The emergency nurse practitioner role in major accident and emergency departments: professional issues and the research agenda

Emergency department nurses' role transition towards emergency nurse practitioner: A realist-informed review

BACKGROUND

The integration of emergency nurse practitioner (ENP) services in emergency departments (EDs) has been well established, especially in high-income countries such as the United Kingdom, the United States and Australia. Different types of reviews, including integrative, literature and systematic, have been carried out to examine evidence regarding the impact of ENPs on the quality of ED services. Unfortunately, there is still limited explanation of the influencing factors that may result in a successful transition process from Registered Nurse to Emergency Nurse Practitioner. This review aims to understand these factors.

METHODS

A realist approach (RAMESES) guided this review. CINAHL Plus, MEDLINE, PsycINFO, EMBASE and Web of Science databases were searched to capture studies from 1990 to 2020, combined with policy documents from professional bodies and government websites and relevant references from identified sources. Realist data analysis was carried out on the included articles to understand how context, mechanism and outcomes related to the ED nurses' role transition.

RESULTS

Forty-eight articles were included. There were differences in preparatory education and scope of practice of the role. The review configured various contexts, mechanisms and outcomes of the role transition along with their interactions.

CONCLUSION

The findings provide a comprehensive understanding regarding the emergency nurses' role transition, with a view to providing better insights and explanations to interested parties who would like to integrate the ENP service in their ED.

An evaluation of the impact of developing nurse-led treatments for minor injuries in community hospital casualty units

This paper reports the evaluation of a nursing role development based on assessment/treatment protocols for minor injuries. The initiative evolved in an integrated way across nine community hospital casualty units, presenting an interesting opportunity to research its impact. A primarily descriptive, developmental evaluation approach was adopted which surveyed the perceptions of the main stakeholders and collated existing data. The development was found to have impacted very positively for the main professional groups involved, and patient waiting times appear to have been reduced. The educational course which underpinned the initiative was an important factor in its success. A number of other influential factors were identified during the research and these are discussed in relation to role development in nursing and evaluation methodology for nursing.

Introducing a nurse practitioner into an urban Canadian emergency department

OBJECTIVE

Our objective was to compare the emergency care provided by a nurse practitioner (NP) with that provided by emergency physicians (EPs), to identify emergency department (ED) patients appropriate for autonomous NP practice and to acquire data to facilitate the development of the clinical scope of practice recommendations for ED practice for NPs.

METHODS

Using a comprehensive 3-part process, we selected and hired the best NP from 12 applicants. The NP was oriented to the operations of our free-standing community ED and incorporated in the care team, working in real time with EP preceptors during a 6-month, prospective clinical assessment comparing NP care with EP care. ED preceptors reviewed every case in real time with the NP and completed an explicit evaluation form to determine whether NP assessment, investigation, treatment and disposition were "all equivalent to emergency physician care" (AEEPC) or whether they differed. The proportion of AEEPC interactions was determined for 23 patient presentation categories. Our a priori assumption was that a patient presentation category might be suitable for autonomous NP practice if 50% of NP encounters in that category were rated as AEEPC. Descriptive data were presented for patient case mix, teaching domains and time criteria.

RESULTS

Eighty-three NP shifts and 711 patient encounters were evaluated by 21 EP preceptors. The NP saw a median of 8 patients per shift. In 43% of encounters, NP care was AEEPC. Highest AEEPC rates were found in the patient follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). NP scores over 50% were also seen for lacerations (63.6%) and isolated sore throats (53%). With teaching, NP performance improved over time.

CONCLUSION

With the exception of follow up-related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience and training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for emergency NPs should focus on a model of collaborative practice with EPs.

Autonomous emergency ophthalmic nursing: a pilot educational module

Enhanced and extended roles proliferate in nursing today. This is, in part, due to changes in doctors' working hours and nursing becoming increasingly specialized. Ophthalmology has always had enhanced roles for nurses and the boundaries continue to evolve and widen. Accredited education in emergency ophthalmic nursing practice is essential to enhance safe practice, peer recognition and professional development in keeping with the Nursing and Midwifery Council's Code of Professional Conduct. Finding no appropriate educational and practice programme available, locally or nationally, the authors decided to devise their own module in conjunction with their ophthalmic department, their hospital's continuing professional practice development department, and Queen Margaret University. This article describes the authors' experience and the progression from inception, planning and organization to completion, and, finally, piloting the module themselves.

Emergency nurse practitioner care and emergency department patient flow: case-control study

OBJECTIVE

The present study aimed to compare ED waiting times (for medical assessment and treatment), treatment times and length of stay (LOS) for patients managed by an emergency nurse practitioner candidate (ENPC) with patients managed via traditional ED care.

METHODS

A case-control design was used. Patients were selected using the three most common ED discharge diagnoses for ENPC managed patients: hand/wrist wounds, hand/wrist fractures and removal of plaster of Paris. The ENPC group (n = 102) consisted of patients managed by the ENPC who had ED discharge diagnoses as mentioned above. The control group (n = 623) consisted of patients with the same ED discharge diagnoses who were managed via traditional ED care.

RESULTS

There were no significant differences in median waiting times, treatment times and ED LOS between ENPC managed patients and patients managed via traditional ED processes. There appeared to be some variability between diagnostic subgroups in terms of treatment times and ED LOS.

CONCLUSION

Patient flow outcomes for ENPC managed patients are comparable with those of patients managed via usual ED processes.

Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors

AIM

This paper reports a study to determine the attitudes of nurses, doctors and general medical practitioners towards the development of an advanced nurse practitioner service within an emergency department.

BACKGROUND

The role of advanced nurse practitioner in emergency care has emerged in a number of countries, and has brought with it confusion about titles, role boundaries, clinical accountability and educational requirements. Initially, the role resulted from a need for healthcare professionals to provide a service to the increased numbers of patients presenting to hospital with less urgent problems. Since then, the service has evolved to one where nurse practitioners provide high-quality and cost-effective care to persons who seek help for non-urgent, urgent or emergent conditions in a variety of emergency care settings. However, little research could be identified on the attitudes of relevant nursing and medical staff towards the development of this role.

METHODS

A questionnaire survey was carried out, and a 29-item Likert rating scale was developed to measure attitudes. Along with some demographic variables, two open-ended questions were added to allow respondents to elaborate on what they perceived as benefits and difficulties associated with an advanced nurse practitioner service. All general practitioners, emergency nurses and emergency doctors in one health board in the Republic of Ireland were targeted, and 25 emergency nurses, 13 emergency doctors and 69 general practitioners were approached to take part. Data were collected in February 2004.

FINDINGS

An overall response rate of 74.8% was achieved. All respondents were positive towards the development of an advanced nurse practitioner service, with general practitioners being less positive. The principal differences appeared between general practitioners and hospital emergency care staff.

CONCLUSION

There is a need for a multidisciplinary approach to the planning of advanced nurse practitioner services. To achieve multiprofessional acceptance, an accredited and standardized education programme is required, and this must address existing role boundaries.

Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department

This study examined the emergency nurse practitioner candidate (ENPC) scope of practice in a Victorian emergency department (ED). The emergency nurse practitioner (ENP) role is relatively new in Victoria and the scope of the ENP(C) practice is yet to be defined. International research literature regarding the ENP role has focused on outcomes such as patient satisfaction, waiting times and/or ED length of stay, accuracy and adequacy of documentation, use of radiography, and patient education, health promotion and communication issues. A prospective exploratory design was used to conduct this cohort study. There were 476 ENPC-managed patients between 14 July 2004 and 31 March 2005 with an average age of 29 years. The majority (77.2%) of ENPC-managed patients were discharged from the ED. The majority of the ENPC time was devoted to clinical practice (55%) and development of clinical practice guidelines (25%). Of patients managed by the ENPC, 49.6% required medications, 51% required diagnostic imaging and 8.6% required pathology testing during their ED stay. The most common discharge referrals were made to local medical officers (73.5%) and the most common referrals made for patients requiring admission were made to the plastic surgery (37.3%) and orthopaedic (35.5%) units. Extensions to the current scope of emergency nursing practice are pivotal to effective management of specific patient groups by ENP. The ENP model of care is an important strategy for the management of increased service demands in Victoria; however, little is known about the scope of the ENPC practice and many outcomes of the ENP care are yet to be defined. Further research to better understand the relationships between ENP outcomes is required if the contribution that ENPs make to emergency care is to be accurately quantified.

