junior doctors' working hours: perspectives on the reforms

R E S E A R C H P A P E R

Junior doctors’ working hours: Perspectiveson the reforms

Carol Wilkinson MSc BA(Hons) RGN Teacher’s Cert Fellow Higher Education AcademyPrincipal Lecturer in Health Studies, Faculty of Health, Life and Social Sciences, University of Lincoln, Lincoln, UK

Accepted for publication November 2007

Wilkinson C. International Journal of Nursing Practice 2008; 14: 200–214Junior doctors’ working hours: Perspectives on the reforms

The European Working Time Directive for junior doctors came into force in Britain in August 2004. The reformsthemselves have been a long time in development and implementation since the inception and debates regarding the NewDeal, to the current formations under health and safety legislation. This study, undertaken within a hospital trust settingin England, provides an insight into the perspectives of doctors, nurses and human resources managers in relation to theEuropean Working Time Directive. Critical consideration is given to the impact of the reforms upon the National HealthService and more specifically to daily working relationships at the point of implementation. The results demonstrate someambivalence towards the reforms because of the major shift in culture for the professions per se, but also for the future ofhealth-care delivery where there are considerable tensions.

Key words: European working time, interviews, junior doctors, new deal.

INTRODUCTIONThe essence of the New Deal and the European WorkingTime Directive (ETWD) have been combined by the Blairgovernment in Britain to assist in the reduction of hours ofwork undertaken by junior doctors.1,2 The journey inarriving at this situation has been problematic and can betraced in the parliamentary debates leading up to changeswhich came into force in August 2004. This has impactedon doctors themselves, nurses and other health profes-sionals regarding the division of labour in health care.

The main issues that emerge:1. Highlight the fact that long hours of work can lead toconsiderable stress and in some cases death which resonateswith many traditional studies into this phenomena.3–5

2. Patient safety is paramount within any health service.Working over long periods of time without taking breaksas appropriate and necessary can lead to compromising ofpatient safety and reduce effectiveness of health-care staff.3. Enforceability of legislation has been difficult withdebates concerning the substitution of skills, managingworkload and finding innovative ways of working whichhave become issues for day-to-day working in health care.There is also the hint of some reliance on other health-careprofessions including nurses to assist in managing andtaking some of this load.

LITERATURE REVIEWDiscussions regarding junior doctors’ working hours inhospitals has been emerging progressively within the par-liamentary records since the early 1990s. The New Dealfor junior doctors was launched in June 1991. It set a scalefor reducing the hours of duty of doctors and dentists intraining. Under the New Deal, average weekly contractedhours of duty were to be reduced initially to 83 per week

Correspondence: Carol Wilkinson, Principal Lecturer in Health Studies,Faculty of Health, Life and Social Sciences, University of Lincoln, UK.Email: [email protected]

International Journal of Nursing Practice 2008; 14: 200–214

doi:10.1111/j.1440-172X.2008.00689.x© 2008 The AuthorJournal compilation © 2008 Blackwell Publishing Asia Pty Ltd

mailto:[email protected]

for those working on call rotas, 72 per week for thoseworking partial shifts, and 60 per week for those workingfull shifts. A target date of 1 April 1993 for achieving thiswas originally planned.6

The average weekly contracted hours of duty were tobe reduced further to a maximum of 72 per week forthose in exceptionally busy on call posts, 64 per week forthose working full shifts by the end of December 1994. Itwas the task of the health minister then to set out thegovernment’s position.

It was stated:

. . . Regardless of contracted hours, our intention is that nojunior doctor employed on a full time basis should normally beexpected to work for more than an average of 56 h per week bythat date. Subject to review by the ministerial group on juniordoctors. The aim is to reduce maximum average contractedhours of duty for on call posts which are considered not to behard pressed to 72 per week by the end of 1996. Doctors inhigher professional training may still contract up to 83 h perweek after that date where it would be to the benefit of theirtraining and they will do so, providing proper support staffingexists and the duties are not harmful either to the trainee or topatients.7

The term ‘junior doctor’ in Britain is used to describea doctor undergoing a prescribed course of training anddenotes the grades of pre-registration house officer,senior house officer or specialist registrars.8 The positionof junior hospital doctors’ working hours has been thesubject of debate for a long time; however, investigationinto working hours and working patterns of this profes-sional group in Britain really only took place following thedebates around the New Deal.

The problem relating to junior doctors’ working hourswas sparked by the death of Robin Senior, a doctor whoworked consecutive duties culminating in 110-h workwithin seven consecutive days of duty.8 This was imme-diately followed up by medical colleagues Diana Walfordand Stephen Hunter who joined the campaign for thereduction of junior hospital doctors’ working hours.Members of parliament subsequently carried forward thiscampaign. Indeed, Dave Nellist, Labour MP for Coventrytaunted the Prime Minister of the day:

. . . Is the Prime Minister aware of the case that I took up twoand a half months ago with the Secretary of State who startedwork at Epsom District Hospital on 1st February, will the

prime minister confirm that today is wholly inadequate. . . how many more junior doctors have to die of stress relatedillness before that is brought down to a sane level.9

Later that year, William Waldegrave Secretary of Statefor Health was charged with the responsibility of inform-ing health boards, health authorities and health trustsabout reducing working hours for hospital doctors anddentists, whereby he stated the publication of guidancerelating to working shift patterns and mobilizing theresources of nursing and midwifery staff to take on roleswhich will free up time for junior doctors and those intraining.10

The working hours of doctors and dentists remained alive parliamentary subject throughout the various changesof government. Patient safety was a considerable issue inreducing the number of hours worked by junior doctors.In fact, it was asked in no uncertain terms how thegovernment was dealing with this:

. . . The big notices on motorways which say tiredness can killand that applies to lorry drivers whose maximum workingweek is a mere 45 h? Is he aware that the 72 contracted hourslevel that has been agreed is on average not maximum andthat as many as six out of 10 junior doctors may regularly beworking more than 72 h? Does he agree that an exhaustedyoung doctor in a hospital ward were a danger to patientssafety?11

