Today the number of tasks undertaken by nurses has increased. This is related to a number of factors, ranging from resource issues such as the need to reduce junior doctors’ hours to the fact that nurses are being entrusted with wider responsibility as recognition of their role as independent practitioners. The government’s published strategy for nursing midwifery and health visiting contained in Making a Difference (Department of Health 1999b) is notable for its proactive stance on nurses taking on more advanced activities. The government would like nurses to extend their role and to make better use of their knowledge and skills. It also wants to make it easier for them to prescribe. The former Health Secretary Alan Milburn laid down a 10-point challenge on nursing skills to be implemented throughout the National Health Service (NHS). This included nurses being able to order diagnostic investigations, e.g. pathology tests and X-rays, make and receive referrals direct to, for example, therapists or pain consultants, run their own clinics, e.g. ophthalmology or dermatology, and take a lead in the way local health services are organised and run (Department of Health 2000a). The momentum for role expansion has been growing steadily for a number of years and it has been firmly taken forward and promoted by the government. The NHS Plan further promoted expanded roles (Department of Health 2000b) and Liberating the Talents (Department of Health 2003) described how ‘nurses with special interests’, i.e. with additional expertise, can be developed by primary care trusts to improve patient care and increase local primary care capacity. Advice for managers on developing key roles for nurses and midwives is provided by the Department of Health 2002.

Nurses now undertake activities such as electrocardiography, defibrillation after a heart attack, verification of death (not in cases of unexpected death), taking blood samples and performing male catheterisation (Eaton 1993). There are nurse-led minor injuries units (MIUs) where nurses carry out a variety of activities, which can include suturing, X-ray, plaster and refer (Carlisle 1995). There are also nurse endoscopists (United Kingdom Central Council 2000). The Department of Health and the Royal College of Nursing (2003) gave some further examples of expanded and advanced roles in their resource to nurses, therapists, health-care professionals, managers and directors to clarify what nurses and allied health professionals (AHPs) are allowed and able to do within their professional codes of conduct. It focuses on the patient journey, and brings together examples in practice that show how practitioners are working to speed up and improve the patient journey and experience by challenging myths.

The advice also provides practical factsheets about the legal and professional frameworks that support and develop professional practice and some good examples of expanded and advanced roles are given:



A contemporary view of nurses working in advanced and extended roles is provided in Department of Health and Royal College of Nursing 2005. This publication reports the findings of a joint Royal College of Nursing (RCN) and Department of Health survey to find out more about nurses working in advanced and extended roles and how proactive they are in developing the roles and services. A total of 758 nurses were asked about what their role entailed, what gave them most satisfaction and how their job fitted in with other nursing roles. Nearly 70% returned completed questionnaires. Survey key findings included that a nursing background is essential to undertake these roles; they are maxi nurses and not mini doctors. Nurses were found to be very positive about these new roles and keen for further role expansion. Nurses are leading multidisciplinary teams, working across organisational boundaries and coordinating packages of care. The roles are having a positive impact on the care of patients and the level of job satisfaction was high among post-holders. The roles create important career development opportunities that allow nurses to retain significant patient contact.

The growth of the nurse’s work has been termed ‘expanded role’ by some commentators. In the past the term ‘extended role’ was used when discussing the issue of nurses carrying out activities traditionally carried out by doctors (Tingle 1993). The position altered, however, in 1992 (Department of Health 1992). This change followed a report issued by the Standing Medical Advisory Committee and the Standing Nursing and Midwifery Advisory Committee (1989). The United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) stated that the terms ‘extended’ or ‘extending roles’ are no longer favoured as they ‘limit, rather than extend the parameters of practice’ (United Kingdom Central Council 1992).

Many see role expansion as presenting an exciting opportunity to develop new specialisms. However, expanding the nursing role has been controversial and there has been disagreement within the nursing profession as to what approach should be taken. There is no national standard or catalogue of expanded roles. Practices differ from region to region and even within hospitals (Standing Medical Advisory Committee and Standing Nursing and Midwifery Advisory Committee 1989). Some nurses argue that nursing may as a result become too technical and less patient-centred (Giles 1993, Shepherd 1993, Healy 1996). Eaton (1993) quotes Derek Dean (formerly Director of Policy and Research at the RCN): ‘The worry among nurses, many of whom welcome this additional responsibility, is that they are being asked to do extra work without anyone extra to take the load off them. A lot of members have expressed concern. They have said, ‘We are being asked to do things and are rushed off our feet.’

Similarly, Waters (1996) quotes RCN community adviser Mark Jones, who presented at a conference a catalogue of cautionary tales illustrating the dangers of nurses overreaching themselves. The list included one case where a practice nurse with no formal midwifery training had taken over antenatal care and had missed a fetus dying in utero.

A report by Doyal and colleagues (1998) looked in detail at the development of four new nursing posts. Each post involved nurses taking over some part of the work previously done by junior doctors. This study explored the views of nurses themselves and was quite revealing. While the study revealed excitement at the professional challenges they faced, the study also indicated that practitioners received little support and there was considerable confusion surrounding their new roles. Some legal and accountability issues were also noted:
The authors make a number of recommendations for managers and postholders about the management of change which include:
The authors of this report were also in a small working group that looked in further detail at the accountability of changing nurses’ roles. The analyses were published in the British Medical Journal (Dowling et al 1996). They noted that the resulting uncertainties about appropriate management for clinical roles evolving between the professions, coupled with a public increasingly going to court, put nurses and consultants at risk. These health-care professionals faced a risk of complaints, litigation and possible disciplinary hearing. Recommendations to reduce risk included: doctors and nurses as equal partners in planning the new roles; patients should also be informed adequately of the postholder’s role and relevant training. Staff should have access to legal advice and support.

