Factors influencing the decision to use nurse practitioners in the emergency department.

INTRODUCTION: Emergency department overcrowding is a serious problem nationwide. Of an estimated 14 million visits to hospital emergency departments, only 12.9% are considered emergent. Many emergency departments, however, employ only physicians despite the fact that nurse practitioners have a proven record of providing high quality, cost-effective care in the emergency department. The purpose of the study was to determine factors that influence the decision to use nurse practitioners in the emergency department. METHODS: Interviews were conducted with ED managers in hospitals that both employ and do not employ nurse practitioners in the emergency department. RESULTS: In this study, the primary reason that nurse practitioners were not employed by emergency departments was that physician groups with whom the hospitals contract refuse to use nurse practitioners. Emergency department managers of facilities with nurse practitioners reported high levels of satisfaction with the nurse practitioners performance. The 2 ED managers without nurse practitioners in their facility were highly supportive of having nurse practitioners in the emergency department and have advocated for hiring nurse practitioners. DISCUSSION: Education needs to occur with emergency departments regarding the value of the nurse practitioner's role to the facility. Research is needed to investigate why emergency department physician groups resist hiring nurse practitioners. Increased staffing with nurse practitioners in the emergency department can serve to reduce overcrowding, reduce waiting times, and increase patient satisfaction.     

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.     

Family physician/nurse practitioner: stories of collaboration

AIMS: This paper presents the experiences of nurse practitioners and family physicians working in collaborative practice at four Canadian rural primary care agencies. It focuses on the qualitative segment of a larger study examining the impact of an educational intervention on interprofessional practice. BACKGROUND: Growing awareness of the importance of health promotion and disease prevention, the increased complexity of community-based care, and the need to use scarce human healthcare resources, especially family physicians, far more efficiently and effectively, have resulted in increased emphasis on primary healthcare renewal in Canada. Key to primary healthcare renewal is care delivery through interdisciplinary teams that include nurse practitioners. METHODS: Narrative analysis, a form of interpretive analysis that respects the integrity of the stories told by participants, was chosen as the strategy to examine the narrative data gathered in two sets of interviews with the nurse practitioners and family physicians. The study was undertaken during 2000. RESULTS: Thirteen family physicians and five nurse practitioners with diverse educational backgrounds and varied experience with collaboration participated in the qualitative component of the study. A number of issues related to working in a shared practice were identified in nurse practitioner and family physician interviews across the research sites. The themes identified in participants' stories included issues related to the scope of practice, emphasizing the importance of role clarity and trust, the ideological difference regarding disease prevention and health promotion, differences in perceptions about the operation of collaborative practice, and the understanding that collaborative relationships evolve. CONCLUSIONS: The placement of nurse practitioners and family physicians in a common clinical practice without some form of orientation process does not produce collaborative practice. Educational strategies related to role expectations are necessary to facilitate the development of care delivery partnerships characterized by interdependent practice.     

Emergency Contraception Provision: A Survey of Emergency Department Practitioners

OBJECTIVES: To determine emergency department (ED) practitioner willingness to offer emergency contraception (EC) following sexual assault and consensual sex, and to compare responses of practitioners from states whose laws permit the refusal, discussion, counseling, and referral of patients for abortions (often called "opt-out" or "abortion-related conscience clauses") with those of practitioners from states without these laws. METHODS: Using a structured questionnaire, a convenience sample of ED practitioners attending a national emergency medicine meeting was surveyed. RESULTS: The 600 respondents were: 71% male, 29% female; 34% academic, 26% community, and 33% resident physicians; and 7% nurse practitioners and physician assistants. Many respondents (88%) were inclined to offer EC to those sexually assaulted by unknown assailants. More practitioners said they were willing to offer EC if the assailant was known to be HIV-infected rather than if the assailant had low HIV risk factors (90% vs. 79%, p < 0.01). More respondents would prescribe EC after sexual assault than consensual sex (88% vs. 73%, p < 0.01). The rates of willingness to offer EC were the same for practitioners in states with "abortion-related conscience clauses" and those from other states. CONCLUSIONS: Most ED practitioners said they were willing to offer EC. Although the risk of pregnancy exists after consensual sex, practitioners were less willing to prescribe EC after those exposures than for sexual assault. "Abortion-related conscience clauses" did not seem to influence willingness to offer EC.     