Therapeutic communication part 1: general approaches that enhance the quality of the consultation

Consultations that place the patient at the centre of the interaction and actively explore their ideas, concerns, fears, cares and expectations strongly correlate with increased satisfaction, concordance, feelings of enablement and symptom resolution. Primary Care clinicians have developed these therapeutic consultation styles as a result of utilising the extensive research that has been undertaken in General Practice. In contrast, consultations in Accident and Emergency (A&E) have received little investigation and communication has a predominant bio-medical focus. This is the first of two papers which presents the results of a substantive review of the literature which explores therapeutic communication strategies appropriate to Emergency Care. This paper sets the scene by describing the current status of the Emergency Care consultation and reviews the proposed benefits of a consultation centred around the patient. The development of "Patient-Centred Communication" and its philosophical underpinnings are also discussed in order to provide further background. Finally, the general characteristics of therapeutic consultations identified in the substantive review of the literature review are analysed. The second paper describes five key communication strategies which when employed in clinical consultations in Emergency Care, could significantly enhance the therapeutic nature of the clinician-patient interaction.

Nephrology nursing: blurring the boundaries: the reality of expert practice

BACKGROUND

Expertise in nursing has been widely studied; there have been no previous studies into what constitute expertise in nephrology (renal) nursing. This paper describes a 'real-world' characteristic of expert nephrology nursing practice.

AIMS AND OBJECTIVES

This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept blurring the boundaries.

DESIGN

The study utilized grounded theory methodology and symbolic interactionism.

METHODS

The study took place in one renal unit in New South Wales. Sampling was purposive then theoretical; the sample consisting of six non-expert and eleven expert nurses. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semi-structured interviews was undertaken.

RESULTS

The study revealed that only expert nephrology nurses 'blurred the boundaries' of professional nursing practice. They did this by moving intermittently and purposefully, for the benefit of particular patients, into medical domains in the areas of prescribing, dispensing and ordering of pathology tests. Non-expert nurses did not cross these professional boundaries.

CONCLUSIONS

Blurring the boundaries was a significant feature of expert nursing practice, and this study was the first to describe explicitly nursing boundaries as two distinct entities; that is, formal and informal.

RELEVANCE TO CLINICAL PRACTICE

There are some nephrology nurses who have sufficient knowledge and experience to prescribe some medications and to order certain investigations.

Interpreting trauma radiographs

BACKGROUND

Many accident and emergency clinicians regard the radiographic image as an extension of the clinical examination, as a provisional diagnosis, based on clinical signs and symptoms, can be confirmed or refuted by inspection of X-rays. However, the value of radiography in this context is not determined by the actual presence of trauma or pathology on the radiograph, but is dependent on the ability of a clinician to identify any trauma or pathology present. Traditionally, the responsibility for interpreting radiographic images within the accident and emergency environment in the United Kingdom (UK) has been with medical clinicians. However, expansion of the nursing role has begun to change the boundaries of professional practice and now many nurses are both requesting and interpreting trauma radiographs.

AIM

To ascertain the ability of accident and emergency doctors and nurses to interpret trauma radiographs, and identify whether there is a consistent standard of interpretive accuracy that could be used as a measure of competence.

