doctors in paediatrics, an ideal model would be a rota with 11 trainees.10 However, it is also acknowledged that for many units, this may not be feasible. It is predicted that approximately 50% of the units still do not have clear strategies in place that will support compliance with the EWTD, and there is no quick-fix solution because there are already insufficient numbers of trainee paediatricians at that level to provide cover for all the rotas.10
What are the alternatives?
In an attempt to ensure appropriate standards of care and maintain staffing levels, many neonatal units in the UK are investing in the training and education of different types of health professionals.
The Hospital at Night
The Hospital at Night model has been proposed as a potential solution for out-of-hours care and for some emergency services; in some specialties, this has involved recruiting night nurse practitioners who work as part of a designated night team.11 However, to date, it seems that this has not been readily adopted within neonatal units, perhaps because of the need for personnel with very specific knowledge and clinical skills.
Physicians' assistants
Another option is that of PAs. PAs are already employed in a number of medical specialties in North America, Canada, the Netherlands12 and Australia, where the government of Queensland is looking to the role of the PA as a potential solution to some of their workforce shortages.13
According to the Department of Health, a PA is “a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or practice team under defined levels of supervision.”14 The expectation is that PAs will be recruited from a previously untapped workforce source—that of science graduates.
Although the role of the PA in the UK is not new,15 16 there has been much debate about the practicalities of the training and education, supervision, legislation and regulation of such a healthcare professional. In 2005, it was suggested that “the use of PAs in the UK appears to be an acceptable model that could eventually reduce the current skill shortage and provide high quality patient care”.16
The role of the PA has recently been evaluated in a pilot project funded by the National Health Service Education for Scotland, where the focus was on the impact and contribution that a cohort of PAs trained in North America could have on delivering effective care. These PAs were based in primary care, accident and emergency departments, out-of-hours clinics, orthopaedics and rehabilitation wards. The findings revealed that “PAs add complementary skills and attitudes to teams and should not be regarded as a potential direct ‘substitute’ for a nurse or a doctor. … If PAs were to undertake some of the work that might ‘replace’ existing roles, then cost savings might result. There would be costs in developing education, accreditation and support structures”.17
In the context of neonatal care, although there is no evidence of PAs being employed in the UK, a precedent has been set in North America, where PAs have been employed for >40 years.18 19 Evaluation studies have reported that when working alongside other non-physician providers (neonatal nurse practitioners or NNPs), PAs may be an effective alternative to medical staff.20 21 More recently, it has been suggested that with the workforce shortages in North America, PAs will increasingly work with NNPs, NNPs and PAs will receive similar salaries and the roles of the two professional groups will be “interchangeable but not identical”.22
The characteristics of these professionals may be important when evaluating the potential return on large-scale investment in their recruitment and training. As science graduates, most of the trainees will be young and mobile, with no health service background, and it may take many years for them to acquire the necessary clinical knowledge and institution. One option may be to consider employing both PAs and advanced NNPs (ANNPs) rather than having one or the other. This multiprofessional approach, though expensive, may be an effective solution that builds on the specific skills, qualities and attributes of each professional with the result that the provision of high-quality neonatal care is promoted.
Consultant expansion
In July 2009, when acknowledging the challenges being faced, the RCPCH stated that “it is fully understandable that consultants will wish to support their departments by taking on unplanned duties (including resident duties)”.23 Evidence from the recent survey by the Royal College of Physicians Medical Workforce Unit suggests that in all areas of medicine, this practice is being undertaken and that “40% of reporting hospitals use consultants to cover short notice daytime medical SpR rota gaps and 18% of hospitals cover short notice night time rota gaps”. Eighty-nine per cent of the consultants in the survey who covered the nights were still expected to assume their normal working responsibilities the next day.24
This pattern is also evident in North America where the current working restrictions apply to junior staff (residents and fellows) but not consultants. A recent paper highlights the inconsistencies in these working arrangements25 by citing examples where, after senior neonatologists have been working all night, they are then expected to continue with their clinical duties and responsibilities the following day. This approach can be neither safe nor sustainable in the longer term.
The requirements of both MMC and the EWTD have resulted in the need for consultants' numbers to increase both to fulfil the responsibilities of the revised education role and to strengthen service provision.26 This move towards a “consultant driven service”27 will require the role of the consultant to be reviewed, particularly in terms of providing resident cover and other clinical responsibilities. In some areas of the UK, these discussions have already taken place and consultant posts are now being advertised with the requirement for the new consultants to be primarily responsible for the provision of senior resident on call cover.28 This requirement to be resident may not apply to consultants already in post, perhaps creating the first indication of a two-tier consultant hierarchy.
