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

What is nursing in advanced nursing practice? Applying theories and models to advanced nursing practice-A discursive review

AIM

This article appraises models and theories related to advanced nursing practice. It argues that while the role of the advanced nurse practitioner builds on and extends beyond traditional nursing, it remains firmly grounded in 'caring'.

BACKGROUND

The stereotype that nurses 'care' and doctors 'cure' is fading. Increasingly, nurses have crossed boundaries and conducted independent assessment, diagnosis, prescribing and consultation, which used to be the doctor's role. Confusion and argument have arisen due to the higher-level practice of the advanced nurse practitioner, as many questions where these 'doctor nurses' stand.

DESIGN

A literature review.

DATA SOURCES

Databases, including CINAHL, Medline and Google Scholar, were searched.

METHOD

Databases were searched, and relevant studies and review articles from 1970 to 2023 were identified using the following keywords: 'advanced nurse practitioner', 'nurse practitioner', 'advanced nursing', 'advance practice', 'nurse practitioner', 'nursing theory' and 'nursing model'.

RESULTS

Although advanced nurse practitioners identify themselves as nurses, there is limited use of nursing theory to conceptualize this new level of practice and to define their contribution to the multi-disciplinary team. It is noted that a holistic approach to personalized patient care, based on therapeutic relationships and effective communication, may help us identify the unique contribution of the advanced nurse practitioner.

CONCLUSIONS

The development of advanced nursing theory needs to capture this holistic approach and its caring element to recognize the value and strengthen the identity allegiance of this hybrid role.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Holistic approach and patient-centred care, effective communication and the therapeutic relationship are strong characteristics relating to ANP practice, the latter of which is yet to be clearly defined and captured in nursing theories. Conceptualizing ANP practice and capturing their valuable nursing care will enable better understanding and clarity for the role to realize its full potential.

Advanced Practice Nursing Roles: A Comparison Between Mexico and the United Kingdom

The COVID-19 pandemic has placed nursing at the forefront of public attention across the globe and has highlighted the critical role of nursing in healthcare service provision. Advanced practice nursing has been recognized for more than 50 years, but the rate of its growth and development varies significantly across the world. One of the key aims of the Better Health Programme Mexico, which commenced in 2019, was to develop advanced practice nursing in Mexico. The Programme was based on the United Kingdom model, where advanced practice nursing has been in place—though not subject to statutory regulation—for more than 40 years. The aim of this article is to compare the frameworks that underpin advanced practice nursing in the United Kingdom and in Mexico. In the present article, current practice in both countries was researched, and the structure, systems, and processes relating to nursing regulation and the frameworks to support advanced practice nursing were examined. A gap analysis report undertaken as part of the Better Health Programme identified challenges in developing advanced practice nursing in Mexico and the United Kingdom and highlighted the need for stakeholders to agree on an approach toward a rigorous regulatory framework in both settings. In summary, this article highlights the issues facing nurses and regulators in both countries in terms of advanced practice nursing and identifies strategies that can be used to strengthen the advanced practice nurse role.

Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes

BACKGROUND

While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED.

METHODS

We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major.

RESULTS

Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these.

CONCLUSIONS

APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.

Progress and challenges for advanced practice nursing in Mexico and the United Kingdom

AIM

The aim of this study is to compare the advanced practice nursing development in Mexico with the United Kingdom.

BACKGROUND

In spite of the involvement of global and local bodies to establish and develop advanced practice nursing worldwide, progress remains variable due to the lack of homogeneity in health care systems and policies.

EVALUATION

Using thematic analysis from interviews of 29 health care professionals in Mexico, we identified four major issues that impact on the development of advanced practice nursing: (a) workforce, (b) organizational and institutional, (c) regulatory and legal and (d) academic and educational.

KEY ISSUES

Learning from the UK experience in relation to overcoming some of these issues has been insightful in terms of how advanced practice nursing skills in Mexican nurses can be developed.

CONCLUSIONS

Mexico is still in early stages of the development of APN. Based on the UK experience, the government may have to move forward to support higher level training, create labour market positions, establish new nursing functions, promote task-shifting and particularly implement solid regulation.

IMPLICATIONS FOR NURSING MANAGEMENT

The development of advanced practice nursing represents important challenges for training and practice of nursing in Mexico and the United Kingdom; therefore, interested actors will have to reach key agreements that could work as the foundations of an assertive planning process.

Inter-specialty variation of the Press Ganey Outpatient Medical Practice Survey

ABSTRACT

Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement.