There was also some debate concerning the impact onnurses’ workload. This was met by frequent contact byministers with the medical professions, and it was clearthat it was something that had been largely dismissed asunimportant by the government:

. . . I certainly acknowledge that the implementation of theNew Deal had implications for nursing workload as well as ofjunior doctors. It might have helped that in maintaining theimplementation of the New Deal . . . 2400 new doctor postswere created under the programme.12

CRITICISMS OF OF THE NEW DEALFrom the evidence available, it appeared that the NewDeal was problematic for several reasons. The first issuerelated to the likely impact on doctors themselves. Thenational picture demonstrated there were inadequatepersonnel to support the changes, poor career guidance asa result of uncertainty, haphazard education, poor living

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© 2008 The AuthorJournal compilation © 2008 Blackwell Publishing Asia Pty Ltd

and working environments and inappropriate workingpractices.13 There was also an imbalance between servicecommitments and educational opportunity. It was consid-ered necessary to address these problems first rather thanconcentrating on the narrow sphere of working hoursin the first instance. The issues of morale, educationalopportunities as well as hours of work for junior doctorshad not made great impact within the profession, despitethe efforts of the General Medical Council (GMC) post-graduate deans. The Department of Health and individualconsultants’ survey showed that the training and workingconditions provided for house officers were still unsatis-factory and inconsistent with the GMC’s recommenda-tions of the period. In addition, there were no establishedmethods for stimulating change locally. It was difficult toproduce lasting change by edict, was feared, and wouldonly lead to reluctant compliance with the maximumrequirements. The medical profession needed to grasp theissues and find practical solutions themselves, or at leastcollectively to work towards this. This was not apparentin the closing days of the Major government.13

The reduction in hours was still a running issue in thenew Labour government of 1997, especially concerningprovisions and plans made. At this stage it was noted thatat least 38.4% of health trusts were not compliant withthe New Deal. This introduced the second major issue ofcompeting priorities.

The New Deal, in terms of practicalities, had sparkedsome debate relating to conflicting pressures created asthe policy and the Calman Report on specialist training allimpinged upon the quality of life that consultants couldexpect in the future, but the immediate impact was onjunior hospital doctors. Concern was expressed about thedifficulties of introducing 72-h limits by the agreed date inDecember 1994. In addition to these direct changes, itwas considered that the impact of the internal market andthe purchaser provider split would lead to large numbersof dissatisfied and demoralized junior doctors. Indeed, asurvey carried out at the time suggested that up to half ofthe doctors had considered leaving medicine.14

The third issue related to the indication of a lack ofteam spirit in the early stages when hospitals attempted tointroduce the New Deal, for example, in the Wirral.15

Only in an institution where junior doctors were sub-jected to the complexities of hospital management, thedifficult decisions made by senior clinicians and managers,and the importance of cost control and quality assurancecould, a team spirit, be maintained. Examples of this

way of working was seen at Pinderfields where it wasacknowledged that greater job satisfaction, higher moraleand better working conditions for juniors had validcontributions to make and problem solving approachesemployed in the day-to-day management of issues of teamworking.16

The fourth issue was reflected in the increase in costeffectiveness in service delivery. The shifting of doctors’duties on to nurses’ was seen as a little misguided.17 Pre-vious studies had suggested that 30–70% of tasks per-formed by doctors could be done by nurses, the implicationbeing that substantial savings could be made by substitutingnurses for doctors. In many situations, it was noted thatmany of the studies were based on the American HealthCare system, and was carried out during the early 1970sand 1980s; therefore, appeared to have little relevance,except in philosophy, to a British health service in the1990s in a comprehensive review of the literature, theevidence base was found to be limited in size.18

The consequence of this was the suggestion that Britainneeded to evaluate exactly what the effect of the doctor–nurse substitution was, both in quality of patient care andthe overall costs. Otherwise, in terms of practicalities,there was a danger that National Health Service (NHS)staff would not be sufficiently employed. Nursing unionrepresentatives subsequently agreed that any changesshould be based on evidence, and that staff such as nursepractitioners were ideally placed not to substitute fordoctors, but to complement them and extend the servicesthey offered. Extended roles for nurses in primary careand in the acute sector would also allow increasedcontinuity of care. This was an issue about availabilityof doctors and nurses and quality of care rather thansavings.19 There is little evidence currently relating to theimpact nurse practitioners and other types of advancednurse have on the service. It can be assumed cost savingshave been made in relation to salary comparisons.

Medical staffing shortages were problematic in theearly stages; during reporting in 1994, it was revealedthere was a major crisis in medical staffing in hospitals inBritain and this was influencing other aspects of health-care delivery. The progress reports, from task forces forthe period 30 September 1993 to 31 March 1994, showedthat if the rate of reduction of hard pressed on call postsremained the same until the end of the year, there wouldbe 5500 posts (meaning 21% of all posts) outside con-tracted targets. Before the New Deal, the conventionalpattern of staffing was the firm consisting usually of two

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consultants, a senior registrar, a senior house officer andone or two pre-registration house officers, a one in tworota was often expected for resident junior staff. It wasnot usual for registrars to be non-resident when on calland even in major teaching hospitals the on call residentstaff were sometimes very junior. Cross cover betweenfirms was often unacceptable or discouraged.20 As thereports were completed, however, several steps havebeen taken. Task forces were given greater roles. Anincrease in funds for additional consultants posts andurgent reviews into the issue of skill mix was conductedby the health authorities and trusts.20

In summary then, the New Deal was considered to beproblematic because of the impact it would have on doctorsthemselves, service delivery maintenance in terms of safetyand quality, as well as the cost implications. The antici-pated change would also impact on morale and ways ofworking. It was apparent that a change in culture wasrequired but would need to be incremental to appeaseresistance within the profession, the professional associa-tions, unions and nurses who would be affected.

