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Keywords:

  • emergency care;
  • emergency nurse practitioner;
  • extended scope physiotherapist;
  • interprofessional working;
  • nursing;
  • professional issues;
  • role substitution

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References

hoskins r. (2011) Interprofessional working or role substitution? A discussion of the emerging roles in emergency care. Journal of Advanced Nursing68(6), 1894–1903.

Abstract

Aims.  This article presents a discussion of emerging non-medical roles in emergency care against the current policy context and the issues of role substitution and interprofessional working.

Background.  Non-medical roles in emergency care have grown internationally in response to an increasing demand for emergency care services and to address the growing importance of the quality healthcare agenda. The blurring of role boundaries between professional groups has become more common.

Data sources.  Searches were made of three electronic databases; CINAHL, Medline and EMBASE. The literature relating to interprofessional healthcare roles, and new roles in emergency care was searched from 1980 to 2010 and underpinned the discussion.

Discussion.  A theoretical framework that has emerged from the literature is that task, role substitution and interprofessional working lie on a spectrum and evolving non-medical roles can be plotted on the spectrum, usually starting at one end of the spectrum under task substitution and then potentially moving in time towards true interprofessional working.

Conclusions.  There is still a great deal of progress to be made until non-medical roles in emergency care can truly be encompassed under the umbrella of interprofessional working and that a more robust critical mass of evidence is required to substantiate the theory that interprofessional working within teams contributes to effective, cost-effective care and better patient outcomes.

Relevance to clinical practice.  It is essential to understand the underlying motivation, policy context and key drivers for the development of new nursing and non-medical roles. This allows services to be established successfully, by understanding and addressing the key predicable barriers to implementation and change.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References
  •  Interprofessional working within health care is viewed as a positive development in meeting increasing patient demand for healthcare services.
  •  New roles in emergency care have been positively evaluated in terms of patient satisfaction and patient outcomes.

What this paper adds

  •  This paper identifies that emergency nurse practitioners were introduced initially in a role substitution role but as it has matured and evolved, the role has developed and now owns its own particular body of professional knowledge.
  •  An emerging theoretical framework of interprofessional working has been developed and new roles can be plotted across a spectrum; ranging from task substitution to interprofessional working.

Implications for practice and/or policy

  •  Understanding the underlying motivation, policy context and key drivers for change in health care allows services to be established successfully.
  •  An understanding of the sociology of professions and the historical evolution of roles and associated discreet professional knowledge can inform and break down potential barriers in the introduction of new roles with health care.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References

The rapid changes in healthcare professional non-medical roles and their scope of practice within the National Health Service (NHS) are occurring in a policy climate that actively supports workforce flexibility for a range of non-medical professions (Department of Health 1997, 2000). Policy changes are impacting on healthcare professions; encouraging role blurring and role redesign, with calls for greater flexibility in individual roles and skills as patient-need demands (Skills for Health 2006). It can be argued that this is the first time in the history of the current professions, that the United Kingdom (UK) government has explicitly supported non-medical practitioners to encroach on traditionally medical roles such as prescribing and diagnosis, to support the claim that interprofessional working within teams contributes to effective, cost-effective care and better patient outcomes.

The development of expanded nursing roles internationally, particularly within emergency care, is growing in arguably a more coherent and standardized way than similar roles in the UK. A review of the international literature (Hoskins 2011) demonstrates that within the emergency care setting four randomized controlled trials (RCTs) have been conducted in the United States of America (USA) (Power et al. 1984), the UK (Sakr et al. 1999, Cooper et al. 2002) and Australia (Chang et al. 1999). All four RCTs concluded that patient satisfaction and acceptance of the emergency nurse practitioner (ENP) role was comparable to satisfaction with the medical role in the emergency setting. In Canada, USA and Australia the title of ‘nurse practitioner’ is protected in law and as a consequence national registers exist, which is not the case in the UK. In addition, these countries demonstrate a standardized approach towards educational preparation for the expanded role of the ENP while in the UK despite lobbying by professional groups the title of ‘advanced practitioner’ is not regulated and the educational preparation has been criticized for lacking a coherent nationally accepted standard (Keating & Thompson 2008).

The aim of this article is to discuss and analyse the increase in emerging non-medical roles within emergency care against the current policy context and to identify whether the spirit of change in this area is one of true interprofessional working or simply of role substitution.

