Perspectives on the impact of the inclusion of non-medical practitioners in the skill mixed staffing teams of English emergency departments: a qualitative study

BACKGROUND: Emergency Departments internationally have struggled to meet increased patient demand in the context of staffing shortages, particularly doctors. Some countries have employed non-medical practitioners (NMPs), such as advanced nurse practitioners and physician assistants, who undertake some of the clinical work of the doctors across the range of patients attending, not just those with minor injuries. This study investigated the perceived impact of skill mixed staffing, which included established NMPs in emergency departments, in the period post pandemic when patient attendances were particularly high. METHODS: Semi-structured interviews were conducted and thematically analysed in six emergency departments with 35 patients and 37 staff members between September 2023- June 2024. RESULTS: Patient participants offered views of positive impact of teams with NMPs in the context of long waiting times but were concerned that all were appropriately trained, supervised and that they were informed of their role. Staff participants also perceived a mix of positive and challenging impacts on aspects of service efficiency, safety, effectiveness and acceptability. Those participants who reported the most positive impacts on patient experience could also identify some challenging issues, for example on the workload of the senior clinical decision makers in supervising both NMPs and resident doctors. Conversely those who reported the most negative impacts, such as potential loss of training opportunities and jobs for doctors, also identified some positive impacts on the service efficiency and staff experience. CONCLUSIONS: The deployment of NMPs in ED/UTCs requires careful planning so the perceived efficiency benefits can be maximised without jeopardising quality of care, safety, and staff experience. Consideration of underlying explanatory mechanisms led to theorisation of the concept of balance as important to the optimal skill-mix within emergency department staffing. The findings suggest that the elements that require attention from clinicians and managers within the complex system of skill-mix staffing in ED/UTCs include balance between patient volume and staffing, between numbers and capacity of senior clinical decision makers and junior clinical decision makers; and between provision of service and provision of training.