METHODS

A literature review was conducted using the Cochrane Library, Medline and CINAHL databases and the keywords radiographic interpretation, radiographic reporting, accident and emergency and emergency/nurse practitioner.

FINDINGS

The ability of accident and nursing doctors and nurses to interpret trauma radiographs accurately varies markedly, and no identified published study has established an appropriate level of accuracy that should be achieved in order to demonstrate satisfactory competence in the interpretation of radiographic images.

CONCLUSIONS

Determining a measure of interpretive accuracy that can be used to assess ability to interpret radiographic trauma images is fraught with difficulties. Consequently, nurses may attempt to prove their skills by directly comparing their abilities to those of their medical colleagues. However, as a result of marked variation in the ability of senior house officers to interpret trauma radiographs, a similar ability does not automatically imply that a satisfactory level of ability has been achieved.

Mapping the range and scope of emergency nurse practitioner services in the Northern and Yorkshire Region: a telephone survey

OBJECTIVE

To map the range and scope of emergency nurse practitioner (ENP) services in the Northern and Yorkshire Region as part one of a three phased study investigating the developing role of the ENP on a multi-professional context.

METHODS

A telephone survey was conducted in the 48 hospital trusts within the region. Semi-structured interviews were arranged with the senior nurses responsible for accident and emergency services in responding departments. Data collection entailed completion of a form comprising 14 open-ended questions designed to elicit information about the range and scope of ENP services (as defined by the Royal College of Nursing). Data were analysed using descriptive statistics.

RESULTS

Interviews were conducted at 35 (73%) of the sites, 22 (63%) of which had an ENP service as defined above. Wide variation was found in the range of services in relation to: hours/days of availability; age range and sources of referrals of patients accessing the service; clinical caseloads of ENPs and the referral pathways to other services.

CONCLUSION

The findings from the survey highlight the organic, context specific nature of ENP role developments in response to national government initiatives, professional agendas, and local service needs.

The expanded role of the critical care nurse: a review of the current position

The advanced practice role of the registered nurse is a topic that is currently being debated both nationally and internationally. This paper examines the literature as it relates to role expansion within nursing in general and more specifically to critical care nurses. The role of the critical care nurse is changing and this has occurred as a result of historical evolution, the use of increasing technology, the blurring of medical and nursing roles and current workforce shortages. The literature reviewed identifies some of the factors that have propelled this process and examines the use of terminology as it relates to advanced practice roles and their titles. Finally, the attributes and educational preparation required to perform at an increased level are examined.

Nurse-initiated x-ray of isolated limb fractures in the emergency department: research outcomes and future directions

Patients presenting at emergency departments with isolated limb trauma face chronic delays due to over crowding and over utilisation of these departments for primary health care. Excessive waiting periods for assessment, definitive diagnostic procedures and subsequent treatment plans compound the current access block for emergency care, with these factors contributing to patient dissatisfaction. To improve patient satisfaction and decrease waiting times for some patients, the literature suggests that nurse initiated x-rays at the point of triage may be of value. Nurses can appropriately determine the need for radiological assessment in patients with isolated limb trauma--a high correlation has been found between doctors' and nurses' ordering of x-rays. To ensure x-rays are accurately and appropriately ordered, it is suggested that strict guidelines and structured educational programmes for nurses be implemented. The findings from this literature review suggest that extending the triage role to include nurse initiated x-rays has the potential to decrease waiting times and to increase patient satisfaction in the emergency department.

Emergency nurse practitioners: should the role be developed?

Trusts have to face a number of challenges in the provision of accident and emergency (A&E) services. One suggested way forward is to introduce the emergency nurse practitioner (ENP) role into A&E. However, this is not without controversy. Thus, this review has been undertaken in order to identify and assess any available evidence. A total of nine studies met the inclusion criteria. The studies fell into a number of categories, e.g. overall evaluation of the role, the use of radiography, and patient satisfaction. Several studies monitored transit times though A&E and there was some limited cost-benefit analysis. Overall, there was little difference found between the performance of ENPs in comparison with that of senior house officers (SHOs). The studies available for review are of poor quality, which limits the conclusions that can be made. At best, it would be reasonable to state that there is no evidence to demonstrate that ENPs are better or worse than SHOs in seeing, treating and discharging patients with minor injuries in A&E.