Background

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References

The past century has seen the growth and transformation of existing professions and the introduction of new roles in health care. These changes are believed to be the result of developments in technology, education, research evidence and new systems of purchasing, organizing and regulating the workforce (Cooper 1998, 2001). Nancarrow and Borthwick (2005) argue that neo-liberal managerial principles have led to a redistribution of resources on the basis of professional competence rather than the historical workforce hierarchies and roles (Hurst 1996, Borthwick 2000). They also suggest that neo-liberalism has been reinforced by the government’s encouragement of consumer involvement in the health service delivery. During the last decade there has been an active move and emphasis in government policy in developing the workforce skills in health care. To achieve this, a greater emphasis on the development and importance of interprofessional working has been witnessed. This policy agenda has been driven by the need to develop a flexible workforce which is responsive to the needs of a rapidly changing service (Miers 2010). Interestingly, interprofessional working was introduced in terms of substitution of roles within the NHS in the NHS Plan within the UK (Department of Health 2000). This policy document discussed the commitment of the NHS to redesign the health service around the needs and concerns of patients and to achieve this by providing flexible services and professionals who were able to deliver appropriate care through the end of demarcation lines especially between doctors and other healthcare professionals. This policy agenda supporting knowledge exchange between professions therefore seems at odds with the professionalization agenda within health care where professionals were working to ‘own’ their specific and separate professional identity (Baxter and Brumfitt 2008). The secretary of state’s introduction to the NHS Plan identified that ‘for the first time, nurses and other health professionals will be given the bigger roles that their qualifications and expertise deserve’. Following this a series of policy documents and initiatives consistently supported the notion that the boundaries particularly between nursing and medicine needed to be further broken down (Department of Health 1997, 2000, 2001, 2002, 2003, 2006, 2008) to improve timely access to health care by developing team working skills, maximizing the contribution of all staff and modernizing education and training while also expanding the workforce. In the NHS Next Stage Review (Department of Health 2008) there is again an emphasis on raising the quality of health care delivered and a call to staff to innovate within and improve the services they offer. Darzi (Department of Health 2008) crucially raises the issue of accountability and responsibility of teams and individual healthcare professionals; ‘every clinician will have the opportunity to be a practitioner, partner and leader and to take collective accountability for performance’. He is seen to advocate a model of professionalism which interestingly reflects Davies’ (1995) new model of professionalism; interdependent decision-making in teams, reflective practice and collective responsibility. Skinner (2007) suggests that while the Department of Health is strongly promoting interprofessional working and shared learning, there is in fact a strong scepticism of this agenda from the medical professionals who see that the interprofessional agenda seeks to produce and equip cheaper generic healthcare workers and de-professionalize medicine.

Alongside the government agenda on access to timely health care, other key drivers supporting the interprofessional agenda have been identified as: rising healthcare costs, patient healthcare needs (such as complex patient care pathways) (Lewy 2010), highly publicized reviews into the failure of health and social care such as The Bristol Inquiry (Kennedy 2001), and the Laming Inquiry (Laming Lord 2003, 2009), reducing service fragmentation and promoting quality patient care (Barr et al. 2005). In many specialties, changes in medical education have seen a decrease in the available medical workforce, and some posts have been left unfilled.

This was the driving force in the development of the Emergency Nurse Practitioner role and it could be argued that the Audit Commission (1996) specifically encouraged a task substitution approach to the development of this role to address service delivery deficiencies as quickly as possible. An additional reason for the development of non-medical roles in emergency care was the introduction of specific targets set to meet the then national policy agenda of timely access to care for patients (Department of Health 2001).

Emergency care policy development

Interestingly there is a lack of any robust evidence on which the 4-hour emergency access target was originally based. Mortimore and Cooper (2007) suggest that it appears to have been founded on the basis that the public perceive speed of treatment to be synonymous with quality (Office for Public Management 1999) and that there is a correlation between patients waiting times and staff satisfaction (Alberti 2003). It is claimed (Department of Health 2001) that the 4-hour target was based on the findings of Cooke et al. (2002). However, this work was based in a different context and setting, finding that the introduction of different processes such as streaming of patients could reduce waiting times by 30% when experienced decision-makers were the first clinicians to see the patient when they arrived at the Emergency Department (ED). One way of achieving a ‘quick win’ was the speeding up of the development of non-medical roles in emergency care which had been slowly and gradually developing for some time to meet the increasing numbers of patients attending emergency departments. It seems that the role was developed sporadically and locally in response to local requirements and increasing patient demand and unfortunately a nationally co-ordinated plan did not support the development and implementation of the role (Meek et al. 1995). The benefits of ENP services are clearly outlined in the literature and include reduced patient waiting times, increased quality and cost-effective care, reduction in complaints and increased staff morale (Coopers & Lybrand Health Practice 1996, Dolan et al. 1997, Dunn 1997, Maclaine 1998, Sakr et al. 2003). The development of the ENP role is well documented internationally and has been subject to evaluation in terms of patient outcome and patient satisfaction (Sakr et al. 1999, 2003, Carter & Chochinov 2007).