EUROPEAN WORKING TIMEDIRECTIVE

In October 1998, the British government agreed to imple-ment the ETWD as an aspect of health and safety legisla-tion. By August 2004, it was stipulated that a doctor intraining should be working no more than 58 h a week(including on call as a result of the SIMAP agreement).This also affected doctors working in primary care.21 Thisis set to further reduce to 56 h by August 2007 and 48 hby August 2009, which might be extended to 2012. Thisis coupled with a series of rest stipulations which indicatesthat many doctors will be forced to work full shits. Thishas been met with dismay by the British Medical Associa-tion junior doctors’ committee.22

The need to incorporate the ETWD for junior doctorswas increasingly significant for the Blair government as itbecame clear that the New Deal was not going to work inBritain because of its lack of compulsion, its difficulty inimplementation, the slowness of progress made, com-pared with other health service reforms over the period asits introduction in the House of Commons and the likelyimpact on other health-care professions without prepara-tion or mobilization of the workforce.

The ETWD was introduced through health and safetylegislation, thereby, making it compulsory and its inputlegally binding by employers.

Unlike Britain, most countries hospitals are not run byjunior doctors with generalist training who call in expertsas and when they are required. Indeed, senior doctorsand nurses are specialists in a range of disciplines work,in teams to provide emergency cover across the board.There is a growing consensus that this is the directionthat trust hospitals in Britain would face with multi-disciplinary and multi-professional teams. This new wayof working is likely to lead to increasing potential forbetter patient care, however, to establish this cultureshift, was considered problematic, and a staged introduc-tion would be necessary.23

The Dutch have been compliant with the ETWD since1997. There has been a transition period for 4 years forhospitals to adjust to the directive in the Netherlands.Hospitals received £26 million per year to make thenecessary arrangements and to increase the numbers ofjunior doctors they employed. Hospitals were alloweduntil early 1999 to meet the working time restrictionsimposed, junior doctors’ working week was fixed to amaximum of 48 h over a period of 13 consecutive weeks(624 h), including all over time and hospital based on callwork. In practice, they could work no more than 10 h aday, with an individual maximum of 12 h. This might onoccasion be 16 h once a week.24

The process of introducing the ETWD in Britain hasbeen given much consideration. Working patterns, skillmix and up-skilling has become a concern, not only fordoctors themselves, but also for other health professionalsincluding nurses and health-care assistants. The situationfor some doctors is complex. Currently 97% of surgicalspecialist registrars in England and Wales have beenworking the traditional on call rotas.25 On an average rotaof one in six, each specialist registrar spends 29.47 h perweek providing day time service. During this time, spe-cialist registrars run the ward, see to the patients, assist intheatre, and gain the knowledge and skills for later con-sultancy work. However, the main concerns that existabout the changes for specialist registrars are twofold. Thefirst is about patient safety. Diagnoses and interventionshave become increasingly complex and the consequencesof error and resultant penalties cannot support suchsolutions. The second is that the purpose of specialistregistrars training is to become increasingly skilled inthose complexities and cross over would normally dilutethis focus of experience.25,26

In order to implement the changes brought by theETWD, the government did suggest an expansion in a



number of trained doctors which was an aspect of theNHS Plan launched in 2001. By 2004 the number ofsurgical consultants was increase by 25%, which meant1100 new posts, and the number of specialist registrars bya maximum of 334 training numbers above 1999/2000baseline figures in England. The current impact is not fullyknown except that there has been an increase in recruit-ment at this level from hospitals around the world toBritain with limited availability of promotion places forjuniors.27

Recruiting extra doctors in order to comply with theEWTD is not the most effective use of human and finan-cial resources, according to the Department of Healthguidance.28 Instead it suggests that creative redesign ofworking patterns of consultants and specialist registrarswould be better to avoid large increases in staffing.29 It isanticipated that national training numbers are expected toproduce an increase of 435 in the number of consultantsurgeons by 2010.

One solution suggested in reducing hours worked byjunior doctors is to increase the work time of the consult-ant, particularly in specialty services. It is suggested thatto increase the involvement of consultants in out of hoursservices. This would release specialist registrars from allduty after midnight with the consultant replacing them.There is a problem, however, under the new contract, inthat any work undertaken by the consultant might furtherdecrease their availability during the day time.26

Another approach suggested was trainees who wouldcover late duties for each other. This has been widelysupported for some senior house officers by the presidentsof the surgical specialist associations, although they thinkthis would result in the transfer of work up the gradesrather and would not be appropriate in specialist units. Allare supported to cross specialty working for specialistregistrars and this is a key obstacle to preserving viableacute surgical services in all district hospitals.28

Developing the skills of other professional groups toundertake wider roles can relieve the workload pressureson doctors and enhance the roles of other professionalgroups who wish to take on new skills. The roles of nightnurse practitioners and specialist nurses has been a majorstep forward in developing roles that were previouslyallocated to junior doctors. Many trusts have training anddevelopment programmes to extend and enhance theroles of other professional groups in their hospitals. Solu-tions that have been attempted are the employment of aprofessional practice development nurse to coordinate

such role enhancement and encourage development. thedevelopment of a nurse led drug administration policywhich allowed designated and trained nurses to supplydrugs against a collectively agreed and medically signedpatient group direction.30 There is also support for the useof nursing staff to carry out phlebotomy, cannulation andinvasive vascular access procedures.31 Support workershave also been supported in training to carry out cannu-lation, which is seem as a progressive step.28

The Royal College of Nursing report from Congress32

on the position of junior doctors, noted that deliveryquality care means an integrated approach and teamworkis necessary. Boundaries must be removed and effortsdirected to solve problems within work roles if theETWD was to be successful in its implementation. Manynurses are supporting the directive, and see this as anopportunity to develop their skills.