Patients' experiences with the advanced practice nurse role in Swiss family practices: a qualitative study

Background

Considering shortages of general practitioners (GP) and strategies for improving the quality of health care provision, many countries have implemented interprofessional care models with advanced practice nurses (APN). International evidence suggests that APN care results in high patient satisfaction. In Switzerland, the role is still new, and the patient perspective has not yet been researched. Our aim was therefore to explore patients’ experiences with the APN role in Swiss family practices.

Methods

We conducted 22 semi-structured interviews in four different family practices with patients aged 18 to 97 suffering from minor acute to multiple chronic diseases, and who had at least one consultation with an APN. All interviews were audiotaped, transcribed verbatim, and analysed using qualitative content analysis.

Results

The analysis resulted in five themes: Despite the unfamiliarity, all patients were willing to be consulted by an APN because it was recommended by their GP (1); after several encounters, most participants perceived differences between the APN and the GP consultation in terms of the length and style of the consultations as well as the complexity of their tasks (2); the interviewees emphasised coaching, guidance, care coordination, and GP-assisting tasks as APN core competencies and attributed the characteristics empathetic, trustworthy, and competent to the APN role (3); most patients especially valued home visits and the holistic approach of the APNs, but they also noticed that in certain cases GP supervision was required (4); and due to the close collaboration between the APN and the GP, patients felt safe, well cared for and experienced improvements in physical and psychological well-being as well as in daily activities (5).

Conclusion

Our results suggested that patients value the APNs’ competencies, despite their initial lack of role knowledge. Trust in the GP seemed to be the most important factor for patients’ receptiveness toward the APN role. Overall, patients perceived an added value due to the enlargement of the scope of practice offered by APNs. The patient perspective might provide valuable insights for further APN role implementation in Swiss family practices.

Quality improvement initiative for improved patient communication in an ED rapid assessment zone

INTRODUCTION

Patient-clinician communication in the Emergency Department (ED) faces challenges of time and interruptions, resulting in negative effects on patient satisfaction with communication and failure to relieve anxiety. Our aim was to improve patient satisfaction with communication and to decrease related patient anxiety.

METHODS

A multistage quality improvement (QI) initiative was conducted in the ED of Toronto General Hospital, a quaternary care centre in Ontario, Canada, from January to May 2018. We engaged stakeholders widely including clinicians, allied health and patients. We developed a 5-point Likert scale survey to measure patient and clinician rating of their communication experience, along with open-ended questions, and a patient focus group. Inductive analyses yielded interventions that were introduced through three Plan-Do-Study-Act (PDSA) cycles: (1) a clinician communication tool called Acknowledge-Empathize-Inform; (2) patient information pamphlets; and (3) a multimedia solution displaying patient-directed material. Our primary outcome was to improve patient satisfaction with communication and decrease anxiety by at least one Likert scale point over 6 months. Our secondary outcome was clinician-perceived interruptions by patients. We used statistical process control (SPC) charts to identify special cause variation and two-tailed Mann-Whitney U tests to compare means (statistical significance p<0.05).

RESULTS

A total of 232 patients and 104 clinicians were surveyed over baseline and three PDSA cycles. Communication about wait times, ED process, timing of next steps and directions to patient areas were the most frequently identified gaps, which informed our interventions. Measurements at baseline and during PDSA 3 showed: patient satisfaction increased from 3.28 (5 being best; n=65) to 4.15 (n=59, p<0.0001). Patient anxiety decreased from 2.96 (1 being best; n=65) to 2.31 (n=59, p<0.001). Clinician-perceived interruptions by patients changed from 4.33 (5 being highest; n=30) to 4.18 (n=11, p=0.98) and did not meet significance. SPC charts showed special cause variation temporally associated with our interventions.

CONCLUSIONS

Our pragmatic low-cost QI initiative led to statistically significant improvement in patient satisfaction with communication and decreased patient anxiety while narrowly missing our a priori improvement aim of one full Likert scale point.

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.

["It will be important to avoid a rift opening up between nurses and advanced practice nurses"]

After a long process of negotiation, laws passed in 2018 mean that advanced practice has finally become a reality for nurses in French legislation. Benefits are expected for patients, doctors, caregivers, management, organisations and for the health system. However, it will be necessary to take into account certain limits, and practices are expected to evolve. This change highlights the evolution of nursing practices thanks to Evidence-Based Nursing. An interview with Christophe Debout, member of the advanced practice network training committee of the International Council of Nurses.

Factors associated with patients' and companions' satisfaction with a hospital emergency department: A descriptive, cross-sectional study

AIM

The aim was to study the level of satisfaction with an emergency department and to identify the factors associated with satisfaction.

DESIGN

This research consisted of a descriptive, cross-sectional study.

