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.     

Pushing boundaries in paediatric intensive care: training as a paediatric retrieval nurse practitioner

Traditionally in the UK, the transportation of the critically ill child to a paediatric intensive care unit has been carried out by a medically led team of doctors and nurses. However, in countries such as the USA and Canada, appropriately trained nurse practitioners have proven to be competent in the transportation of these vulnerable children. This nurse-led team model has also been shown to be successful in the speciality of neonatal care in the UK. The impact of changes in the National Health Service (NHS) has led to an increased demand for the transportation of the child requiring paediatric intensive or high-dependency care, the lifting of restrictions on nursing practice and the reduction of doctors' hours in keeping with the European Working Time Directive. This has led to one NHS Trust in the UK developing the role of paediatric retrieval nurse practitioners (RNP): nurses who lead the retrieval team. The purpose of this article is to describe a pilot initiative to develop the role of RNPs. The comprehensive process of recruitment, training and assessment of competency will be detailed. Personal reflection on the project will also explore the pertinent nursing issues around; role impact and definition, conflict and change management, communication, legislation and personal and professional growth. Recommendations for future initiatives will also be explored.     

The health styles of nurse practitioners

PURPOSE: To examine the formal and informal health care beliefs, behaviors, and practices of nurse practitioners (NPs). DATA SOURCES: A self-administered questionnaire with a primarily closed-ended format was distributed over a 3-day period to a convenience sample of 321 NPs attending a national NP conference. CONCLUSIONS: The overall health status and health practices of NPs were found to be fairly good, but there was room for improvement, particularly with regard to nutrition, health responsibility, physical activity, and stress management. IMPLICATIONS FOR PRACTICE: Respondents were more likely to self-diagnose and self-treat minor illnesses and largely received their primary health care from physicians. The majority of NPs indicated a willingness to receive health care from an NP; however, the nonavailability of NPs restricted this option.     

The role of nurse practitioners in hospital settings: implications for interprofessional practice

Expansion of the nurse practitioner (NP) role worldwide indicates a need to understand how the role functions in interprofessional healthcare teams. Through the adoption of a mixed methods approach that gathered on-site tracking and observation, self-recorded logs of consultations and focus group interviews of team members and NPs, we describe the extent of role activity and the nature of interprofessional practices of 46 NPs and their team members in nine hospital sites across the province of Ontario, Canada. Findings outline the nature of the NP role activities, which largely focused on providing clinical care, with the support of their team, to a range of patients across the study settings. We discuss how ‘embedding’ the NP in this way appears to contribute to utilization of expertise of all professions as well as enabling team members to promote evidence-based practices. We argue that the use of NPs augments interprofessional role utilization through their desire to consult with a range of professionals and the capacity to perform holistic care for patients that is not limited to traditional nursing boundaries.     

An integrated chronic disease nurse practitioner clinic: Service model description and patient profile

BackgroundOne common cluster of chronic conditions — chronic kidney disease, diabetes mellitus and heart failure — places a significant burden on the Australian healthcare system. In combination, these conditions complicate treatment, increase rates of hospitalisation and carry a poorer prognosis for survival. Current health services are organised around single conditions, making coordination of care more difficult and adding complexity to patients’ lives.AimsTo describe an integrated model of care provided by nurse practitioners for patients with multiple chronic diseases.MethodsA prospective, longitudinal study of patients with two or three chronic diseases attending a community-based nurse practitioner clinic. On entry to the clinic demographic and clinical data were collected from patients and health records (n = 121). At six months a subgroup (n = 70) also reported their satisfaction with the clinic.FindingsOver 18 months the clinic provided 925 appointments to patients aged between 27–90 years. Most (79.2%) had chronic kidney disease as one of their diagnoses. At baseline, blood pressure and glycosylated haemoglobin targets were achieved by 66.4% and 83.2% respectively, although only 7.1% had a healthy-range body mass index. After six months of attendance, there was high overall patient satisfaction with the new service (98.7%).DiscussionNurse practitioners can reform healthcare delivery through innovative person-centred models of care, breaking down the siloes of treatment for chronic disease.ConclusionIn the current and growing context of multi-morbid chronic health conditions, integration of care within and across organisations is required to meet future health care demands.     