Advanced neonatal nurse practitioners
In the specialty of neonatal care, ANNPS have been employed in a number of countries.
Developments to date in the UK
In the UK, the first educational training programme for ANNPs was established in 1992. At the time, this was in response to a perceived need to improve the quality of neonatal care29 and to try to reduce fluctuations in the standard of care provision. Currently the lack of professional regulation of ANNPs and the absence of a professional advanced practice register30 make it difficult to quantify accurately the number of qualified ANNPs in this country. It is estimated that there are now at least 250 ANNPs, with many still being trained. In 2009, the demand for ANNP training places on the ANNP training course based at the University of Southampton has been unprecedented, resulting in a waiting list being established. This may be because of a number of factors, the most likely being the impact that the EWTD is having on the neonatal workforce. However, for the seconding units these students are unlikely to be fully clinically functional for at least a couple of years. Although the students enter the programme as very experienced neonatal nurses, their transition to clinically competent ANNP is gradual. This transition takes time and patience, and the support of the neonatal team is pivotal in promoting this ongoing development.31
Evidence suggests that the financial and pastoral investment in ANNPs can be justified in terms of the knowledge and skills that ANNPs can bring to the neonatal team. There have been a number of studies evaluating the effectiveness of ANNPs, both in terms of clinical practice32 33 and their added value as colleagues working in the neonatal setting.34 More recently, the impact that ANNPs have had on the provision of neonatal care has been highlighted in a number of reports, including the National Audit Office (NAO) report35 and “Modelling the Future”.6
The evolving role of ANNPs
The role of ANNPs is multifaceted, and there is evidence that ANNPs are being employed in a variety of neonatal settings.36 The NAO report stated that “A small number of level 1 and level 2 units are led by Advanced Neonatal Nurse Practitioners (ANNPs)”.35 In terms of standards of care provision in these types of units, it has been reported that “good quality neonatal care can be delivered by ANNPs alone without the support of junior medical staff”.37 It has also been proposed that an ANNP model might offer potential benefits in the larger units in supporting medical staffing and consultant on-call requirements, and there is now a growing body of evidence that ANNPs can “provide a high standard of neonatal care” with or without a doctor on site.38
The number of transport teams employing ANNPs, either on a permanent full-time or rotational basis is increasing, and at least one transport service has reported using ANNPs in place of middle-grade staff with evidence that “ANNP-led transport appears to be practical and safe”.39
ANNPs functioning at middle-grade level?
The RCPCH summary “Solutions for the Medical Staffing of Acute Units” reports that there is not only a crisis of staffing in many acute units but also an inability to fill gaps in training programmes particularly at middle-grade level.40 In addition, the recent EWTD survey conducted by the RCPCH has clearly articulated concern about “the difficulty of finding enough locums to cover gaps in hospital rotas and the quality of care provided by external locums”.41
It has been suggested that the employment of ANNPs may enable the number of tiers of medical cover to be reduced. Although it would appear that many neonatal units are already employing ANNPs at middle-grade level, it is unlikely that they are sufficient either in post or in training to meet the challenges faced by neonatal units while they try to comply with the EWTD while providing appropriate education and training for medical staff and ensuring high-quality patient care. The employment of ANNPs at this level will require training that should be “of high quality and reproducible”41; furthermore, while ANNPs may be one of the possible solutions to the EWTD, they “are not an easy or cheap option. The lead time for training is long, and the funding of training and backfill remains a serious constraint”.42
There are now some units that require ANNPs to function at this level, and this is stipulated in the job advert.43 From data relating to the graduates from the Southampton ANNP training course,27 22% of ANNPs who provided detailed information about their level of functioning have already developed their clinical role by assuming middle-grade functions, and it is likely that others will, for a number of reasons, follow in their footsteps.36 It may be that the ANNPs who are willing and able to undertake this challenge are those who have been qualified for many years and have increased their clinical experience and knowledge, or it may be that the more recent cohorts who were trained at master's level have been better prepared to function at a higher level; it is probably a combination of both. It is not clear whether these ANNPs have received any formal preparation for the move to middle-grade level or, indeed, if there is any additional financial remuneration. This may result in a two-tier level of service provision by ANNPs: those who wish to pursue upward mobility and those who are happy in their current role.
