Models of care with advanced practice nurses in the emergency department: A scoping review

INTRODUCTION

Emergency departments play a critical role in healthcare systems internationally. Visits for emergency care continue to increase, related to poor access to primary care, the COVID-19 pandemic, and health human resource issues. International literature shows similar stressors in the emergency department. Extended wait times to see health providers lead to poor outcomes, and innovative models of care are needed to address emergency department overcrowding and to meet the needs of patients. Advanced practice nurses have the expertise and scope of practice to optimize and address primary and acute care needs and could be further integrated into the emergency healthcare systems. It is unclear what and how advanced practice nurses are functioning in emergency departments to improve patient and organization outcomes.

METHODS

This scoping review was a comprehensive search of MEDLINE, EMCARE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and gray literature. Authors developed inclusion and exclusion criteria, performed title and abstract screening, and full text screening using review software. Data about models of care with advanced practice nurses were extracted and organized to understand patient, provider, and organizational outcomes. We also extracted information about the development and implementation of roles.

RESULTS

Of the 6780 records identified, 76 met inclusion criteria. Emergency department models of care, mainly using nurse practitioners, include fast-track, generalized emergency, minor injury, orthopedics, pediatrics, geriatrics, specific populations, and triage. Reported patient outcomes include improvement in key metrics specific to emergency departments, such as total length of stay, wait times to be seen by a provider, left without being seen rates, treatment for pain, costs, and resource use. When comparing nurse practitioners to other providers, outcomes were similar or better for patient and organizational outcomes.

DISCUSSION

Various models of care utilizing advanced practice nurses in emergency departments are present internationally and information about how they are developed, integrated, and utilized provides practical information to support and sustain new roles. There is an opportunity to expand the use of these roles into emergency departments as the nurse practitioner scope of practice grows. Given the current crisis across healthcare systems, there is need for innovation, and improving delivery of emergency services with these advanced practice nursing models of care can help to address important health policy priorities in Canada and other countries.

TWEETABLE ABSTRACT

Advanced Practice Nurse models of care in emergency - Improved outcomes for patients and organizations - A review of the literature. @SamanthaH_RN.

Patient satisfaction with computer-assisted structured initial assessment facilitating patient streaming to emergency departments and primary care practices: results from a cross-sectional observational study accompanying the DEMAND intervention in Germany

Background

Patient numbers in emergency departments are on the rise. The DEMAND intervention aims to improve the efficacy of emergency services by computer-assisted structured initial assessment assigning patients to emergency departments or primary care practices. The aims of our study were to evaluate patient satisfaction with this intervention and to analyse if reduced patient satisfaction is predicted by sociodemographic data, health status or health literacy.

Methods

We conducted a cross-sectional patient survey in emergency departments and co-located primary care practices. Each intervention site was planned to participate for two observation periods, each with a duration of one full week. Study participants were recruited by the local staff. The patients filled out a written questionnaire during their waiting time. Patient satisfaction was assessed by agreement to four statements on a four point Likert scale. Predictors of patient satisfaction were identified by multilevel, multivariable logistic regression models adjusted for random effects at the intervention site level.

Results

The sample included 677 patients from 10 intervention sites. The patients had a mean age of 38.9 years and 59.0% were women. Between 67.5% and 55.0% were fully satisfied with aspects of the intervention. The most criticised aspect was that the staff showed too little interest in the patients’ personal situation. Full satisfaction (“clearly yes” to all items) was reported by 44.2%. Reduced patient satisfaction (at least one item rated as “rather yes”, “rather no”, “clearly no”) was predicted by lower age (odds ratio 0.79 for ten years difference, 95% confidence interval 0.67/0.95, p = 0.009), presenting with infections (3.08,1.18/8.05,p = 0.022) or injuries (3.46,1.01/11.82,p = 0.048), a higher natural logarithm of the symptom duration (1.23,1.07/1.30,p = 0.003) and a lower health literacy (0.71 for four points difference, 0.53/0.94,p = 0.019).

Conclusions

The patients were for the most part satisfied with the intervention. Assessment procedures should be evaluated a) regarding if all relevant patient-related aspects are included; and whether patient information can be improved b) for patients with strong opinions about cause, consequences and treatment options for their health problem; and c) for patients who have problems in the handling of information relevant to health and healthcare.

Trial registration

German Clinical Trials Register (https://www.drks.de/drks_web/setLocale_EN.do) no. DRKS00017014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01825-5.