THE STUDYA study was undertaken by the author in a large teachinghospital in the English Midlands recently, to ascertain theopinions of doctors and nurses and human resources man-agers. In relation to the reforms and the impact it has hadon their daily working lives. It involved conducting aseries of semi-structured interviews which were recordedon tape. Each tape was transcribed verbatim and contentanalysis was undertaken.

RESULTS AND ANALYSISThe themes that emerged from the study were as follows:

• Working hours;

• Occupational boundaries;

• Working relationships;

• Future of health work and health-care delivery.

WORKING HOURSThe working time directive implications for doctorswould mean shift working but they would not necessarilyreceive any payment for working unsocial hours in muchthe same way as the current arrangements that exist fornurses:

. . . In essence it means that everyone who is normally residenteffectively is going to work shifts and that’s what’s happen-ing. Our SHO already currently works shifts and in fact ourappliance now is 56–58 h.

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The anticipated hours of working under the directiveare envisaged as having some difficulty as one consultantstated when he totalled up his average weekly workinghours:

. . . It will be a big problem when it comes down to 48,allegedly we are all meant to be working according to theworking time directive . . . and I am not meant to do morethan 48 h a week but during the diary exercise for me,contract was actually doing 53 h a week, now some of thatwork is at home and probably at least 4 h of that is at homeso in fact you could argue that it is almost 58 h.

To newly qualified doctors, the working time directivedoes not appear to have that much of an impact althoughconsideration has been given to others who qualified sometime ago:

. . . I think it would probably have impacted more if I waslater down the line in my training, because I came into thebeginning of this development but often people who arealready trained get their jobs in line with the directive . . . Ithink if I’d been a house officer two years ago or something,and then this was brought in, then it would make more of adifference because I would have seen what the changewas . . . I started my first job probably almost in line with theEuropean Working Time Directive, so from that point of viewI haven’t noticed a change or anything different.

This particular pre-registration house officer was notentirely certain how the changes had impacted on him,but at the same time, had not really considered it untilprobed further:

Interviewer: So how many hours at the moment do you workduring the week, roughly?Respondent: I don’t know really. I’ve not really counted. Nineto five Mondays to Fridays, one night of those a week, some-times two, I work til eight.Interviewer: And when you’re on call?Respondent: When I’m on call, its nine in the morning tilleight at night or later. That happens once or twice a week, onein four weeks. One in three its twice a week, every week, itsonce a week and then one weekend in four, which is Saturdaymorning and six or nine til 10.

So an average week’s work for a pre registration houseofficer is 44 h, sometimes 47 h. If weekends are included

here the worst case scenario of being on duty all weekendcould be 32 + 47 h = 79 h, without any breaks includedin this calculation.

Naturally this has caused some tension once doctorshave considered their daily routines:

. . . its quite a long day. I think personally, I’m not sayingeveryone’s like this, the thing that really puts me off the workis the call rota, I think during the week isn’t so bad actually,but the weekends I find worse.

It also at times makes for a long stretch of duty overseveral working days:

Its not nice to have your weekend taken away from you, whichthen means of course you don’t get a whole day off for12/13 days, which is a long time without a break especiallyas during those two weeks you are also potentially workinganother four days during the week as well.

Generally, according to this doctor, issues relate to staff-ing in the main:

I think . . . probably . . . [it] . . . evolves around the ageold problem of not being enough staff. if there were moredoctors on call, your busy on call wouldn’t be as busy, itwould probably feel a bit more routine than it does at presentwhen it can be quite a difficult job, and it would mean youdon’t have to do on call quite so frequently.

This again can be demanding for the junior:

On call times are always going to be much more stressfulbecause you’re dealing with sick people who may not havebeen seen for a couple of days, especially at weekends andthere aren’t enough staff and people who are then all verystressed which leads to just a general stressed feeling.

Even when the suggestion of shift work for doctors wasmade, this did not appear to be a satisfactory solution:

I don’t really see that it would work because I think you’dneed a lot more doctors at present than there are to be honest.I think that I quite like working nine to five. Yet, it would benice every now and again to have a bit of a lie in! But nineto five as a routine I think is quite good really.



Other doctors thought that staffing issues rested withfactors outside the NHS, as this senior consultant stated:

The problem is . . . there aren’t enough of us and the reasonsthere aren’t enough of us has been the political decisions overthe last 25/30 years. When I first went to medical school in1981 there were calls to reduce the number of medical schoolplaces because there were going to be 20 000 unemployeddoctors in the year 2000, which was the wrong way round,and whenever there is political interference in a main caredecision then of course you cannot plan for 10/15 yearsahead.

BOUNDARIESNurses, within their advanced roles as nurse practitionersand because of an increasing process of specialization innursing, have made some headway. Within and because ofthe advanced nursing role, there has been a shift in bound-aries to the extent that they do not exist as one respondentnoted in his observation of the field:

We’ve demonstrated over the last two decades in neonatalpaediatrics that there’s been a complete blurring of the for-merly rigid boundaries. We started . . . right at the begin-ning with this huge argument about whether nurses could giveintravenous penicillin and we now have moved on happily towhere our nursing staff are resuscitating babies, intubatingand so on. That’s no problem, and we’re sure they do it better.I think it is only a matter of time before we do exactly the samething in general paediatrics.

Policy makers and health planners never anticipatedboundary shifts to the extent applied to current health-care delivery:

[Locally] . . . , there is clearly a blurring and there has beenfar more of a blur in terms of who actually does what andorganises what, than people who sit in offices in Londonactually ever thought. That all junior doctors are, or certainlyshould be, guided in their view by senior members of thenursing staff and helped and directed. I suspect that attitudeswithin the senior excellence above the medical and nursingprofessions are likely to preclude an easy and happy assimi-lation to a common caring grade.

However, some health professionals prefer a hierarchicalsystem with a clear demarcation of roles:

Some sort of hierarchy in the system that everyone, includingpatients and members of staff to know at what level you’re atin terms of training and what can be expected . . . of you.