This report should now be read alongside Department of Health and Royal College of Nursing 2005, which also looked at how extended and advanced roles are understood and utilised (Table 4.1). Two questions in the joint survey asked whether respondents had ever had a referral or investigation request refused because of being a nurse (not a doctor). Almost one in four (23%) of those who referred patients (n = 428) had had their referrals refused because they were a nurse rather than a doctor. The report also states that a third (33%) of the 315 respondents who ordered investigations had been refused on the same grounds. The likelihood of having referrals refused depends on both job title and sector. The report give more details:
It would be helpful if all these organisations could reach an understanding on expanded role.

Uniform guidance should also be drawn up and a consensus statement issued by the Department of Health with all the professional organisations together, the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC), in conjunction with bodies such as the British Medical Association (BMA) and the RCN, regarding such practice.

The current advice, as will be shown, shows marked differences of approach. It seems from Department of Health and Royal College of Nursing 2005 that whether a nurse who is performing an expanded or advanced role can get a referral appears to be just a matter of luck, which clearly should not be the case.

The emphasis today is upon the nurses themselves making the decision as to whether to undertake an expanded role. If the nurse believes that s/he has the necessary competence, then s/he may undertake the task him/herself. The UKCC was opposed to the use of certificates of competence, a view no doubt shared by its successor, the NMC. Such certificates state that the nurse has undergone a training programme and therefore may be competent to perform a particular task.
It was suggested that the fact that a nurse has been given a certificate might give the nurse a false sense of security and lead her/him to think that accountability for actions had shifted to his/her assessor. But at the same time, before a nurse undertakes an expanded role, appropriate training is essential and such knowledge needs to be sustained and updated.

Employers would need to ensure that a safe system of work is in operation for both staff and patients. As Giliker & Beckwith (2004) state: ‘Employers are required to take reasonable steps to organise and supervise the work of their employees, and to give proper instructions and guidance to employees and check that it is adhered to.’

There is also the common law duty on the employer to provide competent staff. In addition, the nurse maintains a professional duty to act competently through the tort of negligence (Crawford, Bolam, etc., discussed in Ch. 3) and the contract of employment. The requirements of Post-registration Education and Practice (PREP) also imposes an obligation to keep up to date. The NMC (Nursing and Midwifery Council 2004b) states:


A key tool to ensure a safe environment of care may be through the use of guidelines for tasks that have been delegated by doctors to nurses, or where a new role has been developed. The issue of guideline development will be discussed later. In August 2006, the PREP practice will change to 450 hours over three years (NMC 2006).

It is interesting to note that while the discourse in nursing practice is that of the nurse her- or himself undertaking an expanded role, difficult issues remain as to the boundaries of practice and where ultimate responsibility lies. Nurses may take on an increased role because they are acting as independent practitioners. Alternatively it may be because they have been delegated certain tasks to be performed by doctors. Guidance has been issued by the General Medical Council on the issue of delegation stating that (General Medical Council 2001):
There is recognition that doctors can refer cases to nurses as opposed to delegating care; however, overall responsibility still lies usually with the doctor.

Where tasks are delegated, the doctor delegating the task should follow appropriate guidelines. Should the doctor fail to do so and harm results to the patient, the doctor may be held liable in negligence for the harm caused. It may also be the case that, even where the delegation is properly undertaken, the doctor is held ultimately responsible in any event under what is known as the ‘captain of the ship’ approach (Montgomery 1992). It is interesting to note that both the GMC and the BMA assume that, where delegation takes place, the doctor retains ultimate accountability (British Medical Association, 1996 and British Medical Association, 2006). In discussing the competence and curriculum framework for the new NHS post of Medical Care Practitioner the BMA (British Medical Association 2006) state:
It may, however, be questioned to what extent such an approach is appropriate as the role of the nurse develops and s/he is recognised as having greater personal autonomy, and indeed whether the courts would be more likely to hold that the nurse was solely liable where tasks have been legitimately delegated.

The boundaries between activities that are undertaken as part of expanded role and those that follow from delegation are unclear. Darley & Rumsey (1996) note that the use of language such as ‘delegation’ is indicative of hierarchy. They suggest that it would be better to talk in terms of ‘shared care’ or ‘referral’; this would have the advantage of emphasising the partnership and teamwork aspects. To avoid confusion a coordinated approach on these matters is urgently needed from both the GMC and UKCC and from other bodies such as the BMA and RCN (see further Dowling et al 1996).

A key issue inherent with any code, protocol or guidance is the extent to which you can incorporate satisfactorily quite difficult concepts such as competence and accountability without trivialising them or making them too simplistic. Codes can spell out the conventional wisdom of a group of people or organisation, for example the NMC, but the enforceability and absorption of that wisdom are more difficult questions. The Scope document sought to change professional cultures, which is a hard thing to do, and therefore such change will be necessarily incremental and slow. Government initiatives such as the 10-point challenge on nursing skills and the NHS National Plan (Department of Health, 2000a and Department of Health, 2000b) have, however, speeded up the pace of change to our present position where expanded role and advance nursing practice are essential to keep the NHS operating. Initiatives such as NHS Direct and walk-in centres would not be able to operate or exist without general acceptance of the extended and advanced roles of nurses. The whole NHS would probably grind to a halt without them.

The crucial issue for the employer, then, is to ensure that, first of all, the nurse is lawfully undertaking the task. The GP in the case above should have at least asked the nurse whether she had performed an ear syringe before and, if so, how long ago. On the facts of the case, the GP could be viewed as wrongfully assigning the procedure to the practice nurse. This may mean that the GP was acting negligently. Creating and stating job competencies and assessment sorts this problem out. Last et al (1992) raise the point: