Analysis of three advanced practice roles in emergency nursing

Are Italian Newly Licensed Nurses Ready? A Study on Self-Perceived Clinical Autonomy in Critical Care Scenarios

The experience and self-confidence of healthcare professionals play critical roles in reducing anxiety levels during emergencies. It is important to recognize the potential impact of anxiety on performance. To enhance preparedness and confidence in managing emergencies, healthcare professionals benefit from regular training and simulations. Additionally, repeated exposure to emergency scenarios can help modulate physiological responses. Managing anxiety effectively is key, as heightened sympathetic stimulation associated with anxiety can adversely affect performance. This study aimed to investigate nurses' self-assessed ability to manage emergency guidelines and their self-confidence in performing tasks in critical care settings. A questionnaire was provided to 1097 nurses. We compared the self-confidence of experienced nurses (ENs) and newly licensed nurses (NLNs) in managing emergency department shifts or critical patients, and found that ENs are more confident in these scenarios. This phenomenon was also observed in subjects who had taken simulation courses, although they were still a low percentage. Most NLNs feel sufficiently ready to work in medium-intensity wards. Attending advanced training courses enhances nurses' self-confidence and may improve patient safety management., improving patient recovery, and minimizing errors. Attending courses improves the perception of autonomy of nurses in different scenarios.

How can scope of practice be described and conceptualised in medical and health professions? A systematic review for scoping and content analysis

BACKGROUND

The term scope of practice (SOP) refers to the limits of a health professional's knowledge, skills and experience and reflects all tasks and activities they undertake within the context of their professional role. Inconsistency in definitions of SOP contributes to uncertainty and confusion regarding professional practice boundaries and potentially impacts societal access to safe, effective and efficient healthcare options. The aim of this paper is to understand the conceptual diversity that may exist in terminology used to describe medical, nursing/midwifery and allied health SOP within an Australian practice context exemplar.

METHODS

A systematic review for scoping and content analysis of SOP definitions and concepts, involving inductive thematic analysis and synthesis of published and grey literature.

RESULTS

The initial search strategy yielded 11,863 hits, of which 379 were suitable for inclusion. Data coding identified various SOP terms and definitions and the emergence of six, conceptual elements underpinning the theoretical construct. These were subsequently proposed as a preliminary conceptual model ('Solar') to explain how the six conceptual elements may be applied across various professions, clinical settings and jurisdictions to better understand and address current and evolving SOP issues.

CONCLUSION

The findings of this study highlight limited consistency in SOP definitions and terminology within a single jurisdiction, and the conceptual complexity of the underlying theoretical construct. Further research is required to build on the proposed 'Solar' conceptual model and create a universal SOP definition across jurisdictions, to enhance understanding of the importance of SOP to workforce policy, clinical governance, service models and patient outcomes.

Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding-The CREONTE (Crowding and RE-Organization National TriagE) Study Group

Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.

Exploration and model development for emergency department waiting room nurse role: Synthesis of a three-phase sequential mixed methods study

BACKGROUND

To improve flow and care in waiting rooms, some emergency departments introduced a specific nursing role to care for this patient cohort with the aim of commencing interventions early, improving patient safety by reassessing and enhancing communication. The objective of the research was to explore to what extent does qualitative interviews and quantitative survey contribute to describing emergency department waiting room nurses, through integration and synthesis of findings from a multiphase mixed methods study.

METHODS

Multiphase mixed methods exploratory sequential design with integration of findings. Data integration occurred during the phases and when assimilating all findings.

FINDINGS

Experienced emergency nurses, preferably with graduate qualifications, who are autonomous practitioners with highly developed communication skills, clinical decision making and proficiency in assessment and monitoring are required to perform the role. The waiting room nurse provides patient-centered care and ensures safe, timely care is delivered to those in the waiting room. A standardised approach and high risk of exposure to occupational stressors need to be considered.

CONCLUSIONS

This mixed methods sequential design explored the waiting room nurse role from the perspective of emergency nurses generating new knowledge into the role. This advanced practice nursing role contributes to patient safety and delivery of patient centred care in the emergency department waiting room.

Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.

Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient's condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.

Emergency Department Operations I: Emergency Medical Services and Patient Arrival

The emergency department (ED) is by its nature inherently an environment with the potential for chaos because of the high volume and varied types of patients cared for in an ED setting. This article discusses potential system opportunities from the prehospital environment through arrival in the ED before provider evaluation. The Emergency Medical Treatment and Active Labor Act is reviewed in detail. Management and the reduction of risk to waiting room patients and patients who leave without being seen is explored. Description of the risks and mitigation strategies are discussed to decrease risk to patients, providers, and hospitals.

Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study

Objective

Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off‐Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness.

Methods

This was a retrospective observational study over three periods of before (T1), during (T2) and after (T3) the introduction of the EDAOLN role in 2012. Ambulance, ED and cost data were linked and used for analysis. Processes of care measures analysed included: time to be seen by a doctor from ED arrival (primary outcome), ambulance‐ED offload compliance, proportion of patients seen within recommended triage timeframe, ED length of stay (LoS), proportion of patients transferred, admitted or discharged from the ED within 4 h and cost effectiveness.

Results

A total of 6045 people made 7010 presentations to the ED by ambulance over the study period. Several measures improved significantly between T1 and T2 including offload compliance (T1: 58%; T2: 63%), time to be seen (T1: 31 min; T2: 28 min), ED LoS (T1: 335 min; T2: 306 min), ED LoS <4 h (T1: 31%; T2: 33%). Some measures carried over into T3, albeit to a lesser extent. Post‐hoc analyses showed that outcomes improved most for less urgent patients. The annualised net cost of the EDAOLN (if funded from additional resources) of $130 721 could result in an annualised reduction of approximately 3912 h in waiting time to be seen by a doctor.

Conclusion

With the EDAOLN role in place, slight outcome improvements in several key ambulance and ED efficiency criteria were noted. During times of ED crowding, the EDAOLN role may be one cost‐effective strategy to consider.

A Narrative Review of the Description of Training Profiles Used for Emergency Nursing Care Worldwide

BACKGROUND

This study describes the training profiles of emergency care nurses worldwide, which can serve as a guide for training these professionals.

METHOD

A narrative review was developed.

RESULTS

Five training profiles were identified, according to the requirements of undergraduate, postgraduate, complementary training, and previous work experience within the training itineraries of emergency nursing worldwide.

CONCLUSION

The most appropriate level of training for emergency nursing is the 1-year postgraduate level (academic or specialty). The description of these profiles can guide the regulatory organizations and professionals regarding the most appropriate training requirements for effective, safe, and adjusted care assistance. [J Contin Educ Nurs. 2019;50(12):543-550.].

A profile of the waiting room nurse in emergency departments: An online survey of Australian nurses exploring implementation and perceptions

BACKGROUND

In response to increasing waiting times, adverse patient outcomes and patient dissatisfaction, some emergency departments introduced a Waiting Room Nurse role. Despite implementation into routine practice, there remains limited formal evaluation of the role.

AIM

To explore the implementation of a Waiting Room Nurse role in Australian emergency departments and emergency nurses' perceptions.

METHODS

Survey design. A 40-item survey was developed, piloted and then distributed to members of a professional College for online completion. Responses for closed-ended and open-ended items were reported using frequencies or proportions, and quantitative content analysis, respectively.

RESULTS

Respondents (n = 197) reported that 51 emergency departments allocated a Waiting Room Nurse, with varying hours of operation. Five key areas of responsibility were: patient care, patient safety, escalation of care, triage and communication. Role variations were identified in experience, preparation and supporting policies. Challenges, including workload and personal safety issues, were reported.

CONCLUSIONS

The role was perceived as vital, especially at times of high demand, in ensuring that patients were safe to wait, detecting deterioration and escalating care as needed. Communication and therapeutic relationships were key to effective performance. Challenges identified had clear implications for the welfare of nurses performing the role.

Emergency department waiting room nurse role: A key informant perspective

BACKGROUND

Emergency departments have become overcrowded with increased waiting times. Strategies to decrease waiting times include time-based key performance indicators and introduction of a waiting room nurse role. The aim of the waiting room nurse role is to expedite care by assessing and managing patients in the waiting room. There is limited literature examining this role.

METHODS

This paper presents results of semi-structured interviews with five key informants to explore why and how the waiting room nurse role was implemented in Australian emergency departments. Data were thematically analysed.

RESULTS

Five key informants from five emergency departments across two Australian jurisdictions (Victoria and New South Wales) reported that the role was introduced to reduce waiting times and improve quality and safety of care in the ED waiting room. Critical to introducing the role was defining and supporting the scope of practice, experience and preparation of the nurses. Role implementation required champions to overcome identified challenges, including funding. There has been limited evaluation of the role.