A comparison in independent nurse prescribing and patient group directions by nurse practitioners in the emergency department: A cross sectional review

AimTo explore nurse prescribing in an emergency department using patient group directions versus independent nurse prescribing.BackgroundPatient group directions allow restricted access to medication in unselected patients using pre-set criteria. Independent nurse prescribing is a flexible method of medication provision. Limited data exists on the application of either method in clinical practice.MethodsExploration of patient group directions and independent nurse prescribing application in an emergency department using 617 nurse practitioners’ clinical notes; 235 and 382 respectively. Patient attendances from 01/07/2009 to 30/06/2010 were randomly sampled. Prescribing frequency; range of medications and diagnoses; independent episode completion and prescribing safety was explored.ResultsStatistical difference exists in prescribing frequency between the independent nurse prescribers (51.6%, n = 197) and patient group directions (32.3%, n = 76). Appropriate medication given by 99.7% (n = 381) of independent nurse prescribers, with 1 contraindicated drug provided. The limitations of patient group directions was highlighted in 11.8% (n = 9) of cases, however all drugs given were appropriate for the diagnosis. No statistical difference in independent episode completion.ConclusionsNurses provide appropriate medication in an emergency department. Patients being managed by nurse prescribers were more likely to receive medication. Further investigation is required to justify this.     

A narrative review of the training structure,role, and safety profile of advanced critical care practitioners in adult intensive services in the United Kingdom

ObjectiveAdvanced clinical practitioners are a growing part of the National Health Service workforce in the United Kingdom (UK). The concept stems from the progression of skills, knowledge, and experience of healthcare professionals (including nursing, physiotherapists, paramedics, and pharmacists) to a higher level of practice. The addition of advanced critical care practitioners (ACCPs) to the multidisciplinary team of the UK adult critical care is recent; they form part of the fabric of the advanced clinical practitioner workforce. This is a narrative review of the role of ACCPs, considering the evolution of the role, training, accreditation, and evidence supporting the safety profile in adult intensive care in the UK.MethodThis is a narrative review.ConclusionACCPs have evolved from an ad hoc and local training structure, to a UK-wide competency standard and training developed within the Faculty of Intensive Care Medicine. This formed in concert with the advanced clinical practitioner concept. As advanced practice is very much multiprofessional in the UK, a single regulator for multiple base professions is likely neither feasible nor realistic. Over the last 5 years, the UK picture of advanced practice has slowly standardised; an ACCP securely fits under the advanced clinical practitioner umbrella. The ACCP workforce has moved from a handful of early adopters, regional hubs, to a position across most critical care units now have or are developing a team of practitioners. The evidence base for the safety profile of ACCPs is evolving and shows parity in outcomes in the areas currently investigated. The ACCP role provides a vision of a multiprofessional workforce for the future of staffing of critical care services that is diverse and inclusive, not with the intention of competing with our medical colleagues.     

Realist evaluation of privately practising nurse practitioners in Australia: Development and refinement of theories

Background

Nurse practitioners (NPs) have been practising in Australia since 2001, predominantly in the public sector. To facilitate the expansion of NPs working in community and primary health care settings, legislative changes in 2010 led to privately practising NPs (PPNPs) being eligible to provide care subsidised through the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). To date, there has been little evaluation of PPNP services in Australia. Reported in this paper is the process through which national survey data enabled the refinement and development of theories on PPNP services in Australia.