Liability and collaborative arrangements for nurse practitioner practice in Australia

The purpose of this paper is to clarify the relationship between medical practitioners (MPs) and nurse practitioners (NPs) in general, and privately practising NPs (PPNPs) in particular, in relation to collaboration, control and supervision in Australia, as well as to explore the difficulties reported by PPNPs in establishing mandated collaborative arrangements with MPs in Australia. In order for the PPNPs to have access to the Medicare Benefit Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) in Australia, they are required, by law, to establish a collaborative arrangement with an MP or an entity that employs MPs. This paper begins by describing the history of and requirements for collaborative arrangements, then outlines the nature of successful collaboration and the reported difficulties. It goes on to address some of the commonly held misconceptions in order to allay medical concerns and enable less restrictive access to the MBS and PBS for PPNPs. This, in turn, would improve patient access to highly specialised and expert PPNP care.

Ward staff perceptions of the role of the advanced nurse practitioner in a 'hospital at day' setting

AIM

to examine ward staff perceptions on the role of the 'hospital at day' advanced nurse practitioner (ANP). This term is used locally to refer to a model first introduced into 'hospital at night' teams, in response to changes in working patterns of junior doctors, where an advanced nurse practitioner is based on the ward-the model was subsequently rolled out to daytime teams.

METHODS

a qualitative descriptive phenomenological approach was adopted to carry out this study with a purposive sample of ten participants. Participants were interviewed individually using semi-structured interviews to gain insights into their perceptions on the role of the ANP, following Colaizzi's analytical model of data analysis.

FINDINGS

four major themes were identified. The first overarching theme was effectiveness of the ANP role. There was evidence that the role was not only clinically effective in the ward but also in relation to organisational priorities such as impact on patient flow. Secondly it was acknowledged that having an ANP based on the ward and as a 'constant' in the ward area, when medical teams rotate, provides team stability and improves the functioning of the ward area. Despite the positivity recognised, the third theme identified that having a ward-based ANP may affect skill acquisition and development and may lead to the 'de-skilling' of staff. Lastly it was acknowledged that there remains an overall confusion about the role of the ANP.

CONCLUSION

the themes identified reflect what is already known about the wider perceived role of the ANP. Moreover, this study adds to the limited literature available specifically on the benefits of the ANP within 'hospital at day' roles.

Reasons for choosing or refusing care from a nurse practitioner: Results from a national population-based survey

AIM

To understand the public's willingness or lack thereof, to be seen and treated by a nurse practitioner (NP) as the first point of contact when accessing healthcare services.

DESIGN

This cross-sectional, population-based survey study used computer assisted telephone interviewing to elicit public opinions on the topic.

METHODS

Data were collected in July and August 2015 from calls randomly placed to Australian households. Survey questions were developed from previous surveys and pilot tested. Summative content analysis was used to analyse open-ended responses.

RESULTS

Most respondents were always, or in some situations, willing to receive care from a nurse practitioner. The main themes identified from those willing to be seen by a nurse practitioner in any situation were, (a) appropriately qualified nurse practitioners, (b) the knowledge and experience to refer on if necessary. Description of situations from those unwilling to be seen by a nurse practitioner related to concern about appropriate care in a life-threatening condition.

CONCLUSION

Respondents unwilling to consider any care from a nurse practitioner or care in an emergency situation, reveal a lack of understanding of their role in the wider healthcare team. As the number of nurse practitioners increase, professional groups and community awareness programmes should be focused on explaining and promoting their essential role.

IMPACT

This study addresses the increasing healthcare requirements of ageing populations through understanding acceptance by society to the provision of care from health professionals other than medical practitioners. Most respondents were willing to be seen by a nurse practitioner for all or most of their healthcare needs. Lack of understanding of their scope of practice and role in the wider healthcare team, particularly in emergency situations, was reflected in responses. Those who would refuse care from a NP were in the minority. Appropriateness and acceptability of the roles of health professionals to provide quality care collaboration need consideration by policy makers.

Are service and patient indicators different in the presence or absence of nurse practitioners? The EDPRAC cohort study of Australian emergency departments

OBJECTIVES

To evaluate the impact of nurse practitioner (NP) service in Australian public hospital emergency departments (EDs) on service and patient safety and quality indicators.

DESIGN AND SETTING

Cohort study comprising ED presentations (July 2013-June 2014) for a random sample of hospitals, stratified by state/territory and metropolitan versus non-metropolitan location; and a retrospective medical record audit of ED re-presentations.

METHODS

Service indicator data (patient waiting times for Australasian Triage Scale categories 2, 3, 4 and 5; number of patients who did not-wait; length of ED stay for non-admitted patients) were compared between EDs with and without NPs using logistic regression and Cox proportional hazards regression, adjusting for hospital and patient characteristics and correlation of outcomes within hospitals. Safety and quality indicator data (rates of ED unplanned re-presentations) for a random subset of re-presentations were compared using Poisson regression.

