A review of the Transitional Emergency Nurse Practitioner

Introduction

A retrospective exploratory study was conducted to (i) explore the practice patterns of a Transitional Emergency Nurse Practitioner (TENP) working across two urban Emergency Departments (ED); (ii) identify the demographic characteristics of the TENP patient cohort; and (iii) identify if TENP patients were appropriately and timely managed.

Method

The study was conducted across two hospital sites over two consecutive years for a 3-month period. Data collection occurred during the months of December through to February. TENP patients were identified by hospital electronic medical record and were then grouped into a model that included ‘Fast Track’ or ‘See and Treat’ cohort. The cohorts were then analysed for diagnostic groups, age, sex, length of stay, triage category, and re-presentations.

Results

The TENP worked a total of 600 h (Site 1 252 h; Site 2 348 h) across the study period. The TENP managed a total of 481 patients (262 Site 1; 220 Site 2) during the study period. The majority of patients (412; 84%) were managed in the ‘See and Treat’ cohort (Site 1 246, 94%; Site 2 166, 75%) and 70 patients (16%) were managed in the ‘Fast Track’ cohort (Site 1 16, 4%; Site 2 54, 25%). The median length of stay for TENP managed patients was 143 min, with 96% of patients leaving the ED in less than 8 h. There were no TENP unplanned re-presentations at either site. The TENP managed more male patients across both sites. The majority (75%) of patients the TENP managed had musculoskeletal and/or wound conditions or injuries.

Conclusion

TENP practice across the two Sydney metropolitan ED sites was similar. The model adapted for Tertiary Referral centres was appropriate for smaller urban EDs. The study supports existing evidence of timely and appropriate care being delivered by TENPs across Australian EDs. Given the work practice similarities, the study demonstrates that State and/or National standards and policies could be developed for emergency advanced practice roles.     

Point of care ultrasound use by Registered Nurses and Nurse Practitioners in clinical practice: An integrative review

BackgroundNurses and nurse practitioners (NPs) are utilising point of care ultrasound (PoCUS) in practice. PoCUS is a useful tool to enhance clinical assessments and improve patient care. There have been no published literature reviews on this topic.AimsThe objective of this review is to examine the literature on PoCUS and draw conclusions to determine the implications of the use of PoCUS by registered nurses and nurse practitioners to inform nursing practice.DesignIntegrative review.MethodsData bases MEDLINE, EMBASE, CINAHL and Google scholar were searched for relevant articles between 2008 and 2018. The inclusion criteria were registered nurses and nurse practitioners using PoCUS in their clinical practice. Articles retrieved were in English and with full text. Articles were assessed for quality using TREND and a PRISMA flowchart is presented.FindingsSix eligible articles were examined identifying major findings of education in PoCUS, accuracy and mastery of a skill and clinical influence.DiscussionAn evaluation of the use of PoCUS by registered nurses and nurse practitioners provides evidence of its efficacy and potential to improve patient care and inform nursing practice.ConclusionSome registered nurses and nurse practitioners are expanding their scope of practice to include PoCUS to improve patient care. PoCUS requires investment in time and education.     

An ABC approach to assessing the risk of violence at triage

There is evidence to suggest that the incidence of violent behaviour in the emergency department by patients toward staff is on the rise. As part of the process of determining urgency, triage nurses must assess the risk of violence at point of entry. The risk of violence, that is, behaviour that either involves a threat of physical or psychological harm to one's self or to others, is considered a critical predictor of urgency in mental health triage. A rapid violence risk assessment strategy will be described which can be utilised in emergency department triage.     

