Emergency nurse practitioners: An underestimated addition to the emergency care team

Major contributors reducing access to high-quality care in ED include staff shortages, lack of hospital beds and a shift from community-based treatments.1, 2 Nurse practitioners (NP) could play a central role in health-care reforms and represent a new direction and mindset in health-care provision. An alternative model of care, involving training ‘healthcare professionals for the tasks required rather than for roles based on historical models’, has long been suggested as a possible solution to this ongoing crisis faced by our ED.1 The government's recent proposal to recognize NP as ‘independent’ health-care providers with access to funds, such as PBS, has provoked heated debate within medical circles. Supporters view them as one potential solution to an overstretched health-care system, crippled by ‘access block’. In contrast, the Australian Medical Association (AMA) is strongly opposed to the role, being concerned that NP will become ‘doctor substitutes’ while having inferior training and qualifications.3, 4 There are three key themes central to the understanding of the NP role. These include extended practice, autonomous practice and practice within a nursing model of care.5 In Victoria, an NP is defined as: ‘a registered nurse educated for advanced practice, who is an essential member of the interdependent health care team and whose role is determined by the context in which s/he practices’.6 The NP role encompasses the depth of knowledge and expertise associated with advanced clinical nursing practice, with five key extensions to practice. These are: prescribing medications, initiating diagnostic imaging and laboratory testing, referring to medical specialists, admitting and discharging patients, and approving absence from work certificates.7 NP are educated to a Master's level, inclusive of a compulsory pharmacology unit. Candidates undertake a rigorous accreditation process conducted by the Nurses Board of Victoria to ensure a consistent level of competency between endorsed NP in Victoria. The role of the NP should not be confused with ‘practice nurses’ as the two titles are often misused interchangeably. A practice nurse is ‘a registered nurse who is employed by, or whose services are otherwise retained by, a General Practice’.8 This confusion often ignores the skills of a ‘nurse practitioner’, as practice nurses have not undergone formal education to a Masters level and Nurses Board of Victoria accreditation. Notably, this lack of distinction has incorrectly underpinned many arguments against the introduction of independent nursing roles. Victorian ED have seen the greatest recruitment of NP, with the role now firmly established within various Melbourne and regional hospitals. This has impacted positively on departmental key performance indicators, while providing an important resource to the multidisciplinary team.9, 10 These outcomes are welcomed by both health administrators and emergency clinicians. As an example of institutional change, emergency care at The Alfred Hospital Emergency and Trauma Centre, Melbourne has been fundamentally redefined since the introduction of the emergency nurse practitioner (ENP) role in July 2004. The necessity for change was driven by increasing patient attendances and rising community expectation for accessible, efficient and responsive health care.6 Hospital executives responded by investing in alternative models of care, encouraged by key performance indicator-driven, incentive-based Department of Human Service-funded financial bonuses.11 The ENP role emerged as a viable model, successfully improving on key targets, such as ‘percentage of non-admitted patients with a length of stay less than four hours’.12 These favourable outcomes have prompted further recruitment of ENP, a decision at least partly based on a compelling business case. The Alfred Hospital, Melbourne currently employs two endorsed ENP and four ENP candidates in clinical practice, who manage 10% of total annual ED patient presentations.9 The ENP model has positively influenced two key areas: patient care and departmental operation and organization. The Australian experience and international experience have been similar, with consistently reduced patient waiting times and total length of stay, increased patient and staff satisfaction and overall cost-effectiveness.10, 13-17 These results have primarily been achieved by releasing emergency medical staff to apply their knowledge and expertise to sicker patients, while ENP care for lower-acuity patient groups. At the Alfred Hospital, Melbourne, ENP target Australasian Triage Scale category 3–5 patients within the broad categories of musculoskeletal injuries, lacerations, skin infections, respiratory and urinary infections.9 Streamlined patient care has resulted from these types of patients being treated quickly and proficiently.18 Patient care identified as beyond the ENP's scope of practice is referred to medical physicians for collaborative input. The introduction of the ENP model has also seen a reduction in patients who ‘did not wait’ for treatment, providing greater access to this patient group for health promotion and intervention.19 The ENP model has not only enhanced aspects of patient care, but several organizational benefits have also been observed. In an environment of high staff turnover, retention of both medical and nursing personnel is a priority. For differing reasons, both groups have experienced increased job satisfaction.10 First, doctors are not pressured to see every patient, particularly those with minor complaints. Instead, the large patient load facing doctors is shared by ENP independently consulting, treating and referring patients for definitive specialist care. The ENP model also promotes sustainability, keeping senior emergency physicians stimulated and challenged by channelling their skill and knowledge towards critically ill patients, and allowing time for the training of junior staff. Second, the model provides further opportunities for highly trained nurses to use and extend their skills, experience and knowledge. Creation of a highly skilled and motivated nursing workforce helps promote a culture of learning and professional development within the entire nursing community. The permanent ENP staff base ensures an inherent familiarity and proficiency with hospital processes and resource management.20, 21 Rotating junior medical staff can take advantage of this knowledge, allowing for more efficient patient care and resource allocation. Several concerns and limitations of the NP role have been highlighted in the published work. These include concerns regarding medical role substitution, the possible impact on junior doctor training and nursing workforce shortages.3 The substitution of doctors with NP for workforce or cost reasons is of considerable concern to physicians. Critics argue that NP working independently have the potential to create confusion and disharmony in the workplace, adversely affecting patient care.3 In fact, the AMA position dictates that ‘no other class of health practitioner is sufficiently trained in the roles of medical practitioners to meet the health needs of the community’.4 In practice, ENP work independently within a clinical practice guideline model, and patient care falling beyond this scope is referred to an emergency physician for collaborative input. This process ensures patient safety as medical practitioners contribute to the clinical diagnostic and management decisions. The impact on medical student and junior doctor training is another concern to physicians.3 NP could possibly create pressure by limiting valuable training opportunities for doctors as they compete for the low-acuity patient workload. For example, ENP are primarily Fast Track-based, seeing a high turnover of patients requiring simple procedures, such as suturing or plastering. This potentially denies junior doctors the opportunity to refine key skills, such as history taking, clinical examination and simple procedures on uncomplicated ‘well’ patients. A structured education programme and log of junior doctor training will ensure that their skill development is satisfactory. The ENP might contribute to junior doctor training by supporting and supervising their clinical skill development for simple procedures, such as suturing or plastering. Nurses have always had a central role in high-quality health care, with nursing recruitment, retention and sustainability of nursing career structures high on the agenda for hospital administrators. The NP career path undoubtedly provides opportunities for highly motivated nurses. However, the impacts on the greater nursing workforce merit consideration. To date, NP are relatively few in number, but as more nurses commit to the NP role, there is the potential to drain clinical areas of highly skilled nurses.3 The small percentage of nurses in this role, the benefit of a potential mentoring role and the development of a more sustainable long-term career structure for senior clinical nurses make this a small risk. Successful implementation and sustainability of the NP role within hospitals are dependent on medical acceptance and support. Internationally, the NP role is seen as an integral part of the health-care workforce, and Australia is set to follow. The concept of a ‘health care team’ is endorsed by the AMA and believed to underpin high-quality patient care. The ENP model conforms to this collaborative team approach that is complementary in providing safe, efficient, high-quality care to emergency patients in Australia. The ENP model is designed to fill the gaps in access, efficiency and quality of service. It should be viewed as one potential solution to our overstretched public health system and a means to retain a highly skilled nursing workforce.