RESULTS

Of 66 EDs, 55 (83%) provided service indicator data on 2 463 543 ED patient episodes while 58 (88%) provided safety and quality indicator data on 2853 ED re-presentations. EDs with NPs had significantly (p<0.001) higher rates of waiting times compared with EDs without NPs. Patients presenting to EDs with NPs spent 13 min (8%) longer in ED compared with EDs without NPs (median, (first quartile-third quartile): 156 (93-233) and 143 (84-217) for EDs with and without NPs, respectively). EDs with NPs had 1.8% more patients who did not wait, but similar re-presentations rates as EDs with NPs.

CONCLUSIONS

EDs with NPs had statistically significantly lower performance for service indicators. However, these findings should be treated with caution. NPs are relatively new in the ED workforce and low NP numbers, staffing patterns and still-evolving roles may limit their impact on service indicators. Further research is needed to explain the dichotomy between the benefits of NPs demonstrated in individual clinical outcomes research and these macro system-wide observations.

Privately practicing nurse practitioner services in Australia and patient access to care: Results from realist interviews

BACKGROUND

To facilitate the expansion of nurse practitioners working in community and primary health settings, legislative changes were enacted in 2010. These led to privately practicing nurse practitioners (PPNPs) being enabled to provide care subsidized through the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. Little is known about the impact of this legislation on patient access to care in Australia.

PURPOSE

To explore how, why and in which contexts PPNP services in Australia impact on patient access to care.

METHODS

Semistructured interviews using realist evaluation were undertaken with 20 participants, selected through stratified sampling using geographic criteria (State/territory in which practicing) and dividing the sample representatively between those who worked solely in private practice and those who worked in both private and public practice. Thematic analysis of qualitative data was undertaken.

CONCLUSION

Findings suggest that PPNPs have increased access to care for patients, predominantly in community and primary health settings.

IMPLICATIONS FOR PRACTICE

In increasing access to care, PPNPs have the potential to reduce hospital and general practitioner attendance, thereby potentially reducing the ever-increasing demand for health care.

Experiences of working as an advanced practice nurse in Finland--the substance of advanced nursing practice and promoting and inhibiting factors

BACKGROUND

Evaluation of new advanced practice nursing roles, from different angles, is strongly recommended in the literature. New nurses' experiences of working in an advanced role may highlight problems and/or factors that promote or inhibit a successful implementation of new advanced nursing roles.

AIM

To explore advanced practice nurses' experiences of the content of their nursing care and to describe promoting or inhibiting factors for working with a full scope of advanced nursing practice.

METHODS

The study design was explorative and descriptive. A total of 24 advanced practice nurses participated in focus group interviews (two were interviewed individually) about the processes, structure and outcome of working as advanced practice nurses. Qualitative manifest content analysis was used for data analysis.

FINDINGS

The substance of advanced practice nursing can be described with three main themes: a broader and deeper holistic view of patients' state of health, an independent and responsible manner of working and knowing own limits. Promoting factors were an identity as a nurse with advanced competency, feedback from satisfied patients and fruitful teamwork is a necessity. Inhibiting factors were a lack of organisational understanding for advanced nursing practice, poor planning leads to unsatisfactory advanced practice nursing models and advanced practice nurses' lack of courage in adopting new advanced roles.

CONCLUSION

The participants experienced both a personal inner transition and a role transition that were either supported or opposed. Vague or nonexistent definitions and concepts, insufficient knowledge, insufficient support and undefined roles hindered participants' role transition. Two main strategies should be employed. The first is the realisation of more strategic leadership and support from organisations on all management levels, including nursing organisations/unions, while the second is to more realistically prepare future advanced practice nurses for the challenges they will face, through mentorship programmes and continuous further training.

Patient perceptions of emergency department fast track: a prospective pilot study comparing two models of care

BACKGROUND

Emergency department (ED) fast track has been shown to improve patient flow for low complexity presentations.(1) The optimal model of care and service delivery for fast track patients has not been established.

AIMS

The objective of this pilot study was to compare patient satisfaction using two models of ED fast track - one in a tertiary hospital emergency department staffed by doctors and the other in a nearby urban district hospital staffed by nurse practitioners. We also wanted to determine the proportion of fast track patients who would prefer to see a General Practitioner (GP) instead of presenting to the ED. This pilot study was the foundation for subsequent studies later conducted by Dinh et al.(2,3) METHODS: This was an observational study using a convenience sample of patients. Eligible fast track patients were asked to complete a standardised satisfaction survey. Presenting problems and waiting times of patients were collected using patient information systems. Primary outcome measure was satisfaction rating using a 5-point Likert scale. Secondary outcomes were surrogate satisfaction measures encompassing questions on likelihood of returning to ED. A multivariate analysis was performed to obtain odds ratio for higher satisfaction scores.

