Emergency Care Nurse - Essay Example

The Evolving Role of the Emergency Care Nurse and Related Contemporary Issues The role of the nurse in the emergency department has evolved over therecent years. It is not uncommon for radiography requests, intravenous cannulation, and drug prescription to fall within the remit of emergency department nurses. These skills represent an extension of the traditional repertoire of a nurse in an emergency department. The overall clinical responsibility for the patient, however, still lies with a physician. By contrast, the nurse practitioner in an emergency department may practise independently, according to locally agreed protocols, without reference to a physician, and is accountable for his or her actions. Such developments are fairly new in the UK. Physician’s assistants and nurse practitioners were introduced into the US health-care systems in the late 1960s. Physician’s assistants are graduates of accredited educational programmes, and many are board certified. They do not practise independently, unlike nurse practitioners, who are registered nurses trained at masters-degree level. There are training programmes in emergency medicine for both groups, and in 1992 they managed 4%(3-5 million) of all patients attending US emergency departments (Hooker & McCraig, 1996). These changes in the nursing profession have been given impetus by the unrelenting rise in the attendances of emergency departments (Audit Commission, 1996), combined with shortfalls in medical staffing and increase expectations by patients. Nurses, with support from their professional bodies (UKCCFNMV, 1992), have generally been enthusiastic about a nurse practitioner service and expansion of their range of practice. There is evidence that nurse practitioners are as effective as junior doctors of senior house-officer (SHO) grade in recognising the need for a radiograph in subsets of patients, and as competent in the interpretation of the film (Freij, et. al., 1996). There is also evidence that nurse practitioners can prescribe safely and appropriately (Marshall, et al., 1997). The study in today’s Lancet by M. Sakr and colleagues is a reliable comparison between nurse practitioners and SHOs in the service they provide in an emergency department. Patients were allocated randomly to management by a nurse practitioner or an SHO. No significant differences were noted in the accuracy of examination, adequacy of treatment, use and interpretation of plain radiological investigations, or arrangements of follow-up. Fewer patients seen by nurse practitioners needed unplanned follow-up. However, nurse practitioners took longer to assess patients and were more expensive to employ. The findings of this study, in general, support the case for employing nurse practitioners in the emergency department. The findings also raise several points for consideration. Nurse practitioners posts that are to be established within a department should be seen as a new resource and must be supported by appropriate funding to ensure that nursing levels are adequate to provide nursing care to patients not seen by nurse practitioners. If no additional nurses are provided, there may be difficulties in providing an adequate routine emergency service (Tye, et. al., 1998). The nurse practitioners may then be diverted to other nursing tasks, and the impact of having a nurse practitioner is lost. Concerns about the loss of clinical judgments and skills because of specialisation can be addressed by rotation of nurse practitioner duties with those of traditional nursing. Nurse practitioners must not be viewed as an alternative to junior doctors. In the emergency department, these doctors are expected to attend to broad range of acute medical, surgical, traumatic disorders. Nurse practitioners attend to only a very small proportion of a major department’s workload, and they work more slowly than most junior doctors. The service equivalent of a whole-time nurse practitioner is half that of an SHO (BAAEM, 1998). The comparatively high cost of a dedicated nurse practitioner service has to be balanced against the advantages. Patients seen by nurse practitioners tend to be those with minor or isolated complaints, who commonly have the longest wait in emergency departments. Long waits and dissatisfaction with care are contributory factors for complaints (Hunt & Glucksman, 1991). Shorter waits and increased satisfaction of patients should thus reduce the volume of complaints and litigation. Most opportunities for nurses to progress in their careers involve a move into an administrative post. Becoming a nurse practitioner provides an alternative for experienced nurses. Most nurse practitioners in the UK will receive some specific formal training, the academic content and extent of which varies enormously. There is no agrees syllabus or national accreditation for nurse practitioner courses. These inconsistencies may be due to a lack of agreement on the nurse practitioner’s clinical role, which is usually defined locally according to the requirements of a department or health organisation. If the role is to transcend individual emergency departments, it must be developed in a standardised and regulated fashion, with support and supervision from senior medical staff. With such strategies in place, the nurse practitioner may become emblematic