And:

. . . I think it does sometimes, especially on call, takes acertain amount of firmness for you to say actually there aresome jobs that you’re not here to do and I’m not sure whetherthat comes from the title junior.

Knowing your position and parameters of responsibility isimportant according to this PRHO who explained whathappened in the case of cardiac arrest of a patient on hisward:

. . . The ones that I’ve been involved with, you are verysuddenly aware that you are completely fighting the odds, andthat you’re only part of the team in that situation and I thinkyou just have to focus very hard on your little bit, on yourjob . . . as a PRHO its not entirely your responsibility to belooking at the entire crash situation and making decisions,unless you’re the most senior member . . . in the hospitalsituation that’s very rarely the case . . . only for a couple ofminutes or so. Some of the ones I’ve been involved with, I wasactually first to arrive on one of the scenes . . . put out a crashcall and got the patient in the right position and kept theairways open and gave some oxygen . . . I was quite surprisedat how quickly the crash team appeared.

Sometimes if other tasks are taken on by other membersof the health-care team, it can be frustrating if not under-taken properly or there is an issue staffing shortages wheredoctors will find themselves reverting back to the basictechnical tasks that others are no longer able to take on:

Prescribing, catheterisation, cannulation, venepuncture andECG . . . they’re the five jobs that I do varying amounts ofduring the day. If you’re on call or on a ward with nurseshappy to do those things, then it can be fantastic, its reallygreat and having clinical support is a help.

The problem with that lies in fact that you become used tosomeone else doing those jobs for you, and so . . . you cankind of apportion your time to certain tasks because you thinkyou’re not going to have to do some of those things today, andthen if that service somehow doesn’t happen on that day, thenall of a sudden you’ve got three times as much workload thanyou’d planned for that day.

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The issue of competence and skills are more importantthan who does the job according to this PRHO:

Obviously there are some people who find it difficult to takeblood, but in general it’s a basic skill. Personally, I think itwouldn’t be unreasonable to expect the same from nursingstaff, because they’re not that difficult a task really. Itinvolves a certain amount of training on the job. I’ve neverhad any formal training in catheterisation, for example.

Nurses, taking on some of the roles of doctors, haveactually caused resentment on a personal level:

I think it more causes problems with friction between differentcolleagues you know. It can make you resent a person, it canmake you think, well if you’re expecting me to do every singlething for you, I’m not going to do anything for you, youknow. Being a stubborn old devil, I can kind of dig my heelsin and be awkward on purpose . . . I want to be able to doeverything to my best ability, I don’t want to do anythingsecond hand and second class, and at the end of the day thepatient comes first.

The development and up-skilling of other workers inhealth care have also contributed to the blurring ofboundaries:

I’ve seen a difference when I first qualified compared to now.The healthcare support workers or nursing auxiliaries orwhatever job title they’re given nowadays . . . you’ll find agreater number of health support workers compared to quali-fied nursing staff, and you can see that with the developmentof their role, they’re taking on more and more responsibility.They are the people that look at patients day in day out andhave the hands on care and do the personal, intimate thingsthat I used to do you know. I miss that kind of contactsometimes you know . . . they are the ones that do the day today care.

And:

In some respects the healthcare support workers have taken theplace of enrolled nurses without doing medicine rounds. . . it’s the health care support workers giving the basichands on care you know. This isn’t sort of like medicinerounds and taking to theatres and collecting from theatres anddoing those kinds of things, but the day to day ‘hello Nellie�

‘how are you’; how’s your night been� what can we do for youthis morning ‘that’s health care support workers now its notqualified nurses any more.

And:

I think there will always be a place for health care supportworkers, who. Lets be honest about it, healthcare supportworkers at NVQ level 3, do the old EN jobs and that’s whatthey are basically. They have taken over the role of the oldenrolled nurse grade.[res 4]

The demarcation of roles has also sparked a debateconcerning payment of worth for health-care supportworkers:

Some of them are doing extended roles, an enrolled nursegrade wouldn’t have been doing NVQs level 3, they’re beingtaught to take blood, ECGs and there is absolutely nothingwrong with that, right. That’s a personal view anyway. . . are they being paid?

The role of nursing, generally for the qualified practitio-ner, not advanced by definition of the job title, hasbecome rather detached:

. . . when you’ve done a doctor’s round and written all thatup, then you’ve changed all the care plans, then you’remaking phone calls for the discharges, before you know it, itslunch time and you haven’t said hello to anyone. Its veryfrustrating as much as anything else.

There are various issues concerning the advanced nursingrole whether it is defining the term ‘advanced’ as appliedto nursing skills or whether it denotes the specific roleof advanced nurse practitioner, each aspect has its owndevelopment as this historical account of one type ofadvanced nurse development denotes:

I spent 30 years in neonatal paediatrics and my first contactwith nurses working outside the traditional nursing environ-ment was actually in 1977, when I did a year’s fellowship inToronto, where the advanced neonatal nurse practitioner rolewas well established and I had an involvement from those veryearly days in a training package for advanced neonatal nursepractitioners and allowing them to take over many of the rolesof junior and indeed middle grade doctors, so that they would



do neonatal transports, both by land and by air, they wouldput in arterial lines, put babies on ventilators . . .

Observation of the role in Canada and talking to midwivesand neonatal nurses found that the role of the advancedneonatal nurse practitioner had grown out of experiencewithin the field largely:

. . . Feeding back information like blood gases back to base byradio telephone in those days, would be advised by one of themiddle grade or senior doctors on the management of clinicalproblems. It struck me that many of these girls who werefulfilling these roles came from a background of neonatalnursing, but interestingly at least half of them were ex- Britishmidwives and this was at a time when midwives and neonatalnurses weren’t allowed to give intravenous penicillin to babieson wards, and it struck me how incongruous it was that on onehand we had girls intubating thousand gram babies andtransporting them by air on ventilators and on the other handwe had people with the same basic qualifications not allowedto give intravenous penicillin and this was clearly barmy. Sofrom that point of view when I came back to the UK andparticularly when I got my first consultant job . . . which waspredominantly neonatal based, we looked to develop thenursing role.