Supporting Emergency Care Delivery Through Updated Emergency Nurse Practitioner Competencies

As multidisciplinary emergency care becomes increasingly complex, all team members must be aware of their respective roles and responsibilities. In the emergency department, nurse practitioners are integral members of the team. They possess a wide range of clinical and leadership competencies that allow them to perform specific and differentiated tasks within the emergency department. A well-defined competency not only contributes to the promotion of a positive work culture but also clarifies performance expectations, identifies skill gaps, and supports team development. Furthermore, it allows the nurse practitioner to adapt to changing conditions while maintaining patient safety. The competencies of emergency nurse practitioners have evolved over the past 2 decades. The authors discuss the importance of establishing clear expectations for emergency nurse practitioner practice in this article and the alignment of competencies with organizational culture and objectives.     

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

AIM: This paper reports a study to determine the attitudes of nurses, doctors and general medical practitioners towards the development of an advanced nurse practitioner service within an emergency department. BACKGROUND: The role of advanced nurse practitioner in emergency care has emerged in a number of countries, and has brought with it confusion about titles, role boundaries, clinical accountability and educational requirements. Initially, the role resulted from a need for healthcare professionals to provide a service to the increased numbers of patients presenting to hospital with less urgent problems. Since then, the service has evolved to one where nurse practitioners provide high-quality and cost-effective care to persons who seek help for non-urgent, urgent or emergent conditions in a variety of emergency care settings. However, little research could be identified on the attitudes of relevant nursing and medical staff towards the development of this role. METHODS: A questionnaire survey was carried out, and a 29-item Likert rating scale was developed to measure attitudes. Along with some demographic variables, two open-ended questions were added to allow respondents to elaborate on what they perceived as benefits and difficulties associated with an advanced nurse practitioner service. All general practitioners, emergency nurses and emergency doctors in one health board in the Republic of Ireland were targeted, and 25 emergency nurses, 13 emergency doctors and 69 general practitioners were approached to take part. Data were collected in February 2004. FINDINGS: An overall response rate of 74.8% was achieved. All respondents were positive towards the development of an advanced nurse practitioner service, with general practitioners being less positive. The principal differences appeared between general practitioners and hospital emergency care staff. CONCLUSION: There is a need for a multidisciplinary approach to the planning of advanced nurse practitioner services. To achieve multiprofessional acceptance, an accredited and standardized education programme is required, and this must address existing role boundaries.     

Emergency nurse practitioners’ perceptions of their role and scope of practice: Is it advanced practice?

There are multiple interpretations of the nurse practitioner role which appear to be shaped by discourses within and outside the profession and its regulatory body. This study aimed to explore and clarify the role and scope of practice of emergency nurse practitioners in a region in the United Kingdom and determine if they fulfil the proposed criteria for Advanced Nurse Practitioners. A survey approach using questionnaires (n = 42) was adopted. The sample included all emergency nurse practitioners working in Accident and Emergency Departments and Minor Injury Units in the region. Statistical data was analysed using SPSS for Windows and qualitative data was content analysed for themes. Results revealed a variation in education. Investigation of role typology and scope of practice revealed a relatively homogenous group where the clinical aspect of the role dominated. The scope of practice was perceived to be influenced by internal factors such as competence; however protocol use, referral rights and prescribing authority could be considered ways that nursing management and medical staff indirectly control the role. Findings suggested that emergency nurse practitioners were working at a level significantly beyond registration, yet do not fulfil the Nursing and Midwifery Council proposed criteria for Advanced Nurse Practitioner.     

Gender and the attribution of the nurse practitioner and physician status

The purpose of this study was to discover whether sex-role sterotypes were used to identify members of two professions, nurse practitioners and physicians. Participants reported whether they believed a videotaped health care provider was a physician or a nurse practitioner. Results showed that male providers tended to be identified as physicians, whereas female providers tended to be identified as nurse practitioners. Findings indicate that understanding and enactment of the nurse practitioner and physician roles are still affected by gender issues and that both physicians and nurse practitioners remain subject to the force of sex-role stereotypes.     