of the changing role of nurses within the health service and the changing nurse-patient relationship as they assume clinical responsibility for patients. Physicians are no longer in sole charge of the care of patients, and they may soon have to redefine their role. Contemporary Issues on the Emergency Department Triage Nurse The role of the Emergency Department nurse continues to grow because of the increasing use of Emergency Departments for primary care as well as a center for lifesaving treatment. Because the ED is the initial point of contact, the ED triage nurse is charged with determining which patients gain emergency medical care and the priority in which the services are rendered. In this vital role of gatekeeper to emergency services, the ED’s triage nurse plays as a gatekeeper to patient satisfaction and patient loyalty to a particular ED. Although medical, nursing and health services researchers have united to answer questions concerning patient satisfaction in a variety of emergency medical settings, there has been limited research specifically addressing patient satisfaction and the triage process (Hooker & McCaig, 2003). In a study of patient satisfaction with ED nursing care, Raper identified the ED triage nurse-patient interaction as both an initial step in accessing ED care and as a predominant interaction between patient and ED nursing personnel (Audit Commission, 1996). Researchers have noted positive relationships between specific individual patient differences and various dimensions of patient satisfaction with ED care (Audit Commission, 1996; Hooker & McCaig, 2003; United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1992; Freij, R. M., Duffy, T., Hackett, D., Cunningham, & Fothergill, 1996). In an effort to determine patient satisfaction with an ED care facility as a function of patient triage, McMillan et al examined the mail responses of 368 ED patients. The findings revealed that ED patients triaged into higher priority categories reported the most satisfaction. The high level of patient satisfaction was most notable in relation to the ED physician and nurse. Likewise in a survey of 152 ED patients, Lewis and Woodside reported the following: 1) the more urgent the triage category, the more satisfied the patient; 2) the satisfaction was highest in patients who had no or moderate fear of anxiety; 3) patients who had slight fear or anxiety had the most complaints; and 4) patients were highly satisfied with technical competence (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1992). Bursche et al found significant positive relationships among overall satisfaction with ED care and the patients’ perception of the ED nurse’s caring, information from the EED nurse to the patient and family, instructions on discharge, and help in contacting relatives Freij, Duffy, Hackett, Cunningham, & Fothergill, 1996). In addition, the significant statistical predictors of overall ED patient satisfaction were nurse caring as perceived by the patient and information giving by the nurse about what was happening to the patient. More recently, Raper has described positive relationships between patient satisfaction with ED nursing care with patient’s perceived improvement in condition and admission to the hospital (Audit Commission, 1996). He also reported factors affecting the patient’s psychological safety” and “information giving” by the nurse as significant predictors of patient satisfaction with the ED nurse, which in turn was a significant predictor of the patient’s intention to return to a specific ED. Researchers have noted positive relationships between specific individual patient differences and various dimensions of patient satisfaction with ED care (Audit Commission, 1996; Hooker & McCaig, 2003; United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1992; Freij, R. M., Duffy, T., Hackett, D., Cunningham, & Fothergill, 1996). In an effort to determine patient satisfaction with an ED facility as a function of patient triage, Mcmillan, et al. examined the mail responses of 368 ED patients. The findings revealed that ED patients triaged into higher priority categories reported the most satisfaction. The high level of patient satisfaction was most notable as it related to the ED physician and nurse. Likewise, in a survey of 152 ED patients, Lewis and Woodside reported: (1) the more urgent the triage category, the more satisfied the patient; (2)satisfaction was highest in patients who have no or moderate fear or anxiety; (3) patients who had slight fear or anxiety had more complaints; and (4)patients were highly satisfied with technical competence. (3) Bursch, et. al. found significant positive relationships among overall patient satisfaction with ED care and the patients’ perception of the ED nurse’s caring, information from the ED nurse to the patient and family, instructions on discharge, and help in contacting relative(s). (4) In addition, the significant statistical predictors of overall ED patient satisfaction were nurse caring as perceived by the patient and information giving by the nurse about what was happening to the patient. More recently, Raper described positive relationships between patient satisfaction with ED nursing care with patient’s perceived improvement in condition and admission to the hospital (Audit Commission, 1996). He also reported factors