CONCLUSIONS

The waiting room nurse role was introduced to decrease waiting times and contributed to risk mitigation. Common to all roles was standing orders, while preparation and experience varied. Further research into the role is required.

Attributes of innovations and approaches to scalability - lessons from a national program to extend the scope of practice of health professionals

The context for the paper was the evaluation of a national program in Australia to investigate extended scopes of practice for health professionals (paramedics, physiotherapists, and nurses). The design of the evaluation involved a mixed-methods approach with multiple data sources. Four multidisciplinary models of extended scope of practice were tested over an 18-month period, involving 26 organizations, 224 health professionals, and 36 implementation sites. The evaluation focused on what could be learned to inform scaling up the extended scopes of practice on a national scale. The evaluation findings were used to develop a conceptual framework for use by clinicians, managers, and policy makers to determine appropriate strategies for scaling up effective innovations. Development of the framework was informed by the literature on the diffusion of innovations, particularly an understanding that certain attributes of innovations influence adoption. The framework recognizes the role played by three groups of stakeholders: evidence producers, evidence influencers, and evidence adopters. The use of the framework is illustrated with four case studies from the evaluation. The findings demonstrate how the scaling up of innovations can be influenced by three quite distinct approaches – letting adoption take place in an uncontrolled, unplanned, way; actively helping the process of adoption; or taking deliberate steps to ensure that adoption takes place. Development of the conceptual framework resulted in two sets of questions to guide decisions about scalability, one for those considering whether to adopt the innovation (evidence adopters), and the other for those trying to decide on the optimal strategy for dissemination (evidence influencers).

Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times

Emergency departments (EDs) throughout USA have improvised various processes to curb the “national epidemic” termed ED “crowding.” Standing orders (SOs), one such process, are medical orders approved by the medical director and entered by nurses when patients cannot be seen expeditiously, expediting medical decision-making and decreasing length of stay (LOS) and time to disposition. This retrospective cohort study evaluates the impact of SOs on ED LOS and disposition time at a large university ED. Results indicate that SOs significantly improve ED throughput by reducing disposition time by up to 16.9% (p=0.04), which is especially significant in busy ED settings. SOs by themselves are not sufficient for a complete diagnostic assessment. Strategies such as having a provider in the waiting area may help make key decisions earlier.

The Role Descriptions of Triage Nurse in Emergency Department: A Delphi Study

Background. Triage nurses play a pivotal role in the emergency department. However some researchers have attempted to expand triage nurse's role; remarkable discrepancies exist among scholarly communities. The aim was to develop a role description of triage nurse relying on the experts. Methods. A modified Delphi study consisting of 3 rounds was performed from March to October 2014. In the first round, an extensive review of the literature was conducted. Expert selection was conducted through a purposeful sample of 38 emergency medicine experts. Results. Response rates for the second and third rounds were 37% and 58%. Average age of panelists was (38.42 ± 5.94) years. Thirty-nine out of 54 items reached to the final round. Prioritizing had the higher agreement rate and least agreement on triage related interventions. Conclusion. Triage nursing as a relatively new role for nurses needs significant development to be practiced. Comprehensive educational programs and developmental research are required to support diagnostic and therapeutic interventions in triage practice by nurses.

Acute Care Pediatric Nurse Practitioner: The 2014 Practice Analysis

INTRODUCTION

Practice research serves as the certification framework for validating advanced practice roles and updating national qualifying examinations. This national study describes the current practice of the acute care pediatric nurse practitioner (AC PNP) to inform an update of the Certified Pediatric Nurse Practitioner-Acute Care (CPNP-AC) examination content outline.

METHOD

A descriptive analysis was performed of the responses of 319 pediatric nurse practitioners, practicing in an acute care role, who completed a practice survey in 2014.

RESULTS

Respondents were primarily White women with a mean age of 40 years; 75% had been formally educated as AC PNPs, compared with 48% in 2009. Regional practice was most heavily concentrated in the Southeast (28%) and Midwest (27%). Most respondents (81%) practiced in urban areas. Respondents reported spending 75% of practice time in inpatient settings. The most frequently cited areas of practice were critical care (36%), followed by emergency department (9%) and subspecialty practices.

DISCUSSION

This third analysis of AC PNP practice 10 years after initiation of the CPNP-AC certification examination demonstrates changes in clinical practice and educational preparation.