Independence and interdependence of non-medical practitioners in the emergency care skill-mix (SKILLMix-ED): a...

In addressing the many challenges that face them, some emergency departments are changing their staffing to include new roles, such as nurse practitioners and physician associates. Known collectively as non-medical practitioners, they work with varying levels of independence and supervision, which, evidence suggests, may influence outcomes. As part of a larger study investigating the impact of these staff skill-mix changes, we sought to measure quantitatively how such staff work independently or with supervision.

To develop a prototype-structured observational tool for quantitative measurement of levels of independence and supervision of non-medical practitioners in emergency departments and urgent treatment centres in England.

A multimethod study using an incremental and iterative process underpinned by theories suggesting autonomy can be measured by practice independence behaviour.

We undertook three interconnected research activities in March 2021-April 2023: (1) literature review to clarify concepts, and identify classifications and tools associated with independence and supervision; (2) 12 ethnographic observations of non-medical practitioners and resident doctors to describe the enactment of independence and supervision, with data coded and thematically analysed; (3) collaborative prototype tool development incorporating three collaborative sessions with 28 clinicians, non-medical practitioners and patients, and three further stages of stakeholder feedback.

Twenty-six articles were included in the literature review. Nine articles included concepts associated with independence and supervision, the main concepts being clinical decision-making, competence, responsibility and autonomy. These multifaceted concepts were found to be intertwined in complex ways with those of collaboration, teamwork and interdependence. Seventeen articles included classifications or tools to measure levels of independence or supervision. Shared decision-making was the most frequently measured concept. There were no tools or classifications identified for measuring levels of independence or supervision within a skill-mix team. Our clinical observations found that participant clinicians practised with varying levels of independence within an interdependent team. The extent of guidance, education and direction received in discussion with the clinician-in-charge varied widely. In addition to the clinician-in-charge structure, clinical discussion and advice seeking were often with colleagues known and trusted to have specific knowledge. Spatial, temporal and resource constraints also encouraged collaborative working. Patients played an important team role. During collaborative development of the prototype tool, key issues raised by stakeholders and addressed in the prototype included: concerns that an inappropriate binary might be perceived between independence as 'good' and supervision as 'bad'; clinicians practise interdependently with most episodes of care involving some interaction, consultation or advice seeking; and the importance of collecting contextual data.

The literature review was limited by excluding non-English-language papers. Our clinician observations included two sites with self-selecting participants which may have introduced biases. Objectivity and validity of the tool were not tested.

Our data led us to develop a prototype observational tool reflecting non-medical practitioners working within an interdependent skill-mix team. The tool discerns tasks and actions undertaken with varying levels of independence or supervision. Further testing of the tool is required.

The prototype tool was designed for use in later stages of the larger study.

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131356.