Acupuncture for major depressive disorder: A review of the recommendations stated at clinical practice guidelines

BackgroundThe use of acupuncture to treat depression is not uncommon. However, recommendations regarding acupuncture issued by clinical practice guidelines (CPG) vary widely.ObjectiveTo describe the recommendations regarding acupuncture in CPGs for depression in adults, and to assess the methodology used to reach them.MethodsWe conducted a scoping review of CPGs for depression management in adults, which performed systematic reviews (SRs) to answer their review questions, were published between January 2014 and May 2018, and assessed the use of acupuncture as a review question. We limited out search to articles published in English/Spanish. We assessed the SRs quality using the “A MeaSurement Tool to Assess Systematic Reviews-2” (AMSTAR-2), and described how the recommendation regarding acupuncture was reached.FindingsWe found five CPGs that fulfilled our inclusion criteria: three from the US, one from Canada, and one from China. Four CPGs fulfilled between two and three items of AMSTAR-2, and one CPG fulfilled seven items. The methodology used to formulate the recommendations varied between CPGs. Regarding acupuncture use recommendations: three CPGs did not issue any recommendation (although one mentions that it should not be used), whilst two were in favor.DiscussionsThe lack of a clearly stated review question presented in the majority of CPGs prevents the reader from understanding what the CPG developing group was trying to answer. Moreover, the arguments presented to support a decision are usually not detailed enough. Therefore, the assessment of the recommendations was extremely difficult.Clinical implicationsGiven that the formulation of recommendations is not always reliable, clinicians should carefully read and assess the recommendations presented in CPGs before implementing them.     

Experiences of Master's Prepared Clinical Nurse Leaders at Three Years Post-Graduation

Direct Entry Master of Science in Nursing programs that incorporate Clinical Nurse Leader (CNL) education are relatively new in the United States. Little is known about the transition to practice experience of Master's prepared CNL graduates. This evaluation explored how Direct Entry Master of Science in Nursing CNL graduates perceived their transition to practice experience three years post-graduation. All graduates (n?=?21) of an inaugural Direct Entry CNL program were invited to be interviewed 3?years after graduation; 16 (76%) opted to participate. Major findings from the semi-structured interviews included educational satisfaction, challenges in transition to practice, uneven use of CNL education, and anxiety about student debt. Satisfaction with their education and their early application of leadership skills were overshadowed by their frustrations with student debt and the preponderance of bullying experienced in the workplace.     

British Association of Urological Surgeons' suprapubic catheter practice guidelines

The insertion of a suprapubic catheter is an increasingly common urological procedure. However the procedure, whilst beneficial for the patient, is not without significant risk, a situation that is exacerbated by the lack of consensus and practice guidelines. This article is an abridged version of the British Association of Urological Surgeons Suprapubic catheter best practice guidelines published by Harrison et al. in 2011.     

Are specialist nurse‐led check flexible cystoscopy services as effective as doctor‐led sessions?

The demands on service provision have led to an increasing number of check flexible cystoscopies being performed by urology nurse specialists as opposed to doctors. We aimed to compare the performance of urology nurse specialists, in a nurse‐led service, with doctor‐led sessions. Retrospective case note analysis was performed on patients who required further treatment following their check flexible cystoscopies. Data was collected in two separate 3‐month time periods: first (1 October 2012–31 December 2012) all cases that were performed by doctors, second (1 March 2013–31 September 2013) all cases that were performed by nurse specialists. Details recorded included the findings at check flexible cystoscopy, treatment and initial and subsequent histology results. A total of 137 episodes were included in the study (71 – nurse, 66 – doctor). Correct reporting at initial check cystoscopy with subsequent confirmation of TCC, CIS or dysplasia occurred in 99 of 137 (72.3%) of episodes (55 – nurse, 44 – doctor). Over reporting at initial check flexible cystoscopy with findings later showing any variant of inflammation/cystitis, reactive changes, atypia or no lesion occurred in 38 of 137 (27.7%) episodes (16 – nurse, 22 – doctor). The nurse‐led service correctly reported 55 of 71 (77.5%) episodes and over‐reported 16 of 71 (22.5%). The doctors correctly reported 44 of 66 (66.7%) episodes and over reported 22 of 66 (33.3%). This study provides evidence that nurse led check flexible cystoscopy sessions are comparable in quality to doctor‐led sessions and supports the use of these services. This has clear implications on the delivery of a cost effective service to meet current financial demands.     