Data sources

Database and manual literature searches were undertaken across the literature spanning health professions and interdisciplinary working and non-medical roles in emergency care. The data bases CINAHL, Medline and EMBASE were used. The following terms were used in the search: interdisciplinary working, interprofessional working, role substitution, task substitution, Emergency nurse practitioners, extended scope physiotherapists, physician’s assistants and emergency care. International publications were included in the search, but only English language publications were reviewed. The databases were searched for a period covering 30 years from 1980 to 2010.

Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References

Interprofessional working and role substitution

When exploring the concept and definitions of interprofessional working it is important to acknowledge that issues surrounding professionalism are closely associated and underpin an emerging theoretical framework of interprofessional working. Salhani and Coulter (2009) suggest that the idea of interprofessional collaboration means that professional boundaries among healthcare professionals are in fact flexible. This implies that an interprofessional approach means that the traditional characteristics of professions (autonomy, codification of knowledge, professional values and boundaries (Abbott 1988, Freidson 1988), professional jurisdiction and identity, self-regulation and professional territorialism (Axelsson & Axelsson 2009) are challenged by this approach to working.

The current definitions of interprofessional working have been derived from the widely agreed definition of interprofessional learning: when two or more professions learn with, from and about each other to improve collaboration and the quality of care (CAIPE 2002). It is, however, important to distinguish between interprofessional learning and interprofessional working. Lewy (2010) suggests that one of the key underpinning differences is that interprofessional learning provides an environment in which structured opportunities are put in place to facilitate the transfer of professional knowledge and where team processes and working are developed in a structured and more formal way. It could be argued that interprofessional learning takes place in a more controlled environment, than that of a clinical environment. Whereas interprofessional working is seen when professionals work together both informally and formally in response to patient healthcare needs (Lewy 2010). Headrick et al. (1998) suggested that in fact interprofessional working can be thought of as a spectrum of activity, with more loosely co-ordinated effort of collaboration at one end and more tightly organized teams of work at the other. Ovretveit’s et al. (1997) offer a definition of interprofessional working that focuses on communication and cooperation as strategies for achieving a common goal, highlighting the relationships between professional groups, while Leathard (1994) focuses on the sharing of resources, skills and responsibility and suggests that the interdependence of the team members can provide a better service if the various professionals worked alongside but independently of each other. Carrier and Kendall (1995, p. 18) have perhaps constructed a definition which conveys the depth and breadth of the tasks associated with interprofessional working: interprofessional working implies the sharing of knowledge; respect for the individual autonomy of different professional groups and administrators; the surrender of professional territory where necessary; and a shared set of values concerning appropriate responses to share definitions of need. Unsurprisingly the authors admit that professions are likely to find this an ambitious and demanding agenda.

Barriers to interprofessional working

Some key barriers to interprofessional working have been clearly identified in the literature. McPherson et al. (2001) suggests that barriers preventing interprofessional working include a lack of knowledge of the capabilities and contributions of other professionals, and existing rivalries and resentments amongst healthcare professionals about professional boundaries and territories. This, he suggests is compounded by the wide range of stakeholders with their own aims, objectives, priorities and values in establishing different allegiances, not only to the team, but also to their professional groups (Firth-Cozens 2001). McPherson et al. (2001) also identify that there are concerns amongst healthcare professionals that interprofessional working will lead to a blurring of differences between professions, just at a time when non-medical professions are still struggling to establish themselves as ‘true professions’ with a body of discreet, specialized and unique knowledge. Thus, Lewy (2010) suggests that professions are more interested in emphasizing the differences between professions rather than ‘sharing’ knowledge and skills which may be perceived as a threat to their professional status rather than as an opportunity. According to Abbott (1988) all professions are striving for ‘jurisdiction’ over their field of work, suggesting dominance over other professions within the same field and clear boundaries against those professions. The medical profession has also voiced concerns over the safety issues associated with task substitution and true interprofessional working and recommend that doctors retain their central role within health care (Yong 2006). This is despite a Cochrane review which found that nurses could successfully substitute for medical roles in particular circumstances in primary care (Laurent et al. 2005)