ANNP recruitment challenges
Many units in this country are experiencing difficulties in recruiting ANNPs. According to the NAO report, at the end of 2007, there were 98 vacancies for ANNPs.35 Neonatal units in the USA are facing similar problems; in some centres there are insufficient numbers of ANNPS to provide complete (24/7) cover for the neonatal unit, and despite trying to train more ANNPs, they have not been able to find the numbers required.44 According to this survey of the NNP workforce in the USA, there is a “mismatch between supply and demand for NNPs”; the time required to recruit an NNP ranged from <3 months to several years, with most hospitals reporting an average of 6–18 months.44 This situation is not dissimilar to the UK in that recently, a number of ANNP vacancies have not been filled. The first 9 months of the 2008 data from two recruitment sites45 46 show that 13 different National Health Service Trusts were advertising for ANNPs, with a mean of two vacancies each month, and in October 2009, there are currently four vacancies being advertised (three at Band 8a and one at Band 8b).47 One of the reasons for the difficulty in recruitment may be related to the personal characteristics of ANNPs in age and family commitments: ANNPs do not seem to be a mobile population. In addition, there are concerns that the conventional neonatal nursing workforce can ill-afford to lose skilled nurses to the ANNP profession.
In the survey from North America, it is reported the mean age of the NNPs surveyed was 45 years, and it is likely that most ANNPs in this country are in a similar age bracket. This may be one of the reasons why, in the UK, ANNPs do not tend to leave their posts once they are settled. However, with the recent dissatisfaction related to salary scales, there are a number of ANNPs who have been appointed to posts elsewhere, perhaps suggesting that if there are sufficient incentives of increased financial remuneration and improved working arrangements, then ANNPs can be persuaded to move.
Are ANNPs a viable option?
Compared with the young, relatively inexperienced science graduate, it may be that ANNPs are a more robust option than PAs. ANNPs are often older, and generally, their family commitments mean they are established within a geographical area. In care provision, the value of their previous years of nursing experience can provide many tangible benefits, not least ensuring safe practice. This was demonstrated in a recent study that evaluated the accuracy of different professionals in identifying the clinical signs of late-onset sepsis: ANNPs consistently demonstrated superior accuracy at correctly identifying at-risk infants when compared with junior doctors (senior house officers and registrars) and more senior doctors (consultants).48
However, even if sufficient numbers of ANNPs were readily available, consideration has to be given to their capacity to provide complete 24/7 cover given their age distribution and also the continuous exposure to an intensive working environment. The number of ANNPs in the UK working full night shifts is difficult to quantify; in one evaluation study, it was reported that “night shifts were not included as these represented a very small proportion of the shifts worked by ANNPs,”49 whereas in a related study, 44% of ANNPs reported working “some night shifts”.34 This may reflect the age of the current generation of ANNPs, most of whom came to the profession relatively late in their careers. With careful strategic planning, at least some of these challenges may be minimised in the longer term.
Conclusions
The impact that a number of political and societal drivers have had on neonatal care provision make it necessary to review the structure of the neonatal workforce. There is a need for reconfiguration of the infrastructure such that neither the standards of care provision nor the education and training of junior medical staff are compromised. ANNPs are playing a key role in the provision of neonatal care, and many are undertaking middle-grade functions. The good retention rates within both the workforce and the individual units suggest that investment in this role is justified and cost-effective.
However, employers and training institutions must assume responsibility for integrating a more structured approach to the career trajectory of ANNPs. Evidence suggests that these professionals find the initial transition from senior nurse to ANNP challenging, and this is likely to apply as they assume more senior roles. For these individuals, consideration must be given to appropriate preparation, supervision, appraisal and continuing professional development. It is important that everyone within the neonatal workforce has a clear understanding of the scope and the limitations of the ANNP role. Only then can the most valued elements of nursing and medical care be integrated and developed for the benefit of neonatal care provision. Currently, there are challenges related to recruitment, and the relatively small numbers of ANNPs available means they are unlikely to provide an immediate solution for many units.
In the UK, there is no evidence to date of the integration of PAs into the neonatal workforce. Evidence from North America suggests that they can be effective members of the team, and it may be that their role could be integrated and aligned with that of ANNPs. As with implementation of the ANNP role, this would require investment in terms of training, support and professional regulation.
Whereas the increasing expansion of consultant numbers is welcome, the practice of consultants providing middle-grade cover is neither realistic nor financially viable in the long term. The resident consultant model may provide some benefits, but whether this option is readily acceptable to individuals wanting to advance their career is as yet unknown.
Providing sustainable solutions to the workforce and the training challenges facing neonatal services while ensuring the delivery of high-quality 24 h care is complex. Some units are considering new roles, whereas others are evaluating new ways of working. Both approaches require long-term planning and investment and a clear vision of the skills and knowledge that are required at each level of the workforce.
Acknowledgments
The authors would like to thank all the Southampton ANNP graduates who provided evaluation data.
References
Footnotes
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Competing interests MH and SS were both involved in developing the first educational training programme for ANNPs in Southampton. SS is currently one of the programme leads in Southampton, and MH is the medical coordinator for the programme.
Provenance Not commissioned; externally peer reviewed.