affecting the patient’s “psychological safety” and “information giving” by the nurse as significant predictors of patient satisfaction with the ED nurse, which in turn was a significant predictor of the patient’s intention to return to a specific ED. Although the aforementioned findings are very interesting and signal the importance nursing plays in the patient satisfaction process, the available knowledge is limited regarding how individual patient differences , nurse characteristics, and patient satisfaction may relate. For this reason, the current study sought to further the research base through expanded replication. The model of patient satisfaction proposed by Strasser, et. al. served as the framework for the study (Marshall, Edwards, & Lambert, 1997) This dynamic model incorporates six principles grounded in theoretical literature or empirical research about how human judgments are formed and how they may influence human behavior. The Strasser Patient Satisfaction Model incorporates the following six foundational principles: 1. patient satisfaction is a perceptual process. 2. patient satisfaction is both a multi-dimensional construct and a single global construct. 3. patient satisfaction is a dynamic process. 4. patient satisfaction is an attitudinal response. 5. the patient is the judge of satisfaction and is an activist and an endogenous variable in the formation of satisfaction. 6. the process of patient satisfaction formation is individualized. Within the proposed model, Individual Differences, which are based on cultural background, previous experience with health care encounters, and current medical status, influence the global attitude (Attitudinal Reactance) of patient satisfaction in response to value judgments. Thus, as it relates to ED triage nursing care and the ED triage nurse. The level of patient satisfaction is dependent on both the patient-nurse relationship and the general satisfaction the patient experiences during the ED visit. New Trends: Care Coordination for Emergency Nurses The Angliss Hospital in outer eastern Melbourne has introduced the concept of care coordination in its emergency department with great effect. Care coordination at the Angliss Hospital has been remarkably successful and has made a significant contribution to the effective and appropriate management of emergency department clients. Introduced in December 2001, care coordination began as a program designed to facilitate safer and more effective discharge of clients back into the community. By providing early assessment and intervention, the program aimed to maximise client outcomes and reduce unnecessary hospital admissions. During their initial assessment, the primary care nurses complete a risk-screening tool for all clients who visit the emergency department. Those identified as being at high-risk are referred to the care coordination team. The care coordination team currently comprises a care coordinator (RN or allied health), a physiotherapist and a social worker. The care coordinator interviews the client and completes a detailed assessment. This forms the basis for providing health information and education, and for referrals to allied health services. Direct intervention may be provided by the physiotherapist for musculoskeletal injuries, mobility assessments or respiratory illnesses. The social worker may see clients to initiate a care plan and arrange follow-up services such as counseling, aged care or psychiatric assessments or care support. Other allied health, patient-at-their home and acute care services as well as community services are arranged as required, to enable the client to return home with a clear post-discharge plan and appropriate supports already in place (Hall, 2003). These new roles and trends underscore the constantly evolving and continuously value-adding part that the emergency care nurse plays in providing evidence-based care. References Audit Commission. (1996). By accident or design? Improving A&E services in England and Wales. London: HM Stationery Office. British Association for Accident and Emergency Medicine. The way ahead. London: BAEM. Freij, R. M., Duffy, T., Hackett, D., Cunningham, Fothergill, J. (1996). Radiographic interpretation by nurse practitioners in a minor injuries unit. Journal of Accidents and Emergency Medicine, 13, 41-43. Hall, K. (2003). Care coordination: A new role for emergency care nurses. Australian Nursing Journal, 11, 4, 33. Hooker, R.S. & McCaig, I. (1996). Emergency department uses of physician assistants and nurse practitioners: A national survey. American Journal of Emergency Medicine, 14:245-49. Hunt. M. & Glucksman, M. (1991). A review of 7 years of complaints in an inner-city accident and emergency department. Archive of Emergency Medicine, 8, 17-23. Marshall, J., Edwards, C. & Lambert, M. (1997). Administration of medicines by emergency nurse practitioners according to protocols in an accident and emergency department. Journal of Accidents and Emergency Medicine, 14, 233-37. Tye, C.C., Ross, F., Kerry, S.M. (1998). Emergency nurse practitioner services in major accident and emergency departments: A United Kingdom postal survey. Journal of Accidents and Emergency Medicine,15:31-43. United Kingdom Central Council for Nursing, Midwifery and Health Visiting. (1992). The scope of professional practice. London :UKCC. Read More