The evidence for interprofessional working

Interestingly in a health system based on evidence-based health care there appears to be disagreement in the literature as to whether or not interprofessional working does in fact improve patient outcome. The Cochrane systematic review of interprofessional working reviewed 89 articles and found that none met the stringent methodological inclusion criteria (Zwarenstein & Reeves 2006). As a result no conclusive evidence of the effectiveness of interprofessional working in relation to healthcare practice or outcomes was found. More recently Barr et al. (2005) reported findings from a selection of 107 articles (admittedly with less stringent methodological criteria than those of the Cochrane review) and found that there was a very important positive reporting bias. Skinner (2007) suggests that despite this, it is important to realize that the body of interprofessional evidence is evolving and developing and that it has become clear that a qualitative approach to evaluating interprofessional working should be accepted. Evidence of small evaluations from healthcare practice are emerging and demonstrating locally the positive impact on outcome that interprofessional working can have within teams and for patients (Fear and de Renzie-Brett 2006, Dawson 2007, Hudson 2007). Whilst robust large scale evidence is not yet available in order to underpin this change in policy, a pragmatic approach may be taken if there is acceptance that many of the characteristics of good interprofessional working (West 1997) mirror those of the attributes in the literature on successful team work in health care (Headrick et al. 1998).

Task and role substitution

Task substitution is defined as allocation of clinical responsibilities to lesser or more narrowly trained healthcare professionals with or without medical supervision (Yong 2006, p. 27). Task substitution directly contributes to role substitution when aspects of a previously defined role are undertaken by another professional usually a non-medical practitioner. It could be argued that aspects of task and role substitution have been informally embedded within the NHS for many years. For example as nurses contribute to a 24-hour working shift pattern and allied healthcare professions presently do not, many nurses are expected to take on elements of allied healthcare professionals work such as physiotherapy tasks out of hours and at weekends. It is also interesting to note that task and role substitution is associated with negative descriptors in the literature while generally interprofessional working is associated with positive descriptions. Arguably, the foundation of this finding may be found in the traditional characteristics surrounding professional identity particularly in health (Baxter & Brumfitt 2008) where professional groupings, allegiances and underlying philosophical approaches have been identified to be very important to individual health professionals. Thus being seen to ‘substitute’ for aspects of a different professional role is perceived to be an inferior or less worthy characteristic of a professional group.

The terms interprofessional working and role or task substitution seem to be used interchangeably throughout policy and Department of Health literature, however, it is important to be able to differentiate the two concepts when examining the policy context in more detail to understand the evolution in healthcare and more specifically emergency care.

Brook and Crouch (2004) suggest that in emergency departments during most of the twentieth century, there was clear demarcation between the roles of nurse and doctor, where patients received a consultation and examination for diagnostic purposes by doctors who would prescribe treatment and delegate its provision to nurses. However, whilst this may have been the official truth, unofficially there is evidence to suggest that nurses particularly had been expanding their role quietly for some time.

Hughes (1988) in his study undertaken within a ‘casualty’ department in the 1980s found that the distinctive features of ‘casualty’ nursing were found to replicate the findings of Stein (1967) in their increased involvement in decision-making affecting diagnosis and treatment and the flattened hierarchy found in ‘casualty’ departments when compared to wards. He also observed that the medical dominant relationship was weakened by the informal interactions of the nursing staff with the medical staff, the form of subtle cues to medical staff, the heavy work demands associated with the triage function of the department, the potential urgency of treatment and the short-term nature of most medical appointments all increased the nurses’ influence within the department and on nursing and medical relationships. Further ethnographic work in emergency care settings has confirmed that informal boundary blurring between medicine and nursing has been prevalent for many years. Annandale et al. (1999) found that it fell to the senior nursing staff to harness the unpredictability so the workload could be accommodated within the resource constraints. This resulted in the nurses organizing the work of the medical staff and taking on task substitution roles such as suturing and cannulation to speed up the flow of patients through the department and try to reduce bottlenecks in the process.

