Care at issue as the lines are blurred

There always has been some blurring at the edges between the functions of junior doctors and nurses, says Liz Winder, director of Nursing Policy and Practice at the Royal College of Nursing.

"You see it among the young doctors and nurses of at least two and three years' experience and now there is the blurring with junior doctors, nurses and the paramedics. As the technology changes, you will see it more and more," she said.

It is a pragmatic view and one that is in line with the 1992 policy document, The Scope of Professional Practice, published by the UKCC, the nursing profession's statutory body. This has opened the door to nurses training in increasingly technically demanding tasks.

The case of a senior theatre nurse, Valerie Tomlinson, attracted a lot of publicity earlier this year when she took part in an appendicitis operation that went beyond her responsibilities, although her technical competence was not at issue. By contrast, the small number of nurses trained to assist surgeons in heart by-pass surgery, stripping out a vein in the leg, are working appropriately.

"You can train someone who is illiterate to work a kidney dialysis machine at home for their husband or wife or their child. But that does not mean that you would have the same man who can dialyse his son at home in to look after a dialysis ward," Ms Winder said.

But nurses are concerned about the arrival on wards of technicians such as the Scarborough paramedics. The anxiety touches on the ethos of nursing which has to do with the complete welfare of the patient, embracing emotional, social and physical care.

They seem to have no difficulty over other health professionals, with fewer or different skills, performing tasks such as giving injections, taking blood or bed-bathing. But they are worried that this will lead to patient care being stripped down into a series of separate tasks performed by a range of different people.

Maureen Woods, RCN officer for Yorkshire, says that the parademics' duties in Scarborough are largely irrelevant to nursing.

"I do wonder why good clinical nurses are not doing these jobs. Why can't nurses be brought in and paid to do them? Patients need continuity. What bothers me is the idea of focusing on tasks rather than focusing on patients.

"If you looked at a nurse or an auxiliary giving a bed-bath, you could probably not tell the difference in technical terms. But a nurse is taking the opportunity to take a pulse, listening to breathing, and checking on the patient's mobility, orientation and concentration. A nurse will check the patient's eyes, teeth, feet, alimentary and respiratory systems and talk to the patient all in the course of this one task."

She needs to be convinced that the Scarborough initiative, and what can follow from it, is necessarily to the patient's benefit. "If you start taking away every technical task from those who are trained to have a wider knowledge, you are losing a fundamental part of nursing care."

Dr Tim Hopkirk, who represents junior doctors in northern England for the British Medical Association, welcomes the fact that the paramedics relieve junior doctors of a range of mundane technical tasks but feels that the scheme may represent hidden economies.

He said: "Support staff in the NHS are often underpaid. These are difficult questions. All of these manpower changes must be for the benefit of patient care, and not for reasons of economy. This is the standard by which such changes in practice should go forward."