The extent and nature of emergency nurse practitioner services in Scotland

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.

Do emergency department physiotherapy practitioner's, emergency nurse practitioners and doctors investigate, treat and refer patients with closed musculoskeletal injuries differently?

INTRODUCTION

This paper aims to assess whether emergency department physiotherapy practitioner's (EDPPs), emergency nurse practitioner's (ENPs) and emergency department doctors investigate, treat and refer patients with closed musculoskeletal injuries differently.

METHOD

The emergency department records of patients who fitted the departmental criteria for being treated by either ENPs, EDPPs or doctors were selected retrospectively during a 2 1/2 month period between 1 March and 15 May 2005. The investigation, management and referral or discharge of these patients were analysed.

RESULTS

There was no significant difference between the proportion of patients sent for x ray and the type of clinician. (p = 0.17) There was also no significant difference between the proportions of x rays found to have fractures/dislocations with each type of clinician (p = 0.99). All fractures and dislocations were found to have been managed following the written departmental protocols. Consequently, further analysis was for soft tissue injuries only. For soft tissue injuries, senior house officers gave more patients analgesia/non-steroidal anti-inflammatory drugs compared with other clinicians (86%, p<0.001). ENPs gave more structural support (bandages, etc) compared with other clinicians (80%, p<0.001). Consultant's arranged the least formal follow-up although this was not significant (7.6%, p = 0.054) and middle grades offered the most follow-up (17%, p = 0.054) with this again not being significant. However, EDPPs referred significantly more patients for physiotherapy follow-up (9.2%, p = 0.031).

CONCLUSION

ENPs, EDPPs and doctors of all grades investigated patients with fractures and dislocations similarly and managed them following the written departmental guidelines. However, there were statistically significant differences in the way patients with closed soft tissue injuries were treated and followed-up.

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.

Interpretation of trauma radiographs by radiographers and nurses in the UK: a comparative study

The purpose of this study was to identify the number of hospitals employing nurses and radiographers formally to undertake radiographic interpretation of trauma images and to compare the education undertaken by these professionals and any limitations imposed. A cross-sectional questionnaire survey of nurse and radiographer managers responsible for Accident and Emergency services within National Health Service hospitals in the UK was undertaken in January 2002. A total of 526 questionnaires were distributed. Response rates of 75.3% (n=198/263) and 69.2% (n=182/263) were received from radiographer and nurse managers, respectively. 96 nurse managers (52.7%, n=96/182) indicated that nurses within their departments were formally interpreting radiographs as part of their extended role whereas only 68 radiography managers (34.3%, n=68/198) indicated that radiographers were undertaking this role. Education to support radiographic interpretation varied markedly with 92.6% (n=63/68) of radiographers having undertaken a postgraduate qualification in image interpretation. In contrast, nurse education at all levels was more generic to the nursing role. The range of examinations which nurses and radiographers were permitted to interpret also varied markedly. Radiographic interpretation is undertaken by both nurses and radiographers. However, there is interprofessional and intraprofessional inconsistency in the range of examinations they are permitted to interpret and the level of education provided to support this role. Consequently, it can be surmised that national variation in service delivery and quality exists and a review of current service delivery strategies is recommended.

Requesting and interpreting trauma radiographs: a role extension for accident & emergency nurses

Government supported expansion of the nursing role within Accident & Emergency (A&E) departments in the United Kingdom (UK) has begun to break down the traditional barriers to professional practice. Today, many nurses working within A&E departments are both requesting and interpreting radiographic examinations as part of their normal working practice. However, role expansion does not occur without increased responsibility. Unsatisfactory requests for radiography and inaccurate radiographic interpretation may result in inappropriate patient treatment, misuse of resources, patient recall and litigation. Nurses undertaking these role extensions need to ensure that their levels of knowledge and skill to perform the role are appropriate and adequately supported. This article summarises the results of a national questionnaire survey of A&E nurse managers that aimed to identify current working practices, including education, training and limitations to practice, with respect to the requesting and interpretation of trauma radiographs by A&E nurses.

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.

Evaluating Emergency Nurse Practitioner services: a randomized controlled trial

BACKGROUND

Emergency Nurse Practitioners (ENP) are increasingly managing minor injuries in Accident and Emergency departments across the United Kingdom. This study aimed to develop methods and tools that could be used to measure the quality of ENP-led care. These tools were then tested in a randomized controlled trial.

METHODS

A convenience sample of 199 eligible patients, over 16 years old, and with specific minor injuries was randomized either to ENP-led care (n = 99) or Senior House Officer (SHO)-led care (n = 100) and were diagnosed, treated, referred or discharged by this lead clinician. Following treatment, patients were asked to complete a patient satisfaction questionnaire related to the consultation. Clinical documentation was assessed using a 'Documentation Audit Tool'. A follow-up questionnaire was sent to all patients at 1 month. Return visits to the department and missed injuries were monitored.

RESULTS

Patients were satisfied with the level of care from both ENPs and SHOs. However, they reported that ENPs were easier to talk to (P = 0.009); gave them information on accident and illness prevention (P = 0.001); and gave them enough information on their injury (P = 0.007). Overall they were more satisfied with the treatment provided by ENPs than with that from SHOs (P < 0.001). ENPs' clinical documentation was of higher quality than SHOs (P < 0.001). No differences were found in recovery times, level of symptoms, time off work or unplanned follow-up between groups. Missed injuries were the same for both groups (n = 1 in each group).

CONCLUSION

The study was sufficiently large to demonstrate higher levels of patient satisfaction and clinical documentation quality with ENP-led than SHO-led care. A larger study involving 769 patients in each arm would be required to detect a 2% difference in missed injury rates. The methods and tools used in this trial could be used in Accident and Emergency departments to measure the quality of ENP-led care.