Newer roles began to develop such as the extended scope physiotherapist (ESP): a physiotherapist who has additional skills in assessment, diagnosis and management (McClellan et al. 2006). Evaluation of these newer roles is ongoing but early studies demonstrate that there are high levels of patient satisfaction associated with the introduction of these roles into emergency and urgent care settings (McClellan et al. 2006). Some emergency departments found that despite the development of these new roles, difficulties were still being experienced in recruiting enough staff to manage the patient attendances in a timely fashion, and the model of service delivery by physician’s assistants (PAs) as in the USA was adopted. PAs are health professionals with a generalist medical education that allows them to work in a variety of settings. They work under the supervision of a senior doctor. The profession emerged in the USA in the 1960s and is now being adopted by other countries such as the UK to address workforce gaps in medical specialties (Farmer et al. 2009). Interestingly the Scottish BMA (2008) published a position paper on this emerging profession and identified specific issues concerning the role; around value for money, impact on medical training, professional standards and regulation and integration into clinical teams, while praising and supporting the role of the nurse practitioner because they saw this as an expansion of a current role rather than a new role, which was viewed as a more positive approach.

Pollard (2010) suggests that one of the most important features of successful projects which address new ways of delivering a service is one in which a profession takes on and incorporates the tasks of a different professional group. From the evidence examined so far it emerges that the most successful non-medical role in terms of longevity and positive evaluation is that of the ENP (Dunn 1997, Sakr et al. 1999, 2003, Lin et al. 2002, Brook & Crouch 2004). This role has developed from experienced nurses taking on a substitution role that was and still is carried out by junior doctors. Because the role has become well established in emergency care over the past 25 years and developed to address a specific deficit in the workforce, evaluations have taken place which have identified a high level of patient satisfaction and an ability of ENPs to work safely within protocols (Grummisch & Lowe 2007, Carter & Chochinov 2007, Keating & Thompson 2008) There now appears to be a general acceptance of the role within emergency care (Benger & Hoskins 2005, Carter & Chochinov 2007) most importantly by medical colleagues (in terms of encroaching on traditional medical boundaries of minor injury care). The scope of practice within this workforce has gradually been developing and expanding to meet service delivery needs, and now the role has moved away from protocol driven care towards evidenced based care, which it could be argued carries much more risk along with independent prescribing status. With the expansion in scope has come the ability for ENPs to develop the skills to see the more ‘unpopular’ patient presentations and this may be part of the reason why the role expansion has now been accepted with relatively little ongoing resistance from medical colleagues. Incongruously, ENPs are now experiencing a reversal in roles and there is now an expectation and requirement that they will teach junior doctors about the management of minor injuries and illness. Adapting Headrick et al. (1998) concept of a spectrum of interprofessional activity it could be argued that the similar concept of a spectrum of activity can be applied to the range of healthcare roles from task substitution to interprofessional working (with role substitution sitting somewhere between the two) when plotted on a scale. Using this theoretical framework (see Figure 1) it can be observed that as the ENP role has become established it has moved along the spectrum of task and role substitution towards one of interprofessional working as other professions begin to understand and accept their role and the specific knowledge. This professional group is now claiming this area of work as their own, and as a consequence ENPs are being seen to contribute towards successful service delivery and interprofessional working.

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Figure 1.  Interprofessional theoretical framework. Adapted from Headrick et al. (1998)

Download figure to PowerPoint

There are however, identifiable disadvantages to the development of this role. Of particular note in the literature is the concern raised that senior nurses are being removed from the experienced nursing workforce in emergency care and are taking their knowledge and leadership away from the day-to-day running of busy emergency departments and thus diluting the nursing skill mix (Yong 2006). Coupled with this is the potential fear that future ENPS will identify that there is little or no financial reward for undertaking extensive further education and additional responsibility that the role now demands. In addition, where once the role attracted senior nurses who wanted to work more attractive hours, the need to meet growing demand for services out of hours has meant that the service provision has extended and ENPS are now working increasingly unsocial hours. While job satisfaction is a key reason for senior nurses to take on the ENP role, in the future ENPs may become a more mobile workforce when they become increasingly questioning of the prospect of undertaking increased responsibility with no financial award, and working increasing unsocial hours with no clear career progression.