Again, poor recruitment to fill posts of junior doctorscontributed to expediency in the development of theadvanced nursing role:

Here we had a problem, we had to fill the gap in rotas and itwas clear we were not going to get more junior doctors to dothat. And that was the basis on which we got money to getneonatal nurse practitioners in. From my point of view it wasmuch more about quality. I had personal evidence, on a verysmall scale . . . to suggest the advanced nurse neonatal prac-titioners delivered a better quality of care than very juniordoctors, and I don’t think that surprises anybody but we hadactually begun to document it

In addition to this:

. . . We clearly had the opportunity because of the change injunior doctors’ hours, to increase the number of neonatal nursepractitioners and in fact I brought two with me from Hum-berside as they decided they would like to come and work inLincoln. So we have a small tier, not a complete tier yet, ofnurse practitioners, but my aim would be for the unit to be

staffed round the clock, 24 hours a day by those neonatalnurse practitioners, relating to registrars and consultants withno input from senior house officers at all, other than theirexposure on an educational basis for neonatal purposes.

The advanced nursing role has developed within otherclinical areas and has also given nurses a sense ofautonomy. In this particular instance relating to thenursing role in the Accident and Emergency Flying Squad:

You have to be an advanced nurse, an experienced nurse to beable to cope with the pressures of going out . . . you can be atthe forefront of a scene of a major disaster and you need to beable to cope with that, so the experience needs to be there. Youhave the ECG to do, the cannulation and venepuncture,prescribing medicines you know, and working autonomously.

There is some use of initiative which enables the expan-sion of autonomy within the advanced nursing role:

. . . as soon as a patient arrives . . . you take them from theambulance crew . . . if [they]are asthmatic, I would auto-matically get a nebuliser prescribed and administered . . . apatient with chest pain, you automatically do an ECG andthen get it checked straight away you know. There are certaintimes where you automatically do things . . . you know theobservations and the care the patient needs.

One nurse explained that her role gave her a consider-able amount of autonomy but being conscious of herlimitations:

. . . you are expected to look after your own patients inAccident and Emergency and if you forget something the buckstops with you. You are the one that takes the responsibility.

This also applies in the prescribing of medication:

. . . we’ve a list that the Patient Group Directive have comeup with that we are allowed to prescribe our own. Simpleanalgesics like paracetamol, and Ibuprofen . . . um, so whenyou’re in triage, which is another role we take on every nowand again, you can just give the patient simple painkillersand it saves time asking the doctors to write it up.

There is also some authority within the advanced nursingrole:

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. . . I find that sometimes you have to, you are involved inmaking the decisions and you, if you’ve been experienced in apatient’s condition and you see that the particular doctor youare working with doesn’t really get the gist of what’s goingon, depending on who they are, you can either plainly tellthem this, this and this, I’ve seen this before, or with somedoctors you can gently nudge them and let them feel like it wastheir idea, and you’re very much involved in the decisionmaking.

The picture is not always so clear; however, the tensiondoes still exist between doctors and nurses as far as nursesdemonstrating that their authority is concerned:

. . . I do find it with the more experienced doctors as well thatthe need for nudging rather than plain talking. They don’tlike nurses telling them what to do, having been involved inthe medical profession for a long time where nurses were done,did as they were told many years ago . . . they don’t like itbeing reversed and err . . . having nurses telling, especiallyfemale nurses.

Generally, communication as in most occupations is thekey to gaining acceptance and influencing others:

I find it very easy to talk to junior members of staff as withother people, and I do find that quite a lot of them come to mefor explanations.

The advanced nursing role is connected to particular skillsand range of skills which can be used within the role:

. . . ECGs, cannulation being a feature of prescribing medi-cines, these are all part of that. Initially, it was seen as aspecialized role and you know there was only a certain amountof people going to be allowed to do, and you know you kindof felt good about yourself when you were chosen.

Before embarking upon the role, one nurse did questionher ability to live up to task and take on the additionalresponsibility:

I kind of feel now that its something that’s going to beexpected of you, you know, you can’t just be a plain nurse,you have to do x, y and z.

Sometimes, there are difficulties in being accepted by thedoctor

It kind of makes me unhappy sometimes, especially attitudesfrom some doctors, you know. We did have a doctor in ourdepartment who was known to say “why are you allowed inresus when you cannot cannulate?” well you know that’s notparticularly the nurses job in resus when there is a doctoravailable. As a doctor you should be able to cannulate your-self, you shouldn’t be expecting us [nurses] to do it for you. Ithink the attitude of some doctors really doesn’t sit very nicelywith the staff.

The acceptability of the role of advanced nursing is onethat requires some work, still:

The problem is you need to educate the rest of the disciplinesinto accepting from nurse practitioners. An SHO upwards,other nurse practitioners and other disciplines, that’s wherethe education needs to start. Mostly people in the accident andemergency departments see that as the way healthcare shouldbe going. Its educating the rest of the disciplines.

But, other nurses want their experience as a nurseaccepted too:

. . . Even if you’re not a nurse practitioner and you see apatient that quite obviously needs an X-ray of the ankle, youcan’t send that patient to X-ray, you’ve got to send them toa doctor first. What a waste. Because the X-ray departmentwon’t take X-ray requests from plain nurses.

The issue of the being a professional is also a thorny issuewith other health workers particularly doctors:

One of the hardest things is to get the doctors to understandthat nurses are professionals. We fought this battle for severalyears and I think that some of the older consultants stillbelieve that we are not educated and experienced profession-als, but as the new young doctor goes through they can seethat the values of letting nurses do more advanced workencouraging, encouraging them to do an extended role. I’msure when they become consultants they will see the benefitsof this.