Documentation of Health Risks and Health Promotion Counseling by Emergency Department Nurse Practitioners and Physicians

Purpose: The purpose of this study was to examine medical record documentation of health risk factors and health promotion discharge counseling by nurse practitioners and physicians practicing in an emergency department in the U.S. midwest.
Methods: In this two-group comparative study researchers examined random-stratified medical records 305 nonacute ambulatory patients for selected health risk factors, including smoking, alcohol use, elevated blood pressure, obesity, and dental caries.
Results: Fifty-nine percent of this sample of relatively young adults (mean age = 33) had one or more health-risk factors. According to medical record documentation, only 22% of these adults, with nonacute problems, received health promotion counseling. Multivariate analyses indicated that nurse practitioners were slightly more likely to provide smoking cessation counseling than were physicians.
Conclusions: Many opportunities for identification of health risks and follow-up counseling, as recommended in Healthy People 2000 and by the U.S. Preventive Services Task Force, were not documented. To meet the new goals of Healthy People 2010, health care providers in all settings should identify health risk factors and document health promotion counseling during every patient encounter.     

Who is a nurse practitioner? Processes of care and patients' and physicians' perceptions.

During a repeat of a previous study of nurse practitioners conducted at the University of Kansas, an opportunity occurred to examine the impact of two different styles of care provided by nurse practitioners on patients and physicians with whom they worked. The two nurse practitioners involved had similar backgrounds in terms of work experience. The participated in the same training program for nurse practitioners, practice in the same environment, and cared for patients randomly allocated to one or the other practitioner. One practitioner saw her patients more often and for longer periods of time, ordered more medications, and less often sought physician consultation. She also was most optimistic regarding the impact of her services on patients' conditions. The other was more dependent upon physicians for validation of her actions. Physicians did not distinguish between the two practitioners in terms of their performance. However, patients cared for by the practitioner whose behavior suggested an integration of medical and nursing care processes saw nurses as a more common source of information about illness and demonstrated more significant shifts in preferences for services provided by nurses rather than physicians. No significant changes were noted from pretest values among patients cared for by the other nurse practitioner.     

Two explanations of nurse practitioner interactions and participatory decision making with physicians

The purpose of this study was to test a theoretical model that integrated two explanations of nurse practitioner interaction and participatory decision making with physicians. The two explanations were derived from technology theory and social exchange theory. Nurse practitioners (N = 38) responded to a four-scale magnitude estimation instrument measuring each of four concepts in the model: complexity, expected benefit-cost ratio of interaction, interaction, and participatory decision making. Predictions derived from both theories were supported. Nurse practitioner decisions about interaction with physicians were influenced by the dynamics of social exchange with physicians, as well as the technological requirements of primary care. The findings offer nurse practitioners new strategies for managing professional exchanges on behalf of their patients.     

Collaborative practice: a critical theory perspective

The purpose of this critical theory study was to investigate the observed failure of nurses and physicians to collaborate, and the underlying meaning behind this failure. Using a phenomenological and participatory approach, 18 family nurse practitioners and physicians in joint practice were interviewed separately and together about their practice relationships. Transcribed interviews and data summaries were returned to the participants for review and validation. Emergent themes were analyzed using the critical theory of Jürgen Habermas. Results demonstrated that distorted communication and nonmeaningful interactions were promoted by both nurses and physicians. Elements identified as contributing to more successful collaborative practices included a willingness to move beyond basic information exchange in nurse/physician interactions, the willingness and ability to challenge distortions and assumptions in the relationship, and a belief system based on critical self-reflection.     

Nominations for Excellence: Collegial Advocacy for Nurse Practitioners

This study examined physician nomination data submitted for Syntex Nurse Practitioner of the Year Awards for 1988, 1989, and 1990. The physicians identified nurse practitioner contributions to patient care, community service/outreach, and education and research. A content analysis of the text data yielded themes within four major domains that described outstanding nurse practitioners in mutual practice relationships with physicians. The domains were clinical expertise, holistic caring, patient-centered activism, and leadership. The findings in this study indicated that physicians value the contributions of nurse practitioners that enhance the quality and scope of health care for patients within a mutual practice.     

Emergency endotracheal intubation by respiratory care personnel in a community hospital.

We designed and implemented a program to train respiratory therapy personnel to perform emergency endotracheal intubation in a community hospital. During a one-year study period, 143 emergency intubations were attempted by physicians, nurse anesthetists, and respiratory therapy personnel. Respiratory therapy personnel attempted 74 intubations, with 13 complications, for a complication rate per attempt of 18%. Physicians and nurse anesthetists attempted 69 intubations, with 39 complications, for a complication rate of 57%. We conclude that trained respiratory care personnel can safely and effectively secure an airway via endotracheal intubation under emergency circumstances in our institution.