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Doctors and nurses in neonatal intensive care: towards integration.

Much of the current debate about neonatal intensive care services centres on the broader aspects of organisation at national and regional level. Yet the real organisational challenge lies at the point of delivery of the service-in the neonatal intensive care unit itself-where the demand created by an increasing number of ill preterm babies exceeds the available number of doctors and nurses. The medical staffing problem at junior level arises from a conflict between the service needs of patients, and the need to protect the career structure of junior doctors. Put simply, if intensive care cots are to be adequately staffed at junior level this would require additional junior staff, in excess of the numbers needed to be trained to fill predicted vacancies for consultant paediatric posts. Implicit in this is the idea that the primary function of junior doctors is to receive training, and that their role in the provision of a service to patients is of secondary importance. The concept of a neonatal intensive care unit, in which consultants are committed to cot side care, certainly needs to be explored. The nature of neonatal intensive care is such that most consultant paediatricians with responsibilities in this field already spend a substantial proportion of their time directly involved with delivery of the service to the patient in terms of examination, diagnosis, and treatment. An even greater participation in dedicated cot side care, such as carrying out practical procedures, poses the question, 'which other components of the consultant's work might need to be sacrificed?' Consultants have a continuing responsibility for their patients, a privilege which most of them would be reluctant to forego. Any rota arrangement made with a colleague is for personal convenience, and this temporary cover does not negate a consultant's duty to his or her patient. Thus parents identify the consultant as being ultimately responsible for the care of their baby, and also it is the consultant who is in a good position to discuss with parents in a consistent way the varied and often complex aspects of their baby's present and future health. In most cases continuity extends to the outpatient clinic after the baby is discharged. A radical change in the work pattern of consultants on neonatal intensive care units would have to be based on a formal rota or shift system-at the expense of this continuity of personal care and responsibility. This cannot be in the best interests of patients and their parents, nor is it the most cost effective use of a consultant who spends a minimum of 15 years in undergraduate and postgraduate training before being appointed. The basis of neonatal nursing staff shortages is different. Some neonatal intensive care units do not even have a numerically defined establishment of nursing staff. Financial restraint does play an important part in limiting the numbers of neonatal nurses but it is not the only problem. Many neonatal intensive care units, even some traditionally prestigious ones, are experiencing problems in recruiting nurses, and many nurses leave within a short time of being appointed. Poor job satisfaction, lack of a creative role in their work, physical and emotional pressures of neonatal intensive care, and poor salary all contribute to this. Moreover, there is a shortage of trained neonatal nurses from which to draw (see page 760). We have reached a cross road with respect to staffing of neonatal intensive care units, and perhaps now is the time to reflect whether traditional work patterns could be modified. The nature of the clinical work on neonatal intensive care units falls into different but overlapping categories: diagnosis and treatments including the prescription of drugs; monitoring and observations; responding to emergencies; practical procedures; conventional nursing hygiene care; and attending to the very legitimate needs of parents. Can we conceive a strategy that would permit a better integration of nursing and medical care for the benefit of babies, and which would at the same time make the work of neonatal nurses more creative, and perhaps encourage recruitment to the specialty? There is a danger in viewing this solely in terms of an extended role towards carrying out practical procedures, currently the responsibility of doctors. Although this might satisfy some nurses who are gifted in this field, it might tend to encourage the separate growth of nurse technicians and 'task orientation', which creates further polari-