The issue of being accepted with an advanced nursing rolerequires greater recognition from doctors and that theyhave a part to play:

One of the things I used to preach was that to delegate isnot to abdicate. Delegating responsibilities, delegating tasks



down, you can’t delegate your responsibilities, you can’t abdi-cate them and I think that once doctors learn that they candelegate the task down, the responsibilities lie with them so wehave to show we are capable of doing the task and recognisingthat task.

Nurses, making and taking decisions, often speed up thecare delivery for their patients:

. . . I’ve had really good, some good cases, you know, You getpatients in and by the time the doctors come you know you’vedone, you’ve done the majority of the work. All they need todo is do the writing . . . which is good.

In decision-making also, nurses find in some cases thatthere really is no need for a doctor when they can act ontheir own initiative:

. . . like my role now, we don’t need a doctor, we have awoman who we suspect might be pregnant from our observa-tions, use your initiative, get a pregnancy test done straightaway, make sure the patient is stable, all without thedoctor . . .

And also supported by another:

. . . We are looking at simple things like you diagnose apatient with fractures, being able to differentiate between,does this patient need to sit here, see the doctor, sit here fortwo hours and see a doctor and be referred on to the specialist.Does he need to sit here for two hours waiting to be sent on tothe orthopaedic surgeons? These decisions can be made at alower level.

The results highlighted specific features of recruitmentand retention in relation to medical work. In one part ofthe county, there are tensions regarding the recruitmentand retention of doctors:

. . . Politically, that’s a hot potato isn’t it and of course I’mnot sitting here from a G or a B hospital. If I was a consultantat G now I would not be making long-term plans that I wouldbe a consultant in 10 years time . . . but if you look at theage group of consultants in G, most of them will probably beretired in 10 years time anyway and they have stoppedrecruiting because of that reason, anybody now looking for ajob who wants to stay in a place is not secure and so in essenceit will sort itself out.

There are suggestions to solve the recruitment difficulties;however:

. . . You can talk about fast tracking but its how competentyou’ve got to be at the end of it otherwise you spend a lot oftime as a trainee and it still hits you when you come to be aconsultant that there are lots of things that you can’t do.

Some speculation on operations in medical work in thefuture will mean different ways of working for all doctorsas identified by this consultant:

Market forces if you like, will, you can try and recruit but Ithink in essence there will be more done with bigger hospitals’particularly for emergency care, elective care is slightly dif-ferent in that you can support day units, you can support fiveday wards and treatment centres or whatever, but begin, it isthe sort of reason that you can combine emergency and otherwork in the same building. If you’re expected to do youremergency work in one building and your elective work inanother, you can’t do two at the same time. Now that’s fineif the buildings are literally next door to each other . . . thatwas all abandoned 20 years ago . . . sounds like they mightbe expected to re-introduce it . . . to support it . . . I wouldlike to have support consultant teams, I don’t just meanconsultants with juniors, I mean teams of consultants, so youwould see a vascular patient and there would be 3 or 4vascular consultants and within that, there would be some-body on acute, somebody on emergency and so on.

This will also include continuous professionaldevelopment:

It is mainly constant updating. In essence the things that haveadvanced so there are new things that I have introduced. . . from the literature, from conferences that are revised fromtalking to colleagues who have tried it . . . in terms of updat-ing its primarily reading journals, then its meetings. . . you learn through the society and meetings what isimportant and what is not.

One doctor at the beginning of his profession found thatadministrative issues and constant proof of competence isa burden, as he observed of nurses:

I think to become efficient there has to be a lot less paperworkand lots more, how can I put it, a lot more trust I think in theprofession and a lot less proof of competence, I find it amazing

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that nurses have to have certificates for everything . . . thosekind of things are a waste of money and a waste of everybody’stime.

WORKING RELATIONSHIPSWorking relationships, with doctors in accordance withthe changes instituted under the ETWD, have been mixedin consideration to skill and everyday experiences. Somenurses believed the maintenance of team working was abetter solution than deskilling health professionals, par-ticularly doctors:

. . . We are not saying we are going to take that skill awayfrom them, we’re only enhancing that skill, we would say thatwe would share that skill with them, you know you candiagnose, and we’ll suture.

And:

. . . I personally find it more comfortable to be much moreopen with the doctors I work with especially when the workingrole develops you know. The more you get used to each otherand you know that you can nudge and the ones you can plaintalk to.

And:

Quite a lot of our junior doctors are very junior and perhapshaven’t come across that kind of patient before do accept alittle leading now and again.

[Note: nudge in this nurse’s terms means showing,guiding the doctor, pointing him towards a desirableoutcome. This will involve some preparation, observationand getting to know the ways in which the doctor worksto get the doctor to do exactly what the nurse thinks heshould be doing. Emotional labour.]

Some doctors enjoy working with nurses who are sup-portive of the doctors’ role and also use their initiative.One doctor explained the situation on his current ward:

. . . They’re very good in terms of being aware of what medi-cations a patient is on and also what they need to be on, andalso they’re very aware of doses and correct prescribing forthose drugs, so whilst they don’t actually do the prescribing,they do often make suggestions for what we should prescribeand the majority of the time they’re absolutely right.

Supporting roles of other health professionals in aiding thedoctor in his/her work can be rather ambivalent in naturealso:

During week days, and also weekends actually as well there’sa phlebotomist service, but at times like this week for example,they were very short staffed, and so there were not enoughphlebotomists to come and do all the bloods so you end up atthe end of the day having a big stack of bloods that stillhaven’t been done so you go and do them yourself. The nurseson this ward in general don’t take blood as far as I know, butthen there’s not really much need for them to because ingeneral the phlebotomist comes out. So if there’s some bloodthat needs taking, like I need to know the result of it withina certain time scale, like if its not just a routine blood, thenI’ll take it myself in general.