RESULTS

In total, 353 patients were recruited: 212 patients in the doctor treated group (DR) and 141 were in the nurse practitioner treated group (NP). The two groups had similar baseline characteristics in terms of age, gender, referral source and waiting times. Overall, 320/353(86%) patients rated their care as either very good or excellent, with only 0.6% rating their care as poor. Satisfaction scores in the NP group were higher than those in the DR group (median score 4 vs. 3, p<0.01). A greater proportion of patients in the NP group reported that they would return to the ED for a similar problem (99% vs. 91% p<0.01). Overall, 175/353 (50%) of patients indicated that they would prefer to see a general practitioner for a similar problem if available nearby. These numbers were slightly lower in the NP group (43% vs. 53%, p=0.05).

CONCLUSIONS

Most patients were satisfied with ED fast track, irrespective of model of care. Patient satisfaction was greater in the group of patients using the nurse practitioner model of care. Around half of the fast track patients would prefer to see a general practitioner for a similar problem if available nearby.

The tortuous journey of introducing the nurse practitioner as a new member of the healthcare team: a meta-synthesis

The aim of this study was to explore the obstacles to and the opportunities for achieving optimal interprofessional team collaboration with the introduction of the nurse practitioner (NP). A team approach can contribute importantly to sustainable and safe patient care, and NPs have been added to the healthcare team in many countries. Following the international trend towards the development of the acute care NP, the role has recently been initiated in surgical care in Sweden. The introduction of an advanced nursing role into existing organisations raises questions about how the role will be developed and what its effects will be on collaboration between the different professions. We conducted a systematic review of qualitative studies using the meta-ethnographic approach developed by Noblit and Hare. Literature in the field of nursing was searched on PubMed and CINAHL, and empirical qualitative studies from outpatient and inpatient care in seven countries were included. The studies were appraised according to national guidelines and templates and were analysed and synthesised according to the meta-ethnographic approach. A total of 26 studies were included in the synthesis. The analysis revealed four themes: (i) a threat to professional boundaries, (ii) a resource for the team, (iii) the quest for autonomy and control, and (iv) necessary properties of a developing interprofessional collaboration. Based on these themes, the synthesis was created and presented as a metaphorical journey. The implementation of a new nursing role in a traditional healthcare team is a complex process influenced by many factors and can be described as "a tortuous journey towards a partially unknown destination". The synthesised obstacles and opportunities drawn from international studies may help healthcare organisations and new NPs prepare for, and optimise, the implementation of a new nursing role.

The impact of nurse practitioners on care delivery in the emergency department: a multiple perspectives qualitative study

BACKGROUND

Despite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation.

METHODS

A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes.

RESULTS

The impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance.

CONCLUSIONS

Interpretation of the NPs' role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required.

The clinical effectiveness of nurse practitioners' management of minor injuries in an adult emergency department: a systematic review

Background  The increasing cost of healthcare in Australia demands changes in the way healthcare is delivered. Nurse practitioners have been introduced into specialty areas including emergency departments. Specific interventions are known to include the treatment and management of minor injuries, but little has been reported on their work. Objectives  Examine the best available evidence to determine the clinical effectiveness of emergency department nurse practitioners in the assessment, treatment and management of minor injuries in adults. Inclusion criteria  For inclusion studies had to include adult patients treated for minor injuries by nurse practitioners in emergency departments. All study designs were included. Search strategy  English language articles from 1986 onwards were sought using MEDLINE, CINAHL, Embase and Science Citation Index. Methodological quality  Two independent reviewers critically appraised the quality of the studies and extracted data using standardised tools. Data collection  Two independent reviewers assessed the eligibility of each study for inclusion into the review and the study design used. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Data synthesis  Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. For each outcome measure, results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate. Results  Nine studies from a total of 55 participants met the inclusion criteria. Two were randomised controlled trials. Metasynthesis of research findings generated five synthesised findings derived from 16 study findings aggregated into seven categories. Evidence comparing the clinical effectiveness of nurse practitioners to mainstream management of minor injuries was fair to poor methodological quality. When comparable data were pooled, there were no significant differences (P < 0.05) between nurse practitioners and junior doctors. Conclusions  The results emphasise the need for more high-quality research using appropriate outcome measures in the area of clinical effectiveness of nurse practitioners, particularly interventions that improve outcomes for presentations to emergency departments and address issues of waiting and congestion.