Spiritual care practices of nurse practitioners in federally designated nonmetropolitan areas of North Carolina

PURPOSE: The purpose of this study was to explore if and then how nurse practitioners (NPs) living in federally designated nonmetropolitan areas of North Carolina integrated spiritual care into their practices. Participants identified the frequency in which they utilize spiritual care practices, specific spiritual interventions, and their definitions of spiritual care. DATA SOURCES: A sample of 101 NPs was chosen through systematic sampling from 507 eligible NPs. Each participant was mailed a demographic data sheet and the Nurse Practitioner Spiritual Care Perspective Survey (NPSCPS). The NPSCPS was modified from the Oncology Nurse Spiritual Care Perspective Scale developed by Taylor and colleagues. Of the 101 mailings, 65 were returned and included in the analysis. CONCLUSIONS: Although most of the NPs in this study felt that spiritual care was an important part of nursing practice, 73% did not routinely provide spiritual care to their patients. Barriers and limitations to the provision of spiritual care must be explored. IMPLICATIONS FOR PRACTICE: As providers of holistic care, NPs should be proficient and comfortable in providing spiritual care to their patients. Educational programs should provide NPs and NP students with knowledge and skills to provide spiritual care.     

Extending the nursing role in Emergency Departments: Challenges for Australia

As nursing has developed as a profession there has been a continual evolution of the scope of practice in which nurses work. Emergency nursing practice is an example where recently there has been a rapid expansion in the nature and scope of practice. This change in practice has largely resulted from increasing public demand on emergency departments, medical and nursing shortages and governmental pressure to reduced emergency department waiting times and patient length of stay.There have been a number of models worldwide in which the expansion of the Emergency Nurses role has occurred. Recently in New South Wales the Clinical Initiative Nurse role has been developed as an advanced practice role with the objective of initiating treatment based on advanced clinical assessment and to assist emergency departments to meet benchmarks and key performance indicators (KPIs). The scope of practice of this new role did not extend to that of a Nurse Practitioner who is able to discharge patients, prescribe medication and provide medical referral.The variation in advance practice nursing roles in Australia and worldwide has contributed to confusion and uncertainty. The aim of this paper is to explore the various advanced practice roles that may be encountered in emergency nursing practice and examine some of the advantages and limitations to the implementation of these roles.     

Educational strategies to enhance placement and retention of nurse practitioners in rural Arkansas

PURPOSE: To examine the factors and incentives enhancing nurse practitioners' (NPs') long-term employment in rural areas. DATA SOURCE: The participants were 121 master's prepared or higher educated NPs located in rural Arkansas. A survey about role preparation and employment factors was mailed to the participants. CONCLUSIONS: We found that 10% of all respondents were not currently employed in the role of an NP. The majority of rural-employed NPs had didactic content focusing on rural-practice opportunities and engaged in rural practicums while in graduate school. Rural NPs were much more likely to have graduated from research-intensive universities. Nearly 90% of NPs reported they were somewhat to very well prepared for practice in rural Arkansas. IMPLICATIONS FOR EDUCATION: The shortage of health care providers remains one of the most irresolvable problems in the U.S. health care delivery system. Compounding the shortage is the unequal distribution of health care practitioners in rural areas. Evidence indicates that NP students engaged in rural clinical practicums were more likely to practice in rural areas. In light of this information, nurse educators should expand the NP educational process beyond rurally located practicums to deliver the entire educational process to the NP students' rural homes.     

Emergency department image interpretation accuracy: The influence of immediate reporting by radiology

IntroductionThe misinterpretation of radiographs is recognised as a key source of emergency department (ED) errors, regardless of clinician profession. This article compares ENP and medical staff accuracy in the interpretation of musculoskeletal trauma X-rays between immediate and delayed radiology reporting pathways.MethodThe data for this study was drawn from a larger pragmatic randomized controlled trial of immediate reporting. Patients were recruited and randomly assigned to immediate or delayed reporting arms and treated according to group assignment. Image interpretive accuracy between ED staff groups and arms was undertaken together with an assessment of the influence of immediate reporting on patient pathways and journey times.ResultsSix hundred and seventy-four radiographic examinations were performed (598 patients). There was a significant reduction in the interpretive errors in the immediate reporting arm for all ED clinicians (proportional difference = 4.2%; 95% CI [0.017, 0.068]; p = 0.001), but no significant difference in proportion of interpretive errors was evident between ENPs and medical staff. Patient journey times, discharge and referral rates were not significantly different between study arms, although admission rates varied for medical staff collectively.ConclusionENP X-ray interpretation accuracy is comparable with that of medical staff, but immediate reporting was seen to reduce errors without increasing patient journey times.