METHODS

The study population was composed of patients and companions who visited the emergency department during a three-month period. The patients were selected randomly from the register of visits to the emergency department during the period of study. Sociodemographic variables and variables related to the attention received were studied through questionnaires (response rate 33%).

RESULTS

Older age was associated with greater satisfaction (p = 0.002), as was female sex (p = 0.013) and greater optimism (p < 0.001). Greater control of pain was a factor associated with satisfaction (p = 0.033), as was the perception of a shorter waiting time before the medical visit (p < 0.001).

Patient satisfaction: Concept analysis in the healthcare context

OBJECTIVE

Patient satisfaction had been the focus of many scientific studies worldwide. However, very few studies published had addressed the definition of the concept of patient satisfaction. Therefore this present concept analysis is to explore the attributes of the concept in the broader healthcare context.

METHODS

The Rodgers method, an inductive method of concept analysis, was selected to guide this concept analysis.

RESULTS

The attributes of patient satisfaction in the healthcare context identified were provider attitude, technical competence, accessibility, and efficacy. Perception in relation to expectation, patient demographics and personality, and market competition were regarded as prerequisites of patient satisfaction. Consequences of patient satisfaction identified in this analysis were: patient compliance, clinical outcomes, loyalty and referrals.

CONCLUSION

As healthcare is becoming an increasingly competitive marketplace, studying patient experience could certainly help practitioners to better encompass patient perspectives in service delivery and improve patient satisfaction.

PRACTICE IMPLICATIONS

To ensure the validity of patient satisfaction measurement and subsequently improve healthcare quality, practitioners should involve patients in identifying important factors relevant to each attributes of patient satisfaction.

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.

Exploring emergency nurse practitioners' perceptions of their role

Since the 1980s, the emergency nurse practitioner (ENP) role has evolved as increasing socioeconomic pressures and changing government policy have led to new working practices in emergency departments. Similarly, a lack of consensus regarding educational support for ENPs and the regulation of ENP training, mean that variations remain in the scope of practice, role description and academic requirements for ENPs.

AIM

To explore ENPs' perceptions of their changing role, including their educational requirements and whether their training needs are being met.

METHOD

This qualitative phenomenological study examined the views of six ENPs using semi-structured interviews.

FINDINGS

The study identified four themes: inadequate protected time for continuing professional development (CPD); importance of senior medical support in role expansion and CPD; inconsistent educational preparation for expanded roles; and the ENPs' perceived reasons for role expansion. Although all the participants stated that it was challenging to find time for CPD when working in busy clinical environments, this was regarded as less important than the positive effect of senior medical support for advanced roles.

CONCLUSION

Over the past three decades, the ENP role has become well established, which has led to increased confidence, and the development of collaborative ways of working, among ENPs and their colleagues. However, while ENPs have embraced the challenges of their changing role, educational support has not been consistent. There are still disparities in ENPs' scope of practice, expectations of the role between services, and the educational preparation required to undertake the role.

Holistic health care: Patients' experiences of health care provided by an Advanced Practice Nurse

INTRODUCTION

Advanced Practice Nurse (APN) is a fairly new role in the Swedish health care system.

AIM

To describe patients' experiences of health care provided by an APN in primary health care.

METHODS

An inductive, descriptive qualitative approach with qualitative open-ended interviews was chosen to obtain descriptions from 10 participants regarding their experiences of health care provided by an APN. The data were collected during the spring 2012, and a qualitative approach was used for analyze.

RESULTS

The APNs had knowledge and skills to provide safe and secure individual and holistic health care with high quality, and a respectful and flexible approach. The APNs conveyed trust and safety and provided health care that satisfied the patients' needs of accessibility and appropriateness in level of care.

CONCLUSION

The APNs way of providing health care and promoting health seems beneficial in many ways for the patients. The individual and holistic approach that characterizes the health care provided by the APNs is a key aspect in the prevailing change of health care practice. The transfer of care and the increasing number of older adults, often with a variety of complex health problems, call for development of the new role in this context.

The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study

BACKGROUND

Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities.

METHODS

This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.

RESULTS

The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models.

CONCLUSIONS

There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).

Implementing two nurse practitioner models of service at an Australian male prison: A quality assurance study

AIMS AND OBJECTIVES

To examine the quality and safety of nurse practitioner services of two newly implemented nurse practitioner models of care at a correctional facility.

BACKGROUND

Nurse practitioners could help to meet the physical and mental health needs of Australia's growing prison population; however, the nurse practitioner role has not previously been evaluated in this context.

DESIGN

A quality assurance study conducted in an Australian prison where a primary health nurse practitioner and a mental health nurse practitioner were incorporated into an existing primary healthcare service. The study was guided by Donabedian's structure, processes and outcomes framework.