Whereas there is less experience and evaluation of new roles such as the extended scope physiotherapist, there are some themes emerging from the literature. In the case of the extended physiotherapist it could be argued that their role expansion in emergency care has developed in a more interprofessional way mainly because the role brings profession specific expertise to emergency care (McClellan et al. 2006). However, if this role expands further it seems that the role extension could in fact move back along the spectrum towards task substitution as the ESP takes on tasks such as venepuncture and wound management. Positively, this will mean less ‘hand offs’ in care for patients but conversely could mean a perceived dilution of their well-defined and accepted expertise and knowledge by the rest of the workforce.

The physician’s assistant role was specifically developed as a role substitution function within the team (Farmer et al. 2009). Positively, when the role is clearly understood, it seems that the evidence suggests that the role is accepted and ‘owned’ by doctors. This may be in some part due to the use of similar language, values and socialization based around a medical model of learning and working (Axelsson & Axelsson 2009). The role has developed with obvious boundaries and the PA is directly responsible to a medical practitioner. It may be the case in the future that PA roles become so integrated into teams that they begin to claim specific professional knowledge as their own. However, without professional registration in the UK, it is unlikely that this will occur in the foreseeable future.

This different approach to delivering redefined models of care would suggest that healthcare roles are being encouraged towards a model of being based on competence rather than professional identity, in that occupation alone does not determine who conducts these tasks (Cameron & Masterson 2003). Miller (2004, p. 152) argues that the call for collaboration across professions in health care has come at a time when ‘many professionals feel threatened by a loss of identity and autonomy are struggling to maintain a professional role’ and may explain some of the resistance to expansion of roles and a more integrated approach to the concept of interprofessional working within teams. Catto (2005) acknowledges that the exclusivity of medical knowledge and skill is being broken down and suggests that this should not be seen as a diminution of medicine but rather a strengthening of health care. The emphasis in recent UK government policy is to prepare all healthcare students for interprofessional working in order to be able to be flexible and to be able to substitute for roles traditionally undertaken by other occupational groups and the ability to move across traditional role boundaries so that the delivery of care is patient centred rather than task or individual specific. While the underpinning concept is laudable, such flexibility, centred on role substitution and role design can present a challenge to healthcare professionals accustomed to established patterns of professional roles and professional boundaries and professional socialization (Pollard 2010) particularly in teams and professions where a hierarchy in the team is the normal and established approach to delivering a particular service.

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References

Throughout the discussion it has been demonstrated how the main driver for cross boundary working and the development of new roles particularly in emergency care has been a key policy agenda of the previous government for the modernization of the NHS and as a consequence a driver for the redesign of traditional workforce groups and occupations. The pace of change within the NHS in the last decade has been incredibly fast and some would argue unsustainable at the current pace and within the increasingly challenging economic climate.

The concepts of interprofessional working and role and task substitution have been explored in relation to the recent policy agenda and the development of non-medical roles in emergency care. A suggested theoretical framework that has emerged from an analysis of the literature is that task, role substitution and interprofessional working lie on a spectrum and evolving non-medical roles can be plotted on the spectrum, usually starting at one of the spectrums under task substitution and then potentially moving in time towards true interprofessional working. This movement can only take place if the roles are accepted and fully understood by colleagues (particularly medical colleagues) as contributing to a specific and discreet knowledge base. This in turn happens by virtue of developing an evidence base through evaluation of roles and developing specific knowledge within a speciality. As can be seen in the development of the ENP role, the development of knowledge has occurred by identifying a specific aspect of emergency care; that of minor injury and illness and the profession then claiming it as their own. It can be seen that the most successful profession in claiming true interprofessional working in this setting is arguably the extended scope physiotherapist who comes to the new role with a discreet body of knowledge that no other professional has in emergency care. The importance of understanding the underpinning sociological theories surrounding the professionalization agenda has also been highlighted in identifying and overcoming the barriers to interprofessional working. There is still a great deal of progress to be made until non-medical roles in emergency care can truly be encompassed under the umbrella of interprofessional working and that a more robust critical mass of evidence is required to substantiate the theory that interprofessional working within teams contributes to effective, cost-effective care and better patient outcomes. Ideally future work in understanding the significance, value and acceptance of new roles within the interdisciplinary team would be built into all service evaluations.

Funding

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. Discussion
  7. Conclusion
  8. Funding
  9. Conflict of interest
  10. References
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