The accuracy of paediatric limb radiograph interpretation by nurse practitioners in a single centre

BackgroundNurse practitioners (NP) are an integral part of the urgent and emergency care workforce in the United Kingdom providing safe and effective care. Despite this, there is limited research assessing the ability of NPs to correctly interpret isolated paediatric limb injury radiographs in the urgent and emergency care environment.AimThe aim of this study was to compare the accuracy in interpreting isolated paediatric limb radiographs between NPs and consultant radiologists.SettingA nurse-led urgent care centre (UCC) in central London, United Kingdom.Participants296 paediatric patients with isolated limb injuries who had a radiograph requested and interpreted by an NP.MethodsThirteen NPs (adult registered) with various backgrounds and qualifications participated in this prospective, single-centre healthcare analysis. Review of all clinical presentations at the UCC over a 3-month period (September–November 2017) identified 296 paediatric patients (aged 2–15) who received a peripheral limb radiograph. Clinical records for each patient were analysed to document demographics, mechanism of injury, NP examination findings, radiographic interpretation and formal radiologist report. NP interpretation of each radiograph was classified as definite fracture, possible fracture or no fracture. This was compared to the final radiologist report (considered the gold standard) to calculate the sensitivity and specificity of NP radiograph interpretation.ResultsNPs reported a total of 94 radiographs (32%) as definite fracture, 176 (59%) as no fracture and 26 (9%) as possible fracture, as compared to radiologists at 71 (24%), 218 (74%) and 7 (2%). A total of 242 (82%) of radiographs were correctly identified by NPs, while 54 (18%) were incorrectly interpreted. The sensitivity of the NP limb radiographic interpretation was 92%, with a specificity of 78%.ConclusionsThe findings validate the clinical and diagnostic skills of NPs in the interpretation of isolated paediatric limb radiographs.     

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.     

A service evaluation describing a nurse‐led prostate cancer service in NHS,Ayrshire and Arran

From 1999, the NHS Ayrshire and Arran Health Board implemented an innovative nurse‐led collaborative care model for the management of patients with prostate cancer (PC). This article describes the model and presents the results of a local evaluation to assess its impact. The evaluation comprised a retrospective audit of the service against national standards for PC management, undertaken in 2012. Seventy‐one patients, who were under the care of the service during June 2008, were included. Patient and staff satisfaction were also assessed using questionnaires distributed to 75 patients undergoing outpatient or telephone reviews during April 2012 and 7 one‐to‐one semi‐structured staff interviews. The patient audit showed good compliance with standards relating to selection of appropriate PC treatments according to tumour stage and grade; radiotherapy dosing and referral‐to‐treatment times. Areas requiring improvement were the documentation of patients' risk and performance status and provision of verbal and written information to patients and carers. Seventy‐three per cent of the patient questionnaires were returned, with 96% of respondents rating their overall care as ‘excellent’ or ‘very good’. Staff satisfaction was also high and interviewees described many benefits of the service for patients, hospital staff, GPs and the NHS/health board. Negative responses related mainly to demand/capacity issues. Overall, the evaluation showed good compliance with many national standards and high levels of patient and staff satisfaction. This suggests that with trained and competent nursing staff and collaborative multidisciplinary team working, safe and appropriate care can be achieved for more complex, as well as very stable PC patients.     

Pioneering a new role: the beginning, current practice and future of the Clinical Nurse Leader

Aim  To discuss the development of a new nursing role in response to the health care crisis in the United States.
Background  The nursing shortage and fragmentation of care has contributed to the need for nurses who are prepared to laterally integrate care, bring evidence-based practice to the bedside and provide continuity of care to patients and families.
Evaluation  The CNLs review the literature, share their experiences, and discuss outcomes related to improved quality of care.
Key issues  Having clinical nurses with a global perspective acting as facilitators and integrators of care is essential to maintaining a high standard of care. Organizational and management support is critical. The more CNLs that can be embedded in an institution, the more successful the role can be.
Conclusions  The varied utilization of the CNLs in this practice setting has proven its value in a short period of time and facilitated better communication and collaboration among patients and their health care team.
Implications for nursing management  The flexibility and broad scope of this role allows for its use in any practice setting to realize gains in quality outcomes, cost savings, improved patient flow, increased safety, nurse satisfaction and increasing organizational capacity.