METHODS

Routinely collected information included surveys of staff attitudes to the implementation of the nurse practitioner models (n = 21 staff), consultation records describing clinical processes and time use (n = 289 consultations), and a patient satisfaction survey (n = 29 patients). Data were analysed descriptively and compared to external benchmarks where available.

RESULTS

Over the two-month period, the nurse practitioners provided 289 consultations to 208 prisoners. The presenting problems treated indicated that most referrals were appropriate. A significant proportion of consultations involved medication review and management. Both nurse practitioners spent more than half of their time on individual patient-related care. Overall, multidisciplinary team staff agreed that the nurse practitioner services were necessary, safe, met patient need and reduced treatment delays.

CONCLUSIONS

Findings suggest that the implementation of nurse practitioners into Australian correctional facilities is acceptable and feasible and has the potential to improve prisoners' access to health services. Structural factors (e.g., room availability and limited access to prisoners) may have reduced the efficiency of the nurse practitioners' clinical processes and service implementation.

RELEVANCE TO CLINICAL PRACTICE

Results suggest that nurse practitioner models can be successfully integrated into a prison setting and could provide a nursing career pathway.

Integration of nurse practitioners using a change management framework: the way forward

Objective The aim of the present study was to investigate and describe the application of a change management theoretical framework in relation to nurse practitioner (NP) role integration. Methods A survey formed Phase 1 of a broader mixed-methods study to explore perceptions of the change process involved with integrating NPs into Australian health care settings. The stakeholder participants were NPs, nurse managers and nurse policy advisers. Results Key themes were identified adding information about how NPs, nurse managers and nurse policy advisers perceive the integration of NPs into Australian healthcare. The themes correlate to the components of organisational change management necessary to embed NPs into the healthcare workforce. Conclusions Healthcare reform is a complex organisational change. Alignment of several key elements is required for the process to be successful. A change management proposal for reframing organisations provides an apt framework for use in the Australian context of reforming workforce to integrate NPs into healthcare teams. The theoretical framework proposes that multiple lenses be applied to change processes, to integrate NPs into the workforce and highlights the need for exceptional leadership throughout such endeavours. What is known about the topic? NPs provide safe and efficient care to patients, often in settings where access to health care is limited. NPs have been identified as a key strategic workforce reform initiative to address some of the known healthcare gaps. What does this paper add? This paper adds information about how NPs, nurse managers and nurse policy advisers perceive progress of the integration of NPs into healthcare settings. The findings are contextualised within an organisational change framework and highlight the complexity of healthcare reform. What are the implications for practitioners? The findings provide a novel approach for managing workforce reform and identify the components of change management necessary to embed NPs into the healthcare workforce.

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 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 accuracy of adult limb radiograph interpretation by emergency nurse practitioners: A prospective comparative study

BACKGROUND

One of the extensions to practice for the emergency nurse practitioner role is to appropriately order and interpret radiographs in the emergency department.

OBJECTIVE

The aim of the study was to compare the accuracy in interpreting isolated adult limb radiographs between emergency nurse practitioners and emergency physicians.

DESIGN

A prospective comparative study was undertaken.

SETTING

Emergency department in a large metropolitan hospital.

PARTICIPANTS

200 adult patients with isolated limb injuries were consented.

METHODS

Six emergency nurse practitioners and ten emergency physicians participated. One emergency physician and emergency nurse practitioner independently clinically assessed each patient, determined the need for radiograph and separately recorded their interpretation of the radiograph as either definite fracture, no fracture or possible fracture. A single consultant radiologist reviewed each radiograph and their interpretation was seen as the gold standard. The sensitivity and specificity of emergency physicians and emergency nurse practitioners were calculated. To measure the level of agreement between the two-clinician groups, the weighted Kappa statistic was used.

RESULTS

The sensitivity for the emergency nurse practitioners was 91% and 88% for the emergency physicians. The specificity for the emergency nurse practitioners was 85% and for the emergency physicians 91%. The weighted Kappa on the presence of a fracture between the emergency nurse practitioners and emergency physicians was 0.83.

CONCLUSIONS

This study validates the clinical and diagnostic skills of emergency nurse practitioners assessed in the interpretation of isolated adult limb injury radiographs.

Primary care professionals providing non-urgent care in hospital emergency departments

BACKGROUND

In many countries emergency departments (EDs) are facing an increase in demand for services, long-waits and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. It is not known, however, how this impacts the quality of patient care, the utilisation of hospital resources, or if it is cost-effective. 