Determining the Incidence of Adult Fractures: How Accurate Are Emergency Department Data?

Various research methods have been used to obtain skeletal fracture data and report the incidence of fractures. A large number of British studies have used data collected in emergency departments, and not data derived from orthopaedic units. We hypothesised that fracture data will differ depending upon the methodology employed to capture it. Two commonly used sources of fracture data at our institution were compared, (the Emergency Department (ED) database and the Orthopaedic Trauma Unit (OTU) database), using a cohort of adult patients from our defined population as the study sample. We performed univariate analyses to identify differences between groups with accurate and inaccurate ED fracture diagnoses. We then performed a binary logistic regression analysis to determine the best predictors of diagnostic accuracy. In one year, 7,449 patients were referred to the OTU. Three-quarters were referred with fractures. The overall false positive fracture referral rate was 25%. Several fracture subtypes were commonly overdiagnosed in the ED. Regression analysis showed that patient age, patient gender, and the seniority of the referring clinician were independently predictive of an accurate fracture diagnosis. We suggest that studies making use of ED fracture data may potentially overestimate the incidence of adult fractures.

Evaluating new roles within emergency care: a literature review

INTRODUCTION

In recent years economic and political drivers have strongly influenced the development and introduction of new roles such as medical substitution roles within emergency care in the National Health Service (NHS) in the United Kingdom (UK).

AIMS

The aims of this literature review were to establish the national and international evidence available which examine the scope of practice of emergency nurse practitioners, emergency care practitioners and extended scope physiotherapists; to establish the national and international evidence which explores patient satisfaction with non-medical roles in emergency care; to establish the national and international evidence which explores the acceptability of emergency nurse practitioner, emergency care practitioner and extended scope physiotherapists services from a healthcare professional perspective.

METHODS

A search of the literature was undertaken using BNI, CINAHL plus, International Bibliography of the Social Sciences, MEDLINE and SPORTDiscus databases combined with searches of the Cochrane library collection, NICE and the grey literature. Critical assessment of the literature is presented.

RESULTS

A high level of patient satisfaction was found with all the new roles. Interestingly the scope of practice of Emergency nurse practitioners appears to be most limited in the UK. Five major themes were identified from healthcare professionals' perceptions of these new roles.

CONCLUSION

There is general agreement that non-medical roles help to reduce waiting times in emergency departments, as well as attracting a high level of patient satisfaction, confidence and acceptance of these roles. Several issues were identified which warrant further study; including the current UK evidence surrounding the limited scope of practice of these roles.

An exploration of personal initiative theory in the role of consultant nurses

The aim in this paper is to investigate the contribution personal initiative theory makes in understanding the consultant nurse role. The role was introduced in the UK in 2000 to improve patient outcomes, clinical leadership and retention of experienced clinicians. A larger study used a multi-method approach to collect quantitative and qualitative data from focus groups, interviews and a questionnaire administered nationally at two time points. Findings from longitudinal telephone interviews with 30 consultant nurses are the focus of this paper.

Three consultant nurses were selected as case studies to examine the potential of personal initiative theory when applied to new nursing roles. The activities of two of the three demonstrated a high level of personal initiative in the job. They persisted in overcoming problems faced in improving practice. The third scored lower: she emerged as a reactive conformist and less likely than the other two to pursue initiatives of her own.

Personal initiative theory has potential as a framework for evaluating the consultant nurse role, although further research is needed to test it. The longitudinal analysis revealed a determination to stay in the job and overcome difficult challenges when consultants show initiative and are making progress in achieving change.

A survey of patient satisfaction in a metropolitan Emergency Department: comparing nurse practitioners and emergency physicians

The Emergency Nurse Practitioner role was introduced to an Emergency Department, Melbourne in 2004 as an alternative health-care model to provide accessible and efficient patient care. The aim of the study was to explore patient satisfaction using a questionnaire from their emergency department experience comparing Emergency Nurse Practitioners and emergency department doctors. Patients who received care from either Emergency Nurse Practitioners or emergency department doctors were given a self-administered questionnaire to complete. Descriptive statistics and non-parametric tests were used for data analysis. A total of 202 patients completed the survey with 103 seen by the Emergency Nurse Practitioners and 99 seen by emergency department doctors. Significant differences were reported in 12 of the 16 questions comparing patient satisfaction with either Emergency Nurse Practitioners or emergency department doctors with greater patient satisfaction demonstrated with the Emergency Nurse Practitioners. The Emergency Nurse Practitioner model demonstrates consistent levels of patient satisfaction with patients reporting more favourable satisfaction with the Emergency Nurse Practitioners compared with emergency department doctors.