The extent and nature of emergency nurse practitioner services in Scotland

Emergency Nurse Practitioners (ENPs) are being used in an increasing proportion of A&E departments across England and Wales. This paper reports the findings of a postal survey sent to all (94) A&E departments in Scotland including the smaller GP run units. The aim of the study was to document the extent and nature of ENP services in Scotland. Nurses were found to be practising as ENPs in 47% of Scottish A&E departments. The majority (70%) of nurses practising as ENPs had been educated for the role on courses for ENPs. Nurses working as ENPs were being paid at all grades ranging from the lowest grade for a staff nurse (D-grade) through to H-grade. ENPs are practising in all types of A&E department. Most ENPs have been formally trained for the role, however huge variation exists in educational preparation and in remuneration for this expanded nursing role.

Opportunity for audit: establishing and monitoring the use of protocols for nurse-led treatments of minor injuries

During the last three years an integrated initiative has evolved in the casualty units of nine community hospitals in the Grampian region of Scotland. This has involved the development of nurse-led treatments for minor injuries based on a large number of assessment/treatment protocols. This paper describes how this change was used as an opportunity to initiate audit within clinical practice. Methods of auditing the use of the new protocols are detailed and baseline results are reported and discussed. In this way it is hoped that nurses involved in similar developments can learn from the strengths and weaknesses of this initiative.

Research directions for specialist practice

Emergency nursing is a specialist area of practice that demands particular knowledge and skills. This paper reports on a study to identify the research directions necessary to advance emergency nursing as a specialist area of practice. Nurses working in nine Australian hospital emergency departments responded to questions about current research practices, and the research priorities necessary to inform the development of knowledge and practice in the evolving specialty of emergency nursing. Forty-four core topics considered relevant to the knowledge base of emergency nursing were identified by nurses who were directly involved in providing patient care. The highest ranked topics were clustered into four priority areas for further research. The key areas for further research are education needs and opportunities, specialist roles of triage, trauma and practitioner, and nurses' coping mechanisms. Discussion of these topics is framed by the increasing specialisation of nursing practice, thus this paper aims to encourage consideration and debate about the research based development of the specialty of emergency nursing.

Patient satisfaction with a new nurse practitioner service

In the UK the role of the Nurse Practitioner (NP) has been slower to develop than in the USA (Tye 1997). However, since its inception, studies of the role have found positive results in areas of patient satisfaction (Touche Ross 1994). James and Pyrgos (1989) reported 94% of patients suitable to seen by a NP would use a NP if introduced. A study by Freij et al. (1996) concluded that emergency NPs were as competent at interpreting X-rays as casualty officers. Despite such evidence, Meek et al. (1995) noted opposition to this new advanced practice from other disciplines who wished to maintain the 'status quo'. In light of these findings, a study was undertaken to examine the new NP Service at Antrim Hospital, Northern Ireland. A patient satisfaction survey, a retrospective X-ray audit and a subjective assessment by other disciplines, were carried out in order to evaluate the service.

Blurring boundaries: professional perspectives of the emergency nurse practitioner role in a major accident and emergency department