OBJECTIVES

To assess the effects of locating primary care professionals in the hospital ED to provide care for patients with non-urgent health problems, compared with care provided by regular Emergency Physicians (EPs),

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialized register; Cochrane Central Register of Controlled Trials (The Cochrane library, 2011, Issue 4), MEDLINE (1950 to March 21 2012); EMBASE (1980 to April 28 2011); CINAHL (1980 to April 28 2011); PsychINFO (1967 to April 28 2011); Sociological Abstracts (1952 to April 28 2011); ASSIA (1987 to April 28 2011); SSSCI (1945 to April 28 2011); HMIC (1979 to April 28 2011), sources of unpublished literature, reference lists of included papers and relevant systematic reviews. We contacted experts in the field for any published or unpublished studies, and hand searched ED conference abstracts from the last three years.

SELECTION CRITERIA

Randomised controlled trials, non-randomised studies, controlled before and after studies and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs to attend to non-urgent patients, as compared to the care provided by regular EPs. 

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the risk of bias for each included study. We contacted authors of included studies to obtain additional data. Dichotomous outcomes are presented as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes are presented as mean differences (MD) with 95% CIs. Pooling was not possible due to heterogeneity.

MAIN RESULTS

Three non randomised controlled studies involving a total of 11 203 patients, 16 General Practioners (GPs), and 52 EPs, were included. These studies evaluated the effects of introducing GPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The quality of evidence for all outcomes in this review was low, primarily due to the non-randomised design of included studies.The outcomes investigated were similar across studies; however there was high heterogeneity (I(2)>86%). Differences across studies included the triage system used, the level of expertise and experience of the medical practitioners and type of hospital (urban teaching, suburban community hospital).Two of the included studies report that GPs used significantly fewer healthcare resources than EPs, with fewer blood tests (RR 0.22; 95%CI: 0.14 to 0.33; N=4641; RR 0.35; 95%CI 0.29 to 0.42; N=4684), x-rays (RR 0.47; 95% CI 0.41 to 0.54; N=4641; RR 0.77 95% CI 0.72 to 0.83; N=4684), admissions to hospital (RR 0.33; 95% CI 0.19 to 0.58; N=4641; RR 0.45; 95% CI 0.36 to 0.56; N=4684) and referrals to specialists (RR 0.50; 95% CI 0.39 to 0.63; N=4641; RR 0.66; 95% CI 0.60 to 0.73; N=4684). One of the two studies reported no statistically significant difference in the number of prescriptions made by GPs compared with EPs, (RR 0.95 95% CI 0.88 to 1.03; N=4641), while the other showed that GPs prescribed significantly more medications than EPs (RR 1.45 95% CI 1.35 to 1.56; N=4684). The results from these two studies showed marginal cost savings from introducing GPs in hospital EDs.The third study (N=1878) failed to identify a significant difference in the number of blood tests ordered (RR 0.96; 95% CI 0.76 to 1.2), x-rays (RR 1.07; 95%CI 0.99 to 1.15), or admissions to hospital (RR 1.11; 95% CI 0.70 to 1.76), but reported a significantly greater number of referrals to specialists (RR 1.21; 95% CI 1.09 to 1.33) and prescriptions (RR 1.12; 95% CI 1.01 to 1.23) made by GPs as compared with EPs.No data were reported on patient wait-times, length of hospital stay, or patient outcomes, including adverse effects or mortality.

AUTHORS' CONCLUSIONS

Overall, the evidence from the three included studies is weak, as results are disparate and neither safety nor patient outcomes have been examined. There is insufficient evidence upon which to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs versus EPs in the ED to mitigate problems of overcrowding, wait-times and patient flow.

Practical Insights on Expanding Nurse Practitioner’s Role During and Post Hospitalization in U.S. Health Care

Aim: The purpose of this study is to investigate expanding the role of nurses in the current U.S. health care system from the standpoint of nurse–patient interactions and nursing interventions to improve patient care and reduce overall health care costs. Background: Many failures in nurse–patient interactions in the hospital and in postrelease setting can be eliminated with different forms of patient-centered care that include patient education, support, and counseling. Method: This study makes use of extensive review of literature from academic databases to analyze increased Nurse Practitioner (NP) role in nurse–patient interactions during patients’ in-hospital experience and postrelease environment. Conclusions: Expanding the role of nurses would improve the overall health care system in the United States and save money over the long run. Long-term follow-up with patients would promote a healthier lifestyle and reduce the likelihood of return to the hospital. NPs are uniquely positioned to potentially serve as change agents within health care systems. Implications: Nursing educators and managers will need to work closely with policy makers to implement the expanded role of nurses to improve the U.S. health care system.

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.