FUTURE OF HEALTH WORK ANDHEALTH-CARE DELIVERY

The future of health-care professions, according to somedoctors, looks a little fragmented:

Well there will be no team. As happens now, the only personthat in essence gets continuity of care here or who knowswhat’s happening is the patient, which it never used to be inthe past. In essence what I see is things changing into isprobably in the future you will not be under an individualconsultant. As an in patient, particularly as an emergency youwill probably be under the vascular team to the trauma teamand in fact the consultants will change as much as the juniorsdo, I suspect that will come, but that can all be covered whenthere are enough consultants and that system will send todeath all the small district general hospitals, so G and B we’dhave to say goodbye to because this area could only supportone big hospital.

Doctors’ current new ways of working, particularly as itstems from training, will lead others within health-caredelivery to re-think their priorities:

. . . As I’m sure you’re aware the training system is beingrouted to be changed . . . I mean there is a reduction intraining time, one of the things I spent time doing last yearwas a series of master classes for SHOs . . . we’re doing it ina small group of teaching . . . it takes quite a bit of organ-ising . . . what we don’t want to do is reduce the number ofoperations that we actually go through a day . . . training



changes and meeting targets . . . its how competent you’vegot to be at the end of it.

And with reduced opportunities to practice medicine,surgery or any other speciality as a junior doctor is some-thing that consultants are exercised by in how to get thebest out of their team without compromising quality andcompetency. In future:

. . . Governments may still purchase, and will purchase thevast majority of health care excellence but they will not beproviding care in the NHS.

Nurse substitution in conducting medical work is notgoing to solve all the problems for the way in whichmedical work is performed in future:

There are certain things, certain mystique, powers thatacquiring a medical degree conveys on you. The ability todecide a patient is dead, and the ability to give him enoughdrugs to kill him, are two things that are enshrined in themedical degree. We are gradually chipping away at the pre-scribing issue, but I certainly think there are going to be somethings that will remain medically biased. In practical termsI can remember being taught how to put up drips by theward sister . . . so I don’t think we’re talking about anythingterribly new, we’re just recognising what’s always gone on,formalising it and giving it legitimacy, if you like and I thinkthat will continue.

And, he continues:

There will inevitably be some blurring, I think perhaps theimportant difference is that nurse practitioners are workingwithin by and large, a very narrow range of competencies andI think that it is likely to remain the case.

Within other aspects of health care, the future of thegeneric worker is considered to have some problems asseen in the way nursing has developed:

I think that’s going to be difficult for legal reasons the futurearound nurse prescribing which generated more bureaucracythan any other piece of work I’ve ever seen, is just one exampleof the difficulties.

DISCUSSIONThere appears to be some ambivalence towards thereforms themselves. They only seem to be welcomed

because of issues concerning general health and patientsafety.

In relation to working patterns, this has major implica-tions for the medical profession as there will need to be acultural shift in order for full acceptance of the politicalreforms.

It is envisaged that there will be teams of ‘expert’medical firms covering the hospital where skills can bepooled and deployed where best suited covering the hos-pital around the clock. This does increase the likelihoodof shift work for doctors in very much the same way thatnurses have done for years and links with some of thepredictions made in the literature.23,26 The knock-oneffect of this will be to increase the number of doctorsto suit such teams and training within specific priorityareas increase. Consultants will need to work a morevaried pattern across the 24-h cycle. For some particu-larly surgeons and accident and emergency consultants,there is already this type of shift system in operation.

Nurses have undoubtedly benefited by increasing theirskills. It has also increased their sense of autonomy in roleas well as placing them on a more level footing withdoctors in terms of working arrangements, decision-making about treatment and care of patients, as well astheir status within the clinical setting. One has to place inview; however, whether this alteration in future is a falseone in the sense that advanced or specialist nurses arebecoming more medicalized rather than establishing a realposition so far as professional dominance is concerned.One might consider this a pure situation of expediency forthe medical profession rather than real power sharing andnurses acquiescing to both government and medicine tofill a gap because of the rapid pace of change against arelative slowness in recruitment to medicine. Nurses’identity in this might be in question if they want to beregarded as a profession distinct from medicine. Boundarysharing might in the long-run be a transitional process;however, medicine regroups by allowing nurses to takeon roles, and it no longer wants to deal with.

The issue of professional distinctiveness is likely tobecome a problem with the increasing blurring ofboundaries and the fact that some doctors and nursesenvisage a common grade of generic health worker infuture. Nurses, traditionally regarded as the doctor’shand maiden,33,34 now surely have an opportunity todemonstrate their uniqueness and their value as a pro-fession. Medicine demonstrated this some time ago.35 Atpresent, what can be seen is another way for medicine to

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regain its dominance in the health-care arena through themedicalization of as much health work as possible, andthis means the other professions which are allied to it.Ideologically, this goes against social models of healthcare, to which some nurses (and doctors) have beenstriving towards for many years. Although nursing hasadvanced, it might also have the effect of retardingprogress as a profession and remain within the medicalshadow.

CONCLUSIONThe ETWD in Britain was introduced after long and con-siderable debate concerning its workability. The resultsfrom this study have demonstrated that there is still someway to go in terms of the provision of adequate staffing tomake the changes acceptable to all staff involved in health-care delivery. It is too soon to tell whether or not it hasbrought about real improvements in the reduction ofjunior doctors working hours, or has given them betterworking conditions or reduced the stress of performing indifficult working situations. Other health professionalshave realized there is an opportunity to increase theirautonomy in work and decision-making. However, it isunclear whether it provides them with real power as aprofession. Where nurses see themselves within thehealth-care professional hierarchy compared with medi-cine is still open to question as simple gaining territory foreconomic and political expediency can be short lived ifthey become subsumed as a profession. Doctors, them-selves, need to consider whether they feel that shiftworking is the way forward now that they have experi-enced it and also the type of profession they want to be,distinct or generalist.

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junior doctors' working hours: perspectives on the reforms

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