Psychiatric Bulletin (2004) 28: 368-370. doi: 10.1192/pb.28.10.368
© 2004 The Royal College of Psychiatrists
Psychiatric Bulletin (2004) 28: 368-370
© 2004 The Royal College of Psychiatrists
Does a limited nurse triage service reduce junior doctor psychiatric on-call workload?
*A. P. Moore
Specialist Registrar in General Adult Psychiatry, Lyme Brook Mental
Health Resource Centre, Talke Road, Newcastle-under-Lyme, Stoke-on-Trent ST5
7TL
S. Willmott
Statistician, Leighton Hospital, Crewe, Cheshire
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
To investigate whether nurse triage might reduce junior doctors’
on-call workloads in a general adult psychiatry in-patient unit, we measured
changes in workload after the introduction of a limited (overnight and weekend
mornings) nurse triage service on the unit, comparing pre-triage work levels
with levels 1 year later. This time frame allowed the new service to settle
in, and controlled for seasonal variations in workload.
RESULTS
The number of ‘work episodes’ went up, especially during the
night shifts, but the average length of each episode went down (both
statistically significant, P<0.001). The net result was a slight increase
in workload in terms of total time spent dealing with episodes, most notably
at night.
CLINICAL IMPLICATIONS
A limited overnight nurse triage service was ineffective on its own as a
means of reducing the out-of-hours workload of junior doctors, and even
slightly increased it. A more comprehensive triage service, with a greater
range of alternatives to admission, might have had a different result.
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Introduction
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In the past decade, considerable effort has been put into reducing junior
doctors’ workload; this has been driven by diverse but converging forces
and more recently by impending legal deadlines. The ‘New Deal’
(National Health Service Management
Executive, 1991) attempted to reduce working hours, further
enforced by ‘punitive’ pay-banding systems for onerous rotas in
2000 (Department of Health,
2000). More recently, further impetus has come from the European
Working Time Directive (Council Directive,
1993) and the interpretations of the European Court of Justice
ruling (Judgment of 3 October 2000) on what constitutes working hours. These,
along with perceived stress levels associated with on-call work, have led to
innovative ways of trying to reduce the workload of on-call junior medical
staff in a broad range of specialties (Cass
et al, 2003), while maintaining quality of service
provision, or ideally improving it. These have included changes in shift
patterns, use of non-medical practitioners and new service models. Locally,
changes in delivery of mental health services are also likely to have had an
effect on psychiatric junior doctors’ on-call work, with the
introduction of assertive outreach, crisis intervention and home treatment
teams. Nationally, the government is running 20 pilot projects throughout the
country across the specialties, looking at ways to reduce workload to meet the
demands of the new European legislation. Two of these projects involve mental
health provision, one of which hopes to use non-medical ‘mental health
practitioners’.
When our psychiatric unit introduced a limited nurse-led triage service for
on-call work in 2001, we took the opportunity to measure junior doctor on-call
workload before the introduction, and again 1 year later. This time frame
allowed us to compare levels after the service had had plenty of time to
settle in, and also controlled for any seasonal variation in workload. The aim
of the service was twofold: to try to improve service provision (shorter
waiting times for patients, more efficient use of services, less tired junior
doctors) and to try to move closer to meeting the impending demands for
reduction in junior doctors’ working hours. More by chance than design,
there was no other significant change in service provision over this
period.
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Method
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Setting
The study took place in a general adult and old-age psychiatric unit,
serving a mixed urban and rural population of 270 000 persons. The unit was
attached to a district general hospital with an accident and emergency
department, which sees 74 000 patients annually, of whom approximately 100 are
admitted to psychiatric wards. One junior doctor (senior house officer) on
call provided an emergency service to the psychiatry wards and the rest of the
hospital, including the accident and emergency department. During the day,
there was a nurse-led liaison service (restricted to cases of deliberate
self-harm) for patients in the accident and emergency department and the
medical and surgical wards, but outside these hours such duties were covered
by the on-call doctor. There was no home treatment or crisis intervention
service.
The new triage nurses, who were experienced, senior staff, had other
service demands in the form of nursing management duties (overall supervision
of the unit), and these took priority over triage if they clashed.
Unfortunately, we did not specifically measure the frequency of this
occasional unavailability of the triage nurse, or the number of episodes
passed on to the doctor because of it, but the authors’ experience was
that this was not common. The triage service was provided by one of the
nurses, from 21.00 h to 07.00 h each day and from 09.00 to 13.00 h at weekends
(i.e. 78 h per week). The nurses took all calls that would normally have gone
to the on-call junior doctor; both from within the hospital and from outside.
They assessed patients first, using their judgement and experience to decide
what they could deal with, and what would be referred on to the junior doctor.
Junior doctors were encouraged not to repeat any work already performed by the
triage nurse.
Measuring workload
We could find no published study that measured psychiatric junior
doctors’ on-call workloads, so we developed our own data collection form
(copies available from the author upon request), testing several prototypes
before arriving at the final version, which was designed for ease of use. To
optimise data collection, the form was filled out in ‘real time’
as the shift progressed, and was contained in the on-call doctor information
handbook, kept with the doctor at all times.