The role of the emergency nurse practitioner (ENP) has increasingly become part of mainstream healthcare delivery in major accident and emergency departments in the United Kingdom. Although some research data are available in this field, there has been little attempt to evaluate the impact of the implementation of the ENP role from the perspective of those healthcare professionals most closely involved at local level. This paper describes one part of a case study evaluation of the role in an accident and emergency department in the South Thames English region. Nine face-to-face semi-structured interviews were carried out with the key multidisciplinary stakeholders in the organization. Five major themes emerged from the data analysis: blurring role boundaries; managing uncertainty; individual variation; quality vs. quantity; and the organizational context. Whilst some professional consensus was evident regarding the benefits of the role, such as improved waiting times and patient satisfaction, there appeared also to be a degree of ambivalence, particularly regarding current role configuration, value for money, and the extent to which the role should be expanded in the future. These issues are discussed in terms of professional identity, changing role boundaries, and professional personhood. It is argued that the benefits and pitfalls of the ENP role need to be considered within the context of local service provision. The growing emphasis on clinical governance reinforces the need for ongoing audit of role effectiveness in order to meet the challenges and uncertainties of increasingly blurred professional boundaries.

Patient satisfaction with emergency nurse practitioners in A & E

In recent years the complex process of managing services for patients requiring emergency care has been increasingly under scrutiny and considerable diversity has arisen in the organization of emergency care in both hospital and community settings. One innovation which has been particularly widespread is the development of Emergency Nurse Practitioners (ENPs): experienced Accident and Emergency nurses who assume entire responsibility for patients with minor injuries, in emergency settings. The present paper reports on a study which compared patients' satisfaction with care given by Emergency Nurse Practitioners with that provided by doctors and nurses working together in a traditional A & E. Patients were significantly more likely to have received health education and first aid advice from an ENP than from a doctor. They were also significantly more likely to have been given written instructions to take home and told whom to contact if they needed more help and advice following discharge. Those seen by an ENP also reported that they were subsequently significantly less worried about their health, than did patients seen in a traditional A & E.

Intellectual work of the critical care nurse: applications from a qualitative study

Worldwide shortages of critical care (CC) nurses have resulted in efforts targeted at understanding this unique area of nursing practice. This paper describes the findings of a qualitative study in which interviews with 17 CC nurses were conducted and provides insight into the support and continuing education required by both novice and experienced CC nurses. Analysis of the transcripts, field notes, memos and diagrams, and a comparison of the emerging categories to previous research, assisted in identifying several themes important to CC nursing practice. Within one of these themes, labelled 'intellectual work', four categories are described. 'Inquisitive mind', 'seeing the whole picture', 'ongoing vigilant assessment' and 'quick response' each provide evidence to support the need for adequate preparation and ongoing nurturing of CC nurses. Ensuring that educational opportunities for all CC nurses are focused on the development of sound clinical reasoning skills may result in a better prepared and more stable workforce, and optimal outcomes in patient care.

Emergency nurse practitioner services in major accident and emergency departments: a United Kingdom postal survey

OBJECTIVE

To establish the current and predicted distribution of formal emergency nurse practitioner services in major accident and emergency departments in the United Kingdom; to determine organisational variations in service provision, with specific reference to funding, role configuration, training, and scope of clinical activity.

METHODS

Postal survey of senior nurses of all major accident and emergency departments in the United Kingdom (n = 293) in May/June 1996.

RESULTS

There were 274 replies (94% response rate): 98 departments (36%) provided a formal service; a further 91 departments (33%) reported definite plans to introduce a service by the end of 1996; smaller departments, under 40000 new patient attendances annually, were less likely to provide a service than busier units (p < 0.001, chi2 for trend). Three different methods of making the role operational were identified: dedicated, integrated, and rotational. Only 16 (18%) were able to provide a 24 hour service; 91 departments (93%) employed emergency nurse practitioners who had received specific training, but wide variations in length, content, and academic level were noted; 82 departments (84%) authorised nurse practitioners to order x rays independently, but only 35 (36%) allowed them to interpret radiographs; 67 (68%) permitted "over the counter" drug supplying under local protocol, and 52 (54%), "prescription only" drug supplying from an agreed list.

CONCLUSIONS

Formal emergency nurse practitioner services are provided in all parts of the United Kingdom, with predicted figures suggesting a rapidly accelerating upward trend. Wide variations in service organisation, training, and scope of activity are evident.