Nurse competence: advantageous in pre-hospital emergency care?

Flight nursing expertise: towards a middle-range theory

AIM

This paper presents a middle-range Theory of Flight Nursing Expertise.

BACKGROUND

Rotary-wing (helicopter) medical transport has grown rapidly in the USA since its introduction, particularly during the past 5 years. Patients once considered too sick to transport are now being transported more frequently and over longer distances. Many limitations are imposed by the air medical transport environment and these require nurses to alter their practice.

DATA SOURCES

A literature search was conducted using Pubmed, Medline, CINAHL, secondary referencing and an Internet search from 1960 to 2008 for studies related to the focal concepts in flight nursing.

DISCUSSION

The middle-range Theory of Flight Nursing Expertise is composed of nine concepts (experience, training, transport environment of care, psychomotor skills, flight nursing knowledge, cue recognition, pattern recognition, decision-making and action) and their relationships. Five propositions describe the relationships between those concepts and how they apply to flight nursing expertise.

IMPLICATIONS FOR NURSING

After empirical testing, this theory may be a useful tool to assist novice flight nurses to attain the skills necessary to provide safe and competent care more efficiently, and may aid in designing curricula and programmes of research.

CONCLUSION

Research is needed to determine the usefulness of this theory in both rotary and fixed-wing medical transport settings, and to examine the similarities and differences related to expertise needed for different flight nurse team compositions. Curriculum and training innovations can result from increased understanding of the concepts and relationships proposed in this theory.

The encounter with the unknown: Nurses lived experiences of their responsibility for the care of the patient in the Swedish ambulance service

Registered nurses (RNs) have, according to the Swedish National Board of Health and Welfare, the overall responsibility for the medical care in the ambulance care setting. Bringing RNs into the ambulance service are judged, according to earlier studies, to lead to a degree of professionalism with a higher quality of medical care. Implicitly in earlier studies, the work in the ambulance service involves interpersonal skills. The aim of this study was to describe RNs' experiences of being responsible for the care of the patient in the Swedish ambulance service. A reflective lifeworld approach within the perspective of caring science was used. Five RNs with at least five years experience from care in the ambulance care setting were interviewed. The findings show that the essence of the phenomenon is to prepare and create conditions for care and to accomplish care close to the patient. Three meaning constituents emerged in the descriptions: prepare and create conditions for the nursing care, to be there for the patient and significant others and create comfort for the patient and significant others. The responsibility is a complex phenomenon, with a caring perspective, emerging from the encounter with the unique human being.

Caring for older people in prehospital emergency care: can nurses make a difference?

AIMS AND OBJECTIVES

The aim of this paper is to explore older people's experiences in prehospital emergency care, and identify benefits and difficulties associated with developing a nurse-led ambulance service. Data were collected at sites in Sweden and Norway. Focus group interviews were conducted to enable the collection of data from paramedics, ambulance nurses and nursing students, while individual interviews were utilized to gather data from older people.

BACKGROUND

There is little research on the quality of care older people over 65 years old receive in prehospital emergency care. Older people often present with multiple pathology and diverse needs that nurses are well equipped to deal with, but presently there is no clearly defined role for nurses in prehospital emergency care in the United Kingdom, although other countries such as Sweden and Norway are developing an ambulance nurse role.

CONCLUSIONS

If the multiple needs of older people were addressed in the prehospital field, a reduction in readmissions and increased functional ability might be achieved. Comprehensive training is required for ambulance staff to enable them to meet such needs. While nurses have a great foundation for this care, additional specialist ambulance training is required alongside a need for education on older people's needs and attitudes to older people.

RELEVANCE TO CLINICAL PRACTICE

The introduction of ambulance nurses will result in role differentiation between paramedics and ambulance nurses, which has the potential for creating role conflict. To ensure a smooth transition appropriate training and education for nurses and paramedics should be provided. The end result is a potentially greatly enhanced ambulance care provision, enabling high quality care to all patients.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

International EMS Systems: the Nordic countries

Emergency medicine service (EMS) systems in the five Nordic countries have more similarities than differences. One similarity is the involvement of anaesthesiologists as pre-hospital physicians and their strong participation for all critically ill and injured patients in-hospital. Discrepancies do exist, however, especially within the ground and air ambulance service, and the EMS systems face several challenges. Main problems and challenges emphasized by the authors are: (1) Denmark: the dispatch centres are presently not under medical control and are without a national criteria based system. Access to on-line medical advice of a physician is not available; (2) Finland: the autonomy of the individual municipalities and their responsibility to cover for primary and specialised health care, as well as the EMS, and the lack of supporting or demanding legislation regarding the EMS; (3) Iceland is the only country that has emergency medicine (EM) as a recognised speciality but there is a need for more fully trained specialists in EM; (4) Norway: the ordinary ground ambulance is pointed out as the weakest link in the EM chain and a health reform demands extensive co-operation between the new health enterprises to re-establish a nation-wide air ambulance service; (5) Sweden: to create evidence based medicine standards for treatment in emergency medicine, a better integration of all part of the chain of survival, a formalised education in EM and a nation wide physician staffed helicopter EMS (HEMS) cover.

Experiential learning in pre-hospital emergency care: a qualitative study

The primary aim of this project was to explore the effects of experiential learning in pre-hospital emergency care by nursing students on placement with the Northern Ireland Ambulance Service. The literature suggests that experiential learning has great potential for expanding understanding, knowledge and skills. The study employed a qualitative approach that was inductive, exploratory and descriptive, using diaries and focus group interviews to collect data. One hundred and forty-one nursing students participated, providing a response rate of 74%. Content analysis indicated that the concept of holistic nursing comes to the fore in students' thinking and deliberations in pre-hospital emergency care. An appreciation of the skills and abilities of paramedics has created the foundation for enhanced inter-professional collaboration in this setting. In conclusion, experiential learning stimulates the evolvement of an understanding of the complete process of care, from the receiving of the emergency call by ambulance control to the patient's discharge. The study recommends that such an experiential learning placement in pre-hospital emergency care is made a compulsory part of pre-registration education for nurses.