For simplicity, we used ‘number of episodes of work’ and
‘length of episodes’ as proxy measures of workload, allowing us to
combine them to give an overall measure of time worked for each shift. Length
of each episode was estimated by the doctor, and placed into time bands as
follows: ‘short’, 0-20 min; ‘medium’, 20-60 min;
‘long’, 60-120 min; ‘very long’, 120 min or more. For
the purposes of calculating average length of episodes, the middle of each
time band was used as a representative figure: 10 min, 40 min, 90 min and 150
min, respectively. This arrangement was felt to provide the easiest method of
data collection, albeit at the expense of uneven time increments for analysis,
and potentially losing the increased precision that smaller time bands would
have given. We also identified the source of each episode, allowing us to
monitor changes in referral patterns (to be reported separately). All regular
doctors on the rota (one in seven on call) were involved from the conception
of the study, and agreed to take part (short-term locums were excluded for
practical reasons). To ensure consistency, a protocol was developed, by
consensus, as to what constituted an ‘episode’. The data were
analysed using the Statistical Package for the Social Sciences
(SPSS, 1999).
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Results
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The sample size was 205 pre-triage shifts (over 4 months) and 90
post-triage shifts (over 2 months, same mid-point (July), 1 year on).
Table 1 shows the average
number of episodes and their average length for each shift involving triage
nurses, along with the combined estimate of total time spent working per shift
(obtained by multiplying these figures). Data were normally distributed,
allowing parametric tests to be used. The t test (two-tailed) was
used to confirm statistical significance. However, because the changes were in
the opposite directions, i.e. the average episode number increased while the
average length of episode decreased, the total change in workload after
combining the two parameters appeared to be insignificant, with
P=0.299.
The pattern of episode lengths (percentage of short: medium: long: very
long episodes) changed from 54 : 25 : 19 : 2 pre-triage to 65 : 20 : 14 : 1
post-triage, respectively. There were also changes in the daytime on-call
workload (the number of episodes increasing slightly, the length of episode
decreasing and the estimated workload decreasing slightly), but none to
statistically significant levels.
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Discussion
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The overnight shifts were the most affected by the introduction of the new
service. The increased number of episodes at night was counterbalanced by
their shorter duration, the change of pattern indicating a move from medium,
long and very long episodes towards short ones. The overall effect was an
increased night workload in terms of time worked per shift (pre-triage average
of 190 min per night shift compared with a post-triage average of 243 min).
The most likely explanation for this change is an increase in telephone
consultations (usually a ‘short’ episode), for example between the
nurse and the doctor, and a decrease in actual clinical work done by the
doctor for some patients (the rest being done by the nurse). However, other
factors may also be at play. These might include an increase in referrals to
the ‘new’ psychiatric on-call service. Also, the triage nurse
might have had different thresholds for admission from the doctors (e.g.
post-triage there were 121 psychiatric admissions from 74 242 accident and
emergency patient attendances, compared with 96 from 74 040 pre-triage). The
difference is unlikely to be due to ‘settling in’ of the service
or seasonal variation, given the time frames used. An analysis of missing or
inaccurate data input sheets showed these to be randomly distributed, meaning
systematic bias was not a cause.
The reduction in daytime workload, although not reaching statistical
significance, may represent a better ‘mopping up’ of problems the
night before, leaving less to be done the next day. However, it could equally
represent work that might previously have been left to the next day, being
done out-of-hours instead, albeit shared between the nurse and doctor.
These results must be interpreted in the light of the whole service model
at the time of study, especially the relative lack of alternatives to
admission and the limited nature of the triage service itself (limited hours,
competing duties). A more comprehensive and focused triage service might well
obtain quite different results, especially if part of a coordinated package
including viable alternatives to admission. This is an important point, as in
the present financial climate mental health providers may be tempted to cut
corners in their search for ways to reduce junior workloads. However, this
study implies that a less than comprehensive and coordinated approach might be
at best a waste of resources, at worst a step backwards, at least in terms of
improving juniors’ working hours. Some more ambitious alternatives are
being piloted in mental health services elsewhere by the government but only
in one site for out-of-hours work, while the legally driven time scale is
pressing hard. It is likely that most service providers will have to plan
their immediate workforce changes before the results are clear. Our study
implies that simply adding a limited triage service alone is insufficient to
reduce hours, and that whatever solutions are attempted, the resultant changes
should be monitored, rather than taken for granted.
With regard to patient and staff satisfaction, anecdotally both patients
and staff (nursing and medical) liked the new triage service, but
unfortunately we did not formally measure this. There was no complaint related
to the new service, and the annual number of formal complaints for the whole
unit decreased from 36 (pre-triage) to 15 (during triage), implying the new
service probably had not had a detrimental effect on quality, and had possibly
improved it.
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Acknowledgments
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We thank the junior doctors at Leighton Hospital, Crewe, who filled out all
the data forms while on shift, and Dr C. Findlay and Dr R. Hodgson, consultant
psychiatrists, for comments on the script, encouragement and guidance. Thanks
also to Hillary Hall who input the data. The Mid Cheshire Hospitals NHS Trust
sponsored the study.
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References
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CASS, H. D., SMITH, I., UNTHANK, C., et al
(2003) Improving compliance with requirements on junior
doctors’ hours. BMJ,
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COUNCIL DIRECTIVE (1993) Council Directive 93/104/EC.
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DEPARTMENT OF HEALTH (2000) A General Guide
to the New Pay System. London: Department of Health.
Judgement of 3 October 2000: Case C-303/98 Sindicato
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European Court Reports, 2000, 1
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NATIONAL HEALTH SERVICE MANAGEMENT EXECUTIVE (1991)
Junior Doctors: The New Deal. London: